The value of multi-slice-computed tomography coronary angiography for risk stratification

Multi-slice-computed tomography coronary angiography (CTA) provides direct non-invasive anatomic assessment of the coronary arteries allowing for early identification of coronary artery disease (CAD). This information is useful for diagnosis of CAD, particularly the rule out of CAD. In addition, early identification of CAD with CTA may also be useful for risk stratification. The purpose of this review is to provide an overview of the current literature on the prognostic value of CTA and to discuss how the prognostic information obtained with CTA can be used to further integrate the technique into clinical practice. Non-invasive anatomic assessment of plaque burden, location, composition, and remodeling using CTA may provide prognostically relevant information. This information has been shown to be incremental to the Framingham risk score, coronary artery calcium scoring, and myocardial perfusion imaging. Characterization of atherosclerosis non-invasively has the potential to provide important prognostic information enabling a more patient-tailored approach to disease management. Future studies assessing outcome after CTA-based risk adjustments are needed to further understand the value of detailed non-invasive anatomic imaging

Arrhythmic risk stratification by cardiac magnetic resonance tissue characterization: disclosing the arrhythmic substrate within the heart muscle

Sudden cardiac death (SCD) is a pivotal health problem worldwide. The identification of subjects at increased risk of SCD is crucial for the accurate selection of candidates for implantable cardioverter defibrillator (ICD) therapy. Current strategies for arrhythmic stratification largely rely on left ventricular (LV) ejection fraction (EF), mostly measured by echocardiography, and New York Heart Association functional status for heart failure with reduced EF. For specific diseases, such as hypertrophic and arrhythmogenic cardiomyopathy, some risk scores have been proposed; however, these scores take into account some parameters that are a partial reflection of the global arrhythmic risk and show a suboptimal accuracy. Thanks to a more comprehensive evaluation, cardiac magnetic resonance (CMR) provides insights into the heart muscle (the so-called tissue characterization) identifying cardiac fibrosis as an arrhythmic substrate. Combining sequences before and after administration of contrast media and mapping techniques, CMR is able to characterize the myocardial tissue composition, shedding light on both intracellular and extracellular alterations. Over time, late gadolinium enhancement (LGE) emerged as solid prognostic marker, strongly associated with major arrhythmic events regardless of LVEF, adding incremental value over current strategy in ischemic heart disease and non-ischemic cardiomyopathies. The evidence on a potential prognostic role of mapping imaging is promising. However, mapping techniques require further investigation and standardization. Disclosing the arrhythmic substrate within the myocardium, CMR should be considered as part of a multiparametric approach to personalized arrhythmic stratificatio

Right Ventricular Strain and Dyssynchrony Assessment in Arrhythmogenic Right Ventricular Cardiomyopathy: Cardiac Magnetic Resonance Feature-Tracking Study

BACKGROUND: Analysis of right ventricular (RV) regional dysfunction by cardiac magnetic resonance (CMR) imaging in arrhythmogenic RV cardiomyopathy (ARVC) may be inadequate because of the complex contraction pattern of the RV. Aim of this study was to determine the use of RV strain and dyssynchrony assessment in ARVC using feature-tracking CMR analysis. METHODS AND RESULTS: Thirty-two consecutive patients with ARVC referred to CMR imaging were included. Thirty-two patients with idiopathic RV outflow tract arrhythmias and 32 control subjects, matched for age and sex to the ARVC group, were included for comparison purpose. CMR imaging was performed to assess biventricular function; feature-tracking analysis was applied to the cine CMR images to assess regional and global longitudinal, circumferential, and radial RV strains and RV dyssynchrony (defined as the SD of the time-to-peak strain of the RV segments). RV global longitudinal strain (-17\ub15% versus -26\ub16% versus -29\ub16%; P-23.2%, SD of the time-to-peak RV longitudinal strain >113.1 ms, and SD of the time-to-peak RV circumferential strain >177.1 ms allowed correct identification of 88%, 75%, and 63% of ARVC patients with no or only minor CMR criteria for ARVC diagnosis. CONCLUSIONS: Strain analysis by feature-tracking CMR helps to objectively quantify global and regional RV dysfunction and RV dyssynchrony in patients with ARVC and provides incremental value over conventional cine CMR imaging

Changes of left ventricular mechanics after trans-catheter aortic valve implantation and surgical aortic valve replacement for severe aortic stenosis: A tissue-tracking cardiac magnetic resonance study

Background: Left ventricular (LV) mechanics are impaired in patients with severe aortic stenosis (AS). The aim of the present study was to assess their changes early and late after trans-catheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) using cardiac magnetic resonance (CMR) tissue-tracking imaging. Methods: In 59 patients with severe AS undergoing either TAVI (n = 35) or surgical AVR (n = 24), CMR with late gadolinium enhancement (LGE) imaging was performed before and early post-procedure to evaluate LV function and mass, and presence/extent of LGE. A third CMR scan was performed in 29 patients after a mean follow-up of 15 ± 4 months. Tissue-tracking analysis was applied to cine CMR images, to assess LV global longitudinal (GLS), circumferential (GCS) and radial (GRS) strains.
 Results: The TAVI and surgical AVR groups were similar with respect to baseline (p = 0.14) and early post-procedure (p = 0.16) LV ejection fraction. However, baseline LV GLS was significantly impaired in TAVI patients compared to surgical AVR patients (p = 0.025). Early post-procedure, TAVI resulted in a significant improvement of LV GLS (p = 0.003), while a significant worsening of LV GLS was observed early after surgical AVR (p = 0.012). At longer term follow-up, both TAVI and surgical AVR groups experienced a significant reduction of LV mass and a significant improvement of LV myocardial mechanics in all the three directions. Conclusions: Treatment-specific differences in the changes of LV myocardial mechanics early after afterload release by TAVI and surgical AVR are present. Later, both interventions are associated with an improvement of LV myocardial deformation, alongside a regression of LV hypertrophy

Long term prognostic importance of late gadolinium enhancement in first-presentation non-ischaemic dilated cardiomyopathy

© 2019 Elsevier B.V. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (January 2019) in accordance with the publisher’s archiving policyBackground Presence of myocardial fibrosis in well-established non-ischaemic dilated cardiomyopathy (NIDCM) is associated with adverse clinical outcomes. However, the impact of myocardial fibrosis at first presentation in NIDCM, and its long-term association with left ventricular (LV) dysfunction, heart failure (HF) and ventricular arrhythmia (VA) remains unclear. We investigated whether the presence of myocardial fibrosis quantified by late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) at presentation, is independently associated with long-term major adverse cardiovascular events (MACE) in patients with first presentation NIDCM. Methods Consecutive patients with a first diagnosis of NIDCM were recruited. Patients underwent LGE-CMR at baseline. Replacement myocardial fibrosis by LGE-CMR was quantified by experienced observers blinded to patient outcome. MACE was defined as a composite end-point including cardiac death, HF rehospitalisation and the occurrence of sustained VA. Results Fifty-one patients with first presentation NIDCM were included, of which 49 (96%) had follow up and outcome data. Median follow up was 8.2 years. Both the LGE positive and LGE negative groups had similar clinical characteristics at follow up. In univariate Cox regression analysis, positive LGE was associated with MACE (HR:3.44; 95% CI:1.89 to 6.24, p-value < 0.001) and HF rehospitalisation (HR:2.89; 95% CI:1.42 to 5.85, p-value = 0.003). In multivariate Cox regression, positive LGE-CMR was independently associated with MACE (HR:3.53; 95% CI:1.51 to 8.27, p-value = 0.004) and HF rehospitalisation (HR:3.07; 95% CI:1.24 to 7.59, p-value = 0.015). Conclusions The presence of myocardial fibrosis in first presentation NIDCM is independently associated with an increased risk of HF rehospitalisation, at long term follow-up