Is there a role for thoracic aortic calcium to fine-tune cardiovascular risk prediction?

Screening asymptomatic subjects to streamline measures for the prevention of cardiovascular events remains a major challenge. The established primary prevention risk-scoring methods use equations derived from large prospective cohort studies, but further fine-tuning of cardiovascular risk assessment remains important as 25 % of individuals with low estimated risk may experience cardiac events. Independent studies provided evidence that extended risk assessment using coronary artery calcium quantification may improve risk stratification as it can lead to reclassification of persons at increased risk. Particularly in intermediate-risk subjects, coronary artery calcium scoring can help to correctly identify individuals at highest risk. Data on the extent of calcification of the ascending and descending thoracic aorta might be useful for additional cardiovascular risk stratification. Future analyses and studies will be required to answer the question of whether the implementation of such data may allow further fine-tuning of cardiovascular risk prediction in specific subpopulations—for instance in women or men with an increased risk of stroke and/or symptomatic peripheral vascular diseas

Coincidence of substantial right- and left-sided intracardiac thrombi

A 63-year-old previously healthy man presented with deep vein thrombosis and dyspnoea. He developed atrial fibrillation during hospitalisation. A CT scan of the chest revealed filling defects of the atria and ventricles (Fig. 1, panel a and b). Upon transoesophageal echocardiography (TEE) (Fig. 1, c–f) intracardiac masses suspect for thrombi were seen in the left atrium (LA) and right atrium (RA). There was no atrial septum defect or patent foramen ovale. The patient was treated with intravenous heparin and a vitamin K antagonist. At follow-up TEE the intracardiac masses disappeared. Despite adequate anticoagulation, the patient developed an intracerebral infarction and died from recurrent aspiration pneumonia. Simultaneous occurrence of massive thrombus formation in both right and left heart chambers is extremely rare [1]. The findings suggest the presence of an intensely activated coagulation, as for instance occasionally seen in patients with systemic inflammatory diseases or malignancies [2]. In the present case, during the short clinical course, none of the common causes of strongly activated coagulation were found to be presen

Three-Dimensional Intravascular UItrasound Assessment of Coronary Lumen and Atherosclerotic Plaque Dimensions

Since the introduction of coronary balloon angioplasty in the clinical arena, percutaneous catheter- based interventions are perfornled with coronary angiographic guidance, depicting the lumen of an entire coronary artery in certain angiographicviews. Subsequently, quantitative coronary angiography was developed as an instnullent for off-line quantitative analysis of the acute and long-tenn effects of catheter-based and phanl1acological approaches on atherosclerotic lesions and on lesion recurrence following angioplasty. Despite some inherent limitations, tills analysis method became generally accepted for on-line guidance of balloon angioplasty and alternative catheterbased techniques. Thereafter, intravascular ultrasound (IVUS) was introduced as a new imaging method that provided deeper insights into the pathology of coronary artery disease by defining vessel wall geometry and the major components of the atherosclerotic plaque. Although invasive, IVUS is safe and allows in vivo a more comprehensive assessment of the plaque than the 'luminal silhouette' furnished by coro

Challenging pacemaker implantation:persistent left superior vena cava with absent right superior vena cava

A persistent left superior vena cava (PLSVC) in combination with an absent right superior vena cava (RSVC) is a rare congenital cardiovascular abnormality which is usually found by chance during pacemaker (PM) implantation. In this case we describe a PM implantation using right cephalic approach through PLSVC and coronary sinus (CS), with lead fixation in right atrium and a posterolateral branch of the CS

Relationship between infarct tissue characteristics and left ventricular remodeling in patients with versus without early revascularization for acute myocardial infarction as assessed with contrast-enhanced cardiovascular magnetic resonance imaging

Left ventricular (LV) remodeling following myocardial infarction (MI) is the result of complex interactions between various factors, including presence or absence of early revascularization. The impact of early revascularization on the relationship between infarct tissue characteristics and LV remodeling is incompletely known. Therefore, we investigated in patients with versus without successful early revascularization for acute MI potential relations between infarct tissue characteristics and LV remodeling with contrast-enhanced (CE) cardiovascular magnetic resonance (CMR). Patients with versus without successful early revascularization underwent CE-CMR for tissue characterization and assessment of LV remodeling including end-diastolic and end-systolic volumes, LV ejection fraction, and wall motion score index (WMSI). CE-CMR images were analyzed for infarct tissue characteristics including core-, peri- and total-infarct size, transmural extent, and regional scar scores. In early revascularized patients (n = 46), a larger area of infarct tissue correlated significantly with larger LV dimensions and a more reduced LV function (r = 0.39-0.68; all P ≤ 0.01). Multivariate analyses identified peri-infarct size as the best predictor of LV remodeling parameters (R2 = 0.44-0.62). In patients without successful early revascularization (n = 47), there was no correlation between infarct area and remodeling parameters; only peri-infarct size versus WMSI (r = 0.33; P = 0.03) and transmural extent versus LVEF (r = -0.27; P = 0.07) tended to be related. A correlation between infarct tissue characteristics and LV remodeling was found only in patients with early successful revascularization. Peri-infarct size was found to be the best determinant of LV remodeling. Our findings stress the importance of taking into account infarct tissue characteristics and success of revascularization when LV remodeling is studie

Infarct tissue characterization in implantable cardioverter-defibrillator recipients for primary versus secondary prevention following myocardial infarction: a study with contrast-enhancement cardiovascular magnetic resonance imaging

Knowledge about potential differences in infarct tissue characteristics between patients with prior life-threatening ventricular arrhythmia versus patients receiving prophylactic implantable cardioverter-defibrillator (ICD) might help to improve the current risk stratification in myocardial infarction (MI) patients who are considered for ICD implantation. In a consecutive series of (ICD) recipients for primary and secondary prevention following MI, we used contrast-enhanced (CE) cardiovascular magnetic resonance (CMR) imaging to evaluate differences in infarct tissue characteristics. Cine-CMR measurements included left ventricular end-diastolic and end-systolic volumes (EDV, ESV), left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and mass. CE-CMR images were analyzed for core, peri, and total infarct size, infarct localization (according to coronary artery territory), and transmural extent. In this study, 95 ICD recipients were included. In the primary prevention group (n = 66), LVEF was lower (23 ± 9 % vs. 31 ± 14 %; P < 0.01), ESV and WMSI were higher (223 ± 75 ml vs. 184 ± 97 ml, P = 0.04, and 1.89 ± 0.52 vs. 1.47 ± 0.68; P < 0.01), and anterior infarct localization was more frequent (P = 0.02) than in the secondary prevention group (n = 29). There were no differences in infarct tissue characteristics between patients treated for primary versus secondary prevention (P > 0.6 for all). During 21 ± 9 months of follow-up, 3 (5 %) patients in the primary prevention group and 9 (31 %) in the secondary prevention group experienced appropriate ICD therapy for treatment of ventricular arrhythmia (P < 0.01). There was no difference in infarct tissue characteristics between recipients of ICD for primary versus secondary prevention, while the secondary prevention group showed a higher frequency of applied ICD therapy for ventricular arrhythmia.\u