ROC analysis.

<p>ROC analysis.</p

Right atrial volume by cardiovascular magnetic resonance predicts mortality in patients with heart failure with reduced ejection fraction

<div><p>Background</p><p>Right Atrial Volume Index (RAVI) measured by echocardiography is an independent predictor of morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). The aim of this study is to evaluate the predictive value of RAVI assessed by cardiac magnetic resonance (CMR) for all-cause mortality in patients with HFrEF and to assess its additive contribution to the validated Meta-Analysis Global Group in Chronic heart failure (MAGGIC) score.</p><p>Methods and results</p><p>We identified 243 patients (mean age 60 ± 15; 33% women) with left ventricular ejection fraction (LVEF) ≤ 35% measured by CMR. Right atrial volume was calculated based on area in two- and four -chamber views using validated equation, followed by indexing to body surface area. MAGGIC score was calculated using online calculator. During mean period of 2.4 years 33 patients (14%) died. The mean RAVI was 53 ± 26 ml/m²; significantly larger in patients with than without an event (78.7±29 ml/m² vs. 48±22 ml/m², p<0.001). RAVI (per ml/m²) was an independent predictor of mortality [HR = 1.03 (1.01–1.04), p = 0.001]. RAVI has a greater discriminatory ability than LVEF, left atrial volume index and right ventricular ejection fraction (RVEF) (C-statistic 0.8±0.08 vs 0.55±0.1, 0.62±0.11, 0.68±0.11, respectively, all p<0.02). The addition of RAVI to the MAGGIC score significantly improves risk stratification (integrated discrimination improvement 13%, and category-free net reclassification improvement 73%, both p<0.001).</p><p>Conclusion</p><p>RAVI by CMR is an independent predictor of mortality in patients with HFrEF. The addition of RAVI to MAGGIC score improves mortality risk stratification.</p></div

The Systematic Evaluation of Identifying the Infarct Related Artery Utilizing Cardiac Magnetic Resonance in Patients Presenting with ST-Elevation Myocardial Infarction

<div><p>Background</p><p>Identification of the infarct-related artery (IRA) in patients with STEMI using coronary angiography (CA) is often based on the ECG and can be challenging in patients with severe multi-vessel disease. The current study aimed to determine how often percutaneous intervention (PCI) is performed in a coronary artery different from the artery supplying the territory of acute infarction on cardiac magnetic resonance imaging (CMR).</p><p>Methods</p><p>We evaluated 113 patients from the Reduction of infarct Expansion and Ventricular remodeling with Erythropoetin After Large myocardial infarction (REVEAL) trial, who underwent CMR within 4±2 days of revascularization. Blinded reviewers interpreted CA to determine the IRA and CMR to determine the location of infarction on a 17-segment model. In patients with multiple infarcts on CMR, acuity was determined with T2-weighted imaging and/or evidence of microvascular obstruction.</p><p>Results</p><p>A total of 5 (4%) patients were found to have a mismatch between the IRA identified on CMR and CA. In 4/5 cases, there were multiple infarcts noted on CMR. Thirteen patients (11.5%) had multiple infarcts in separate territories on CMR with 4 patients (3.5%) having multiple acute infarcts and 9 patients (8%) having both acute and chronic infarcts.</p><p>Conclusions</p><p>In this select population of patients, the identification of the IRA by CA was incorrect in 4% of patients presenting with STEMI. Four patients with a mismatch had an acute infarction in more than one coronary artery territory on CMR. The role of CMR in patients presenting with STEMI with multi-vessel disease on CA deserves further investigation.</p></div

Mortality estimates by RAVI more or less than the median at the time of CMR imaging.

<p>Mortality estimates by RAVI more or less than the median at the time of CMR imaging.</p

Multiple Infarcts on CMR and CA.

<p>CMR with evidence of multiple infarcts in LAD, RCA, and LCx distribution (A-C). Angiography with high-grade stenosis in LCx and LAD, 100% stenosis RCA (D-F)</p

Mismatch between Cardiac Magnetic Resonance and Angiography.

<p><b>1A:</b> The clinical interpretation of the IRA was the RCA (white arrow), (A) which underwent PCI with stent placement. The IRA was indeterminate by blinded analysis. CMR showed an inferolateral wall infarct (white arrow) (LCx distribution) (B). With the CMR data available, reviewing the angiography data again, the OM was seen to have a flush occlusion that was filled retrograde (white arrows) (C and D). <b>1B:</b> The clinical and blinded interpretation of the IRA was the RCA, which underwent PCI with stent placement (white arrow) (A). CMR showed infarcts in both the RCA and LCx distribution (white arrows) (B and C). T2 weighted imaging indicated that the OM territory was acute (white arrow) (D). With the CMR data available, angiography revealed retrograde filling of OM (white arrows) (E and F). <b>1C:</b> The clinical and blinded interpretation of the IRA was the RCA, which underwent PCI with stent placement (white arrow) (A). CMR showed an infarct in the inferolateral (LCx) distribution with no scar in the inferoseptal wall (white arrow) (B). There was also retrograde filling of the OM (white arrow) (C). <b>1D:</b> The clinical and blinded interpretation of the IRA was the RCA, which underwent PCI with stent placement (white arrow) (A). CMR showed an infarct in the mid-distal anterior wall (LAD distribution) (white arrows) (B and C). On cardiac angiography, there was stenosis noted in the mid-LAD territory (white arrow) (D). <b>1E:</b> The clinical and blinded interpretation of the IRA was the LAD, which underwent balloon angioplasty (white arrow) (A and B). CMR showed an infarct in the inferoseptal wall, (gray arrow) (C) which does not correlate with the area of distribution of the distal LAD. This area of distribution, is attributed to the PDA, which originates from the LCx, however no obvious stenosis was appreciated in that region (white arrow) (D).</p

Multivariable Cox Proportional Hazard Model.

<p>Multivariable Cox Proportional Hazard Model.</p

Baseline characteristics.

<p>Baseline characteristics.</p

Patient Characteristics.

<p>Cerebral vascular accident, CVA, Pro-BNP, pro-brain natriuretic peptide; LDL, low-density lipoprotein; HDL, high density lipoprotein; RVEF, right ventricular ejection fraction; RVSP, right ventricular systolic pressure; mPAP, mean pulmonary artery pressure; LVEF, left ventricular ejection fraction. Measurements of RV and LV volumes, mass, regional wall motion abnormalities, and function were obtained by CMR; TR and PAP by echocardiography.</p><p>Patient Characteristics.</p

Baseline Characteristics of Patients.

<p>Baseline Characteristics of Patients.</p