Left ventricle diastolic vortex ring characterization in ischemic cardiomyopathy: insight into atrio-ventricular interplay

Diastolic vortex ring (VR) plays a key role in the blood-pumping function exerted by the left ventricle (LV), with altered VR structures being associated with LV dysfunction. Herein, we sought to characterize the VR diastolic alterations in ischemic cardiomyopathy (ICM) patients with systo-diastolic LV dysfunction, as compared to healthy controls, in order to provide a more comprehensive understanding of LV diastolic function. 4D Flow MRI data were acquired in ICM patients (n = 15) and healthy controls (n = 15). The lambda 2 method was used to extract VRs during early and late diastolic filling. Geometrical VR features, e.g., circularity index (CI), orientation (alpha), and inclination with respect to the LV outflow tract (ss), were extracted. Kinetic energy (KE), rate of viscous energy loss (EL center dot\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{\mathrm{EL}}$$\end{document}), vorticity (W), and volume (V) were computed for each VR; the ratios with the respective quantities computed for the entire LV were derived. At peak E-wave, the VR was less circular (p = 0.032), formed a smaller alpha with the LV long-axis (p = 0.003) and a greater ss (p = 0.002) in ICM patients as compared to controls. At peak A-wave, CI was significantly increased (p = 0.034), while alpha was significantly smaller (p = 0.016) and beta was significantly increased (p = 0.036) in ICM as compared to controls. At both peak E-wave and peak A-wave, (ELVR)-V-center dot/(ELLV)-L-center dot\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\dot{\mathrm{EL}}}_{\mathrm{VR}}/{\dot{\mathrm{EL}}}_{\mathrm{LV}}$$\end{document}, WVR/WLV, and VVR/VLV significantly decreased in ICM patients vs. healthy controls. KEVR/VVR showed a significant decrease in ICM patients with respect to controls at peak E-wave, while VVR remained comparable between normal and pathologic conditions. In the analyzed ICM patients, the diastolic VRs showed alterations in terms of geometry and energetics. These derangements might be attributed to both structural and functional alterations affecting the infarcted wall region and the remote myocardium

Cardiac magnetic resonance predictors of left ventricular remodelling following acute ST elevation myocardial infarction: The VavirimS study

Left ventricular (LV) remodelling (REM) ensuing after ST-elevation myocardial infarction (STEMI), has typically been studied by echocardiography, which has limitations, or cardiac magnetic resonance (CMR) in early phase that may overestimate infarct size (IS) due to tissue edema and stunning. This prospective, multicenter study investigated LV-REM performing CMR in the subacute phase, and 6 months after STEMI

366 The use of dedicated long-axis views focused on the left atrium improves the accuracy of left atrial volumes and function measured by cardiovascular magnetic resonance

Abstract Aims The use of apical views focused on the left atrium (LA) has improved the accuracy of LA volume evaluation by two-dimensional echocardiography. However, routine cardiac magnetic resonance (CMR) evaluation of LA volumes still uses standard 2- and 4-chamber cine images focused on the left ventricle. To investigate the potential of LA-focused CMR cine images, we compared LA maximal (LAVmax) and minimal (LAVmin) volumes, and emptying fraction (LA-EF) calculated on both standard and LA-focused long-axis cine images with LA volumes obtained by short-axis cine stacks covering the LA. Methods and results LA volumes and LA-EF were obtained from 108 consecutive patients by applying the biplane area-length algorithm to both standard and LA-focused 2- and 4-chamber cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method. Compared to the reference method, the standard approach significantly underestimated LA volumes (LAVmax: bias −13 ml; LOA = +11 ml, −37 ml; LAVmin; bias −10 ml, LOA: +9 ml, −28ml), and overestimated LA-EF (bias= 5%, LOA: +23%, −14%). Conversely, LA volumes (LAVmax bias −0.03 ml; LOA: +10 ml, −10 ml. LAVmin bias = −1.5 ml; LOA: +7 ml, −10 ml), and LA-EF (bias 2%, LOA: +11%, −7%) by LA-focused cine images were similar to those measured using the reference method. Moreover, LA volumes by LA-focused images were obtained faster than using the reference method (1.2 vs. 4.5 min, P < 0.001). Conclusions LA volumes and LA-EF measured using dedicated LA-focused long-axis cine imaging are more accurate than using standard (LV-focused) cine images

Predictors of adverse prognosis in COVID-19: a systematic review and meta-analysis

Background: Identification of reliable outcome predictors in coronavirus disease 2019 (COVID-19) is of paramount importance for improving patient's management. Methods: A systematic review of literature was conducted until 24 April 2020. From 6843 articles, 49 studies were selected for a pooled assessment; cumulative statistics for age and sex were retrieved in 587 790 and 602 234 cases. Two endpoints were defined: (a) a composite outcome including death, severe presentation, hospitalization in the intensive care unit (ICU) and/or mechanical ventilation; and (b) in-hospital mortality. We extracted numeric data on patients’ characteristics and cases with adverse outcomes and employed inverse variance random-effects models to derive pooled estimates. Results: We identified 18 and 12 factors associated with the composite endpoint and death, respectively. Among those, a history of CVD (odds ratio (OR) = 3.15, 95% confidence intervals (CIs) 2.26-4.41), acute cardiac (OR = 10.58, 5.00-22.40) or kidney (OR = 5.13, 1.78-14.83) injury, increased procalcitonin (OR = 4.8, 2.034-11.31) or D-dimer (OR = 3.7, 1.74-7.89), and thrombocytopenia (OR = 6.23, 1.031-37.67) conveyed the highest odds for the adverse composite endpoint. Advanced age, male sex, cardiovascular comorbidities, acute cardiac or kidney injury, lymphocytopenia and D-dimer conferred an increased risk of in-hospital death. With respect to the treatment of the acute phase, therapy with steroids was associated with the adverse composite endpoint (OR = 3.61, 95% CI 1.934-6.73), but not with mortality. Conclusions: Advanced age, comorbidities, abnormal inflammatory and organ injury circulating biomarkers captured patients with an adverse clinical outcome. Clinical history and laboratory profile may then help identify patients with a higher risk of in-hospital mortality. © 2020 Stichting European Society for Clinical Investigation Journal Foundatio

The use of dedicated long-axis views focused on the left atrium improves the accuracy of left atrial volumes and emptying fraction measured by cardiovascular magnetic resonance

Abstract Background The use of apical views focused on the left atrium (LA) has improved the accuracy of LA volume evaluation by two-dimensional (2D) echocardiography. However, routine cardiovascular magnetic resonance (CMR) evaluation of LA volumes still uses standard 2- and 4-chamber cine images focused on the left ventricle (LV). To investigate the potential of LA-focused CMR cine images, we compared LA maximuml (LAVmax) and minimum (LAVmin) volumes, and emptying fraction (LAEF), calculated on both standard and LA-focused long-axis cine images, with LA volumes and LAEF obtained by short-axis cine stacks covering the LA. LA strain was also calculated and compared between standard and LA-focused images. Methods LA volumes and LAEF were obtained from 108 consecutive patients by applying the biplane area-length algorithm to both standard and LA-focused 2- and 4-chamber cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method. In addition, LA strain reservoir (εs), conduit (εe) and booster pump (εa) were calculated using CMR feature-tracking. Results Compared to the reference method, the standard approach significantly underestimated LA volumes (LAVmax: bias − 13 ml; LOA =  + 11, − 37 ml; LAVmax i: bias − 7 ml/m2; LOA =  + 7, − 21 ml/m2; LAVmin; bias − 10 ml, LOA: + 9, − 28 ml; LAVmin i: bias − 5 ml/m2, LOA: + 5, − 16 ml/m2), and overestimated LA-EF (bias 5%, LOA: + 23, − 14%). Conversely, LA volumes (LAVmax: bias 0 ml; LOA: + 10, − 10 ml; LAVmax i: bias 0 ml/m2; LOA: + 5, − 6 ml/m2; LAVmin: bias − 2 ml; LOA: + 7, − 10 ml; LAVmin i: bias − 1 ml/m2; LOA: + 3, − 5 ml/m2) and LAEF (bias 2%, LOA: + 11, − 7%) by LA-focused cine images were similar to those measured using the reference method. LA volumes by LA-focused images were obtained faster than using the reference method (1.2 vs 4.5 min, p < 0.001). LA strain (εs: bias 7%, LOA = 25, − 11%; εe: bias 4%, LOA = 15, − 8%; εa: bias 3%, LOA = 14, − 8%) was significantly higher in standard vs. LA-focused images (p < 0.001). Conclusion LA volumes and LAEF measured using dedicated LA-focused long-axis cine images are more accurate than using standard LV-focused cine images. Moreover, LA strain is significantly lower in LA-focused vs. standard images

Myocardial infarction with non‐obstructive disease and anomalous coronary origin: look for the common in the uncommon

Abstract Management of congenital coronary artery anomalies (CAA) is not standardized due to the variety of conditions included and their rare prevalence. Detection of CAA during myocardial infarction with non‐obstructive coronary arteries (MINOCA) may induce clinicians to address the patient for surgery as CAA is not included in any algorithm1,2 for the management of MINOCA and American Association for Thoracic Surgery evidence‐based guidelines suggest surgical repair for patients with anomalous aortic origin of a coronary artery and symptoms compatible with myocardial ischaemia.3 We present the case of a 35‐year‐old man with an anomalous origin of left coronary artery from right Valsalva sinus with pre‐pulmonic course detected during urgent coronary angiography for suspected myocardial infarction. Stress cardiac magnetic resonance did not show signs of ischaemia at high‐dose dobutamine but did reveal a recent myocarditis. This clinical case highlights the need for accurate risk stratification in CAA especially when confounding clinical scenarios co‐exist

ECG-based score estimates the probability to detect Fabry Disease cardiac involvement

Objectives: To elaborate an ECG-based nomogram estimating the probability to detect cardiac involvement by cardiac magnetic resonance (CMR) in Fabry Disease (FD). Methods: 119 FD patients and 26 healthy controls underwent ECG and CMR. Test (n = 88, 60%) and validation cohorts (n = 57, 40%) were randomly derived. Cardiac involvement was defined as the presence of low myocardial T1 value, a CMR-surrogate of myocardial glycosphingolipid storage. ECG changes associated with low T1 value were identified in the test cohort, included in the nomogram and then tested in the validation cohort. Results: Sokolow-Lyon index (AUC = 0.769), ratio between P-wave and PR-segment durations (Pwave/PRsegment) (AUC = 0.778), QRS duration (AUC = 0.703), QT (AUC = 0.769) duration were independently associated with the presence of low T1 on CMR at multivariate analysis. An ECG-based nomogram including these four parameters was accurate in identifying patients with CMR evidence of glycosphingolipid storage (c-index of the derived-nomogram = 0.90 in the test group; 0.81 in the validation group). Conclusion: We propose a practical ECG-based nomogram accurately estimating the probability to detect low T1 values by CMR in FD patients. The application of this tool in clinical practice could improve early detection of FD cardiac involvement.</p

Mitral annulus disjunction in consecutive patients undergoing cardiovascular magnetic resonance:where is the boundary between normality and disease?

Background: The presence of mitral annulus disjunction (MAD) has been considered a high-risk feature for sudden cardiac death based on selected study populations. We aimed to assess the prevalence of MAD in consecutive patients undergoing clinically indicated cardiovascular magnetic resonance (CMR), its association with ventricular arrhythmias, mitral valve prolapse (MVP), and other CMR features. Methods: This single-center retrospective study included consecutive patients referred to CMR at our institution between June 2021 and November 2021. MAD was defined as a ≥1 mm displacement between the left atrial wall-mitral valve leaflet junction and the left ventricular wall during end-systole. MAD extent was defined as the maximum longitudinal displacement. Associates of MAD were evaluated at univariable and multivariable regression analysis. The study endpoint, a composite of (aborted) sudden cardiac death, unexplained syncope, and sustained ventricular tachycardia, was evaluated at a 12-month follow-up. Results: Four hundred and forty-one patients 55 ± 18 years, 267/441 (61%) males) were included, and 29/441 (7%) had MVP. The prevalence of MAD ≥1 mm, 4 mm, and 6 mm was 214/441 (49%), 63/441 (14%), and 15/441 (3%), respectively. Patients with MVP showed a higher prevalence of MAD greater than 1 mm (26/29 (90%) vs 118/412 (46%)); p &lt; 0.001), 4 mm (14/29 (48%) vs 49/412 (12%)); p &lt; 0.001), and 6 mm (3/29 (10%) vs 12/412 (3%)); p = 0.03), and a greater MAD extent (4.2 mm, 3.0–5.7 mm vs 2.8 mm, 1.9–4.0 mm; p &lt; 0.001) compared to patients without MVP. MVP was the only morpho-functional abnormality associated with MAD at multivariable analysis (p &lt; 0.001). A high burden of ventricular ectopic beats at baseline Holter-electrocardiogram was associated with MAD ≥4 mm and MAD extent (p &lt; 0.05). The presence of MAD ≥1 mm (0.9% vs 1.8%; p = 0.46), MAD ≥4 mm (1.6% vs 1.3%; p = 0.87), or MVP (3.5% vs 1.2%; p = 0.32) were not associated with the study endpoint, whereas patients with MAD ≥6 mm showed a trend toward a higher likelihood of the study endpoint (6.7% vs 1.2%; p = 0.07). Conclusion: MAD of limited severity was common in consecutive patients undergoing CMR. Patients with MVP showed higher prevalence and greater extent of MAD. Extended MAD was rarer and showed association with ventricular arrhythmias at baseline. The mid-term prognosis of MAD seems benign; however, prospective studies are warranted to search for potential “malignant MAD extents” to improve patients’ risk stratification.</p

Atrial Dysfunction Assessed by Cardiac Magnetic Resonance as an Early Marker of Fabry Cardiomyopathy

In this retrospective, observational study, 45 patients with Anderson-Fabry disease (AFD) underwent CMR with T1 mapping using shortened modified Look-Locker inversion recovery sequences, 2-dimensional echocardiography and quantification of Mainz Severity Score Index (MSSI). LA total strain showed very good correlation with native septal T1, LV maximum wall thickness, atrial volumes, and global or cardiovascular MSSI. A good correlation was found with native T1 values, which in pre-hypertrophic patients with AFD had been shown to provide prognostic information. This study contributes to the characterization of the pre-hypertrophic phenotype of AFD, introducing LA total strain as a potential novel indicator of early cardiac involvement and a possible tool to personalize management decisions in Fabry disease patients