Apical Ischemia Is a Universal Feature of Apical Hypertrophic Cardiomyopathy

BACKGROUND: Apical hypertrophic cardiomyopathy (ApHCM) accounts for ≈10% of hypertrophic cardiomyopathy cases and is characterized by apical hypertrophy, apical cavity obliteration, and tall ECG R waves with ischemic-looking deep T-wave inversion. These may be present even with <15 mm apical hypertrophy (relative ApHCM). Microvascular dysfunction is well described in hypertrophic cardiomyopathy. We hypothesized that apical perfusion defects would be common in ApHCM. METHODS: A 2-center study using cardiovascular magnetic resonance short- and long-axis quantitative adenosine vasodilator stress perfusion mapping. One hundred patients with ApHCM (68 overt hypertrophy [≥15 mm] and 32 relative ApHCM) were compared with 50 patients with asymmetrical septal hypertrophy hypertrophic cardiomyopathy and 40 healthy volunteer controls. Perfusion was assessed visually and quantitatively as myocardial blood flow and myocardial perfusion reserve. RESULTS: Apical perfusion defects were present in all overt ApHCM patients (100%), all relative ApHCM patients (100%), 36% of asymmetrical septal hypertrophy hypertrophic cardiomyopathy, and 0% of healthy volunteers (P<0.001). In 10% of patients with ApHCM, perfusion defects were sufficiently apical that conventional short-axis views missed them. In 29%, stress myocardial blood flow fell below rest values. Stress myocardial blood flow was most impaired subendocardially, with greater hypertrophy or scar, and with apical aneurysms. Impaired apical myocardial blood flow was most strongly predicted by thicker apical segments (β-coefficient, -0.031 mL/g per min [CI, -0.06 to -0.01]; P=0.013), higher ejection fraction (-0.025 mL/g per min [CI, -0.04 to -0.01]; P<0.005), and ECG maximum R-wave height (-0.023 mL/g per min [CI, -0.04 to -0.01]; P<0.005). CONCLUSIONS: Apical perfusion defects are universally present in ApHCM at all stages. Its ubiquitous presence along with characteristic ECG suggests ischemia may play a disease-defining role in ApHCM

Reliability of core test – Critical assessment and proposed new approach

Core test is commonly required in the area of concrete industry to evaluate the concrete strength and sometimes it becomes the unique tool for safety assessment of existing concrete structures. Core test is therefore introduced in most codes. An extensive literature survey on different international codes’ provisions; including the Egyptian, British, European and ACI Codes, for core analysis is presented. All studied codes’ provisions seem to be unreliable for predicting the in-situ concrete cube strength from the results of core tests. A comprehensive experimental study was undertaken to examine the factors affecting the interpretation of core test results. The program involves four concrete mixes, three concrete grades (18, 30 and 48 MPa), five core diameters (1.5, 2, 3, 4 and 6 in.), five core aspect ratios (between 1 and 2), two types of coarse aggregates (pink lime stone and gravel), two coring directions, three moisture conditions and 18 different steel arrangements. Prototypes for concrete slabs and columns were constructed. More than 500 cores were prepared and tested in addition to tremendous number of concrete cubes and cylinders. Results indicate that the core strength reduces with the increase in aspect ratio, the reduction in core diameter, the presence of reinforcing steel, the incorporation of gravel in concrete, the increase in core moisture content, the drilling perpendicular to casting direction, and the reduction in concrete strength. The Egyptian code provision for core interpretation is critically examined. Based on the experimental evidences throughout this study, statistical analysis has been performed to determine reliable strength correction factors that account for the studied variables. A simple weighted regression analysis of a model without an intercept was carried out using the “SAS Software” package as well as “Data Fit” software. A new model for interpretation of core test results is proposed considering all factors affecting core strength. The model when calibrated against large number of test data shows good agreement. The proposed model can effectively estimate the in-situ concrete cube strength from core test results

Forced Diuresis with Matched Isotonic Intravenous Hydration Prevents Renal Contrast Media Accumulation

The accumulation of contrast media in the kidneys might lead to contrast-induced acute kidney injury. In this prospective, controlled observational study, we aimed to evaluate whether forced diuresis with matched isotonic intravenous hydration prevents the accumulation of contrast media in the kidneys of patients undergoing cardiac interventional procedures. We compared the intensity of contrast media accumulation as observed in nephrograms following these procedures, with and without peri-procedural controlled renal flushing. The study group consisted of 25 patients with impaired renal function treated with the RenalGuard system. The two control groups included 25 patients with normal kidney function and 8 patients with impaired renal function undergoing similar procedures with routine pre-procedural hydration, but without controlled renal flushing. Renal contrast media accumulation at the end of each procedure was scored by blinded cardiologists. The renal contrast accumulation score (CAS) in the study group was significantly lower, with a median score of 0 (IQR (0–0)) compared with 1.5 (IQR (1–2)) in the normal renal function control group and 1 (IQR (0.38–1.62)) in the impaired renal function control group (p < 0.001 and 0.003, respectively). In a multivariate analysis of CAS, RenalGuard treatment was independently associated with lower CAS compared to both control groups. In conclusion, RenalGuard use prevents renal contrast accumulation in patients with impaired renal function undergoing cardiac procedures with intra-arterial contrast media injection

Valvular Heart Disease following Anthracycline Therapy&mdash;Is It Time to Look beyond Ejection Fraction?

The association between anthracycline (ANT) and left ventricle (LV) dysfunction is well known; however, data regarding its direct effect on cardiac valve function is limited. We aimed to evaluate how ANT therapy affected valvular function in patients diagnosed with breast cancer. Data were prospectively collected as part of the Israel Cardio-Oncology Registry (ICOR). Patients underwent echocardiography exams at baseline (T1), during ANT therapy (T2), and after completion within 3 months (T3) and 6 months (T4). A total of 141 female patients were included, with a mean age of 51 &plusmn; 12 years. From T1 to T4, we observed a significant deterioration in LV ejection fraction (60.2 &plusmn; 1.5 to 59.2 &plusmn; 2.7%, p = 0.0004) and LV global longitudinal strain (&minus;21.6 (&minus;20.0&ndash;&minus;23.0) to &minus;20.0 (&minus;19.1&ndash;&minus;21.1)%, p &lt; 0.0001)), and an increase in LV end-systolic diameter (25 (22&ndash;27) to 27 (24&ndash;30) mm, p &lt; 0.0001). We observed a significant increase in the incidence of new mitral regurgitation (MR) development (4 to 19%, p &lt; 0.0001), worsening with concomitant trastuzumab therapy (6% to 31%, p = 0.003), and a trend for tricuspid regurgitation development (4% to 8%, p = 0.19). ANT therapy is associated with the development of a new valvular disease, mainly MR, which may imply the need for a valvular focus in the monitoring of cancer patients