Topic: Imaging

Abstract

Reproducibility of Clinical Late Gadolinium Enhancement Magnetic Resonance Imaging in Detecting Left Atrial Scar after Atrial Fibrillation Ablation.

Kamali R, Schroeder J, DiBella E, Steinberg B, ... Macleod RS, Ranjan R
Background
Late gadolinium enhancement (LGE) cardiac MRI can be used to detect post-ablation atrial scar (PAAS) but its reproducibility and reliability in clinical scans across different magnetic flux densities and scar detection methods is unknown.
Methods
Patients (n=45) having undergone two consecutive MRIs (three months apart) on 3T and 1.5T scanners were studied. We compared PAAS detection reproducibility using four methods of thresholding: simple thresholding, Otsu thresholding, 3.3 standard deviations (SD) above blood pool (BP) mean intensity, and image intensity ratio (IIR). We performed a texture study by dividing the left atrial wall intensity histogram into deciles and evaluated the correlation of the same decile of the two scans as well as to a randomized distribution of intensities, quantified using Dice Similarity Coefficient (DSC).
Results
The choice of scanner did not significantly affect the reproducibility. The scar detection performed by Otsu thresholding (DSC of 71.26±8.34) resulted in better correlation of the two scans compared to the methods of 3.3 SD above BP mean intensity (DSC of 57.78±21.2, p<0.001) and IIR above 1.61 (DSC of 45.76±29.55, p<001). Texture analysis showed that correlation only for voxels with intensities in deciles above the 70 percentile of wall intensity histogram was better than random distribution (p<0.001).
Conclusions
Our results demonstrate that clinical LGE-MRI can be reliably used for visualizing PAAS across different magnetic flux densities if the threshold is greater than 70 percentile of the wall intensity distribution. Also, atrial wall based thresholding is better than BP based thresholding for reproducible PAAS detection. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 14 Sep 2020; epub ahead of print
Kamali R, Schroeder J, DiBella E, Steinberg B, ... Macleod RS, Ranjan R
J Cardiovasc Electrophysiol: 14 Sep 2020; epub ahead of print | PMID: 32931635
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Abstract

Recovery of atrial contractile function after cut-and-sew maze for long-standing persistent valvular atrial fibrillation.

Jin Y, Wang HS, Han JS, Zhang J, ... Yu Y, Zhao Y
Objective
The recovery of atrial contractile (AC) after maze has been concerned and even questioned. Now, studied the AC recovery degree and its influencing factors .
Method
237 patients with valvular long-standing persistent atrial fibrillation (AF) were retrospectively grouped according to whether sinus rhythm(SR) maintained and AC restored: SR-AC (163 cases), SR-no-AC (41 cases) and AF-no-AC (33 cases). SR-AC were grouped according to Em/Am ratio. Em/Am≤2 showed that the AC recovered well.
Results
The SR maintained rate (161/177, 90.96%) in patients underwent the cut-and-sew maze III (CSM) was significantly higher than that in cryoablation (43/60, 71.7%). Preoperative AF duration had no significant difference among three groups (P = 0.679). Maze methods had significant relationship with whether SR recovered, P < 0.05, but no significant relationship with whether AC recovered in SR maintained patients (P = 0.280). Nearly 80% (163/204) patients can recover AC, among 156 patients (156/204, 76.5%) recovered contractile of left and right atrium, and 63 (63/204, 30.1%) recovered significant left atrial contractile, that is, Em/Am≤2. Whether AC was significantly restored was not related to maze methods, P = 0.370. AC recovered degree in rheumatic heart disease (RHD) patients was worse than that in mitral valve prolapse (MVP) patients, P = 0.004.
Conclusion
To sum up, the CSM is safe and effective, and the atrial contractile function recovery was found in 80%. The key to the success of maze is to form a complete and lasting electrical isolation, and there was no difference in the rate of atrial contractile recovery when postoperative SR was maintained, no matter what maze method is used. MVP patients should be treated with maze more actively than RHD patients.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 09 Sep 2020; epub ahead of print
Jin Y, Wang HS, Han JS, Zhang J, ... Yu Y, Zhao Y
Int J Cardiol: 09 Sep 2020; epub ahead of print | PMID: 32920067
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Abstract

Effect of Progression of Valvular Calcification on Left Ventricular Structure and Frequency of Incident Heart Failure (from the Multiethnic Study of Atherosclerosis).

Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED

Heart failure (HF) is a leading cause of morbidity. Strategies for preventing HF are paramount. Prevalent extracoronary calcification is associated with HF risk but less is known about progression of mitral annular (MAC) and aortic valve calcification (AVC) and HF risk. Progression of valvular calcification (VC) [interval change of >0 units/yr] was assessed by 2 cardiac computed tomography scans over a median of 2.4 years. We used Cox regression to determine the risk of adjudicated HF and linear mixed effects models to determine 10-year change in left ventricular (LV) parameters measured by cardiac magnetic resonance imaging associated with VC progression. We studied 5,591 MESA participants free of baseline cardiovascular disease. Mean ± SD age was 62 ± 10 years; 53% women; 83% had no VC progression, 15% progressed at 1 site (AVC or MAC) and 3% at both sites. There were 251 incident HF over 15 years. After adjusting for cardiovascular risk factors, the hazard ratios (95% confidence interval) of HF associated with VC progression at 1 and 2 sites were 1.62 (1.21 to 2.17) and 1.88 (1.14 to 3.09), respectively, compared with no progression (p-for-trend <0.001). Hazard ratios were higher for HFpEF (2.52 [1.63 to 3.90] and 2.49 [1.19 to 5.25]) but nonsignificant for HFrEF. Both AVC (1.61 [1.19 to 2.19]) and MAC (1.50 [1.09 to 2.07]) progression were associated with HF. VC was associated with worsening of some LV parameters over 10 years. In conclusion, VC progression was associated with increased risk of HF and change in LV function. Interventions targeted at reducing VC progression may also impact HF risk, particularly HFpEF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Aug 2020; epub ahead of print
Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED
Am J Cardiol: 14 Aug 2020; epub ahead of print | PMID: 32917344
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Abstract

Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week.

Teran F, Prats MI, Nelson BP, Kessler R, ... Arntfield RT, Bahner D

Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 10 Aug 2020; 76:745-754
Teran F, Prats MI, Nelson BP, Kessler R, ... Arntfield RT, Bahner D
J Am Coll Cardiol: 10 Aug 2020; 76:745-754 | PMID: 32762909
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Abstract

Management and Outcomes of Transvenous Pacing Leads in Patients Undergoing Transcatheter Tricuspid Valve Replacement.

Anderson JH, McElhinney DB, Aboulhosn J, Zhang Y, ... Cabalka AK,
Objectives
The aim of this study was to determine the prevalence of pacemaker lead-related complications following transcatheter tricuspid valve replacement (TTVR).
Background
The rate of permanent pacemaker implantation following tricuspid valve (TV) surgery is high, and many patients have transvenous leads. The feasibility, safety, and outcomes of subsequently performing TTVR in the setting of transvenous pacemaker leads have not been established.
Methods
The VIVID (Valve-in-Valve International Database) registry was used to review 329 patients who underwent TTVR following TV repair or replacement. Patients were subdivided into 3 cohorts for intergroup comparisons: no lead, epicardial lead, and transvenous lead (entrapped or not entrapped during the TTVR procedure).
Results
Of 329 patients who underwent TTVR, 128 (39%) had prior pacing systems in place, 70 with epicardial and 58 with transvenous leads. A total of 31 patients had leads passing through the TV. Three patients had the right ventricular (RV) lead extracted prior to TTVR. The remaining 28 patients had the RV lead entrapped between the transcatheter TV implant and the surgical valve (n = 22) or the repaired TV (n = 6). One patient had displacement of the RV lead during the procedure, and 2 experienced lead failure during follow-up. Overall, there was no significant difference in the cumulative incidences of competing outcomes (death, TV reintervention, TV dysfunction) between patients with and those without pacing leads or entrapped RV leads.
Conclusions
TTVR in the setting of trans-TV pacemaker leads without lead extraction or re-replacement can be performed safely with a low risk for complications, offering an alternative to surgical TV replacement.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Interv: 07 Aug 2020; epub ahead of print
Anderson JH, McElhinney DB, Aboulhosn J, Zhang Y, ... Cabalka AK,
JACC Cardiovasc Interv: 07 Aug 2020; epub ahead of print | PMID: 32800497
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Abstract

Identifying Cardiac Amyloid in Aortic Stenosis: ECV Quantification by CT in TAVR Patients.

Scully PR, Patel KP, Saberwal B, Klotz E, ... Moon JC, Pugliese F
Objectives
To validate computed tomography measured ECV (ECV) as part of routine evaluation for the detection of cardiac amyloid in patients with aortic stenosis (AS)-amyloid.
Background
AS-amyloid affects 1 in 7 elderly patients referred for transcatheter aortic valve replacement (TAVR). Bone scintigraphy with exclusion of a plasma cell dyscrasia can diagnose transthyretin-related cardiac amyloid noninvasively, for which novel treatments are emerging. Amyloid interstitial expansion increases the myocardial extracellular volume (ECV).
Methods
Patients with severe AS underwent bone scintigraphy (Perugini grade 0, negative; Perugini grades 1 to 3, increasingly positive) and routine TAVR evaluation CT imaging with ECV using 3- and 5-min post-contrast acquisitions. Twenty non-AS control patients also had ECV performed using the 5-min post-contrast acquisition.
Results
A total of 109 patients (43% male; mean age 86 ± 5 years) with severe AS and 20 control subjects were recruited. Sixteen (15%) had AS-amyloid on bone scintigraphy (grade 1, n = 5; grade 2, n = 11). ECV was 32 ± 3%, 34 ± 4%, and 43 ± 6% in Perugini grades 0, 1, and 2, respectively (p < 0.001 for trend) with control subjects lower than lone AS (28 ± 2%; p < 0.001). ECV accuracy for AS-amyloid detection versus lone AS was 0.87 (0.95 for Tc-3,3-diphosphono-1,2-propanodicarboxylic acid Perugini grade 2 only), outperforming conventional electrocardiogram and echocardiography parameters. One composite parameter, the voltage/mass ratio, had utility (similar AUC of 0.87 for any cardiac amyloid detection), although in one-third of patients, this could not be calculated due to bundle branch block or ventricular paced rhythm.
Conclusions
ECV during routine CT TAVR evaluation can reliably detect AS-amyloid, and the measured ECV tracks the degree of infiltration. Another measure of interstitial expansion, the voltage/mass ratio, also performed well.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 04 Aug 2020; epub ahead of print
Scully PR, Patel KP, Saberwal B, Klotz E, ... Moon JC, Pugliese F
JACC Cardiovasc Imaging: 04 Aug 2020; epub ahead of print | PMID: 32771574
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Abstract

Prognostic Value of Stress CMR Perfusion Imaging in Patients With Reduced Left Ventricular Function.

Ge Y, Antiochos P, Steel K, Bingham S, ... Simonetti OP, Kwong RY
Objectives
The aim of this study was to investigate the prognostic value of stress cardiac magnetic resonance imaging (CMR) in patients with reduced left ventricular (LV) systolic function.
Background
Patients with ischemic cardiomyopathy are at risk from both myocardial ischemia and heart failure. Invasive testing is often used as the first-line investigation, and there is limited evidence as to whether stress testing can effectively provide risk stratification.
Methods
In this substudy of a multicenter registry from 13 U.S. centers, patients with reduced LV ejection fraction (<50%), referred for stress CMR for suspected myocardial ischemia, were included. The primary outcome was cardiovascular death or nonfatal myocardial infarction. The secondary outcome was a composite of cardiovascular death, nonfatal myocardial infarction, hospitalization for unstable angina or congestive heart failure, and unplanned late coronary artery bypass graft surgery.
Results
Among 582 patients (mean age 62 ± 12 years, 34% women), 40% had a history of congestive heart failure, and the median LV ejection fraction was 39% (interquartile range: 28% to 45%). At median follow-up of 5.0 years, 97 patients had experienced the primary outcome, and 182 patients had experienced the secondary outcome. Patients with no CMR evidence of ischemia or late gadolinium enhancement (LGE) experienced an annual primary outcome event rate of 1.1%. The presence of ischemia, LGE, or both was associated with higher event rates. In a multivariate model adjusted for clinical covariates, ischemia and LGE were independent predictors of the primary (hazard ratio [HR]: 2.63; 95% confidence interval [CI]: 1.68 to 4.14; p < 0.001; and HR: 1.86; 95% CI: 1.05 to 3.29; p = 0.03) and secondary (HR: 2.14; 95% CI: 1.55 to 2.95; p < 0.001; and HR 1.70; 95% CI: 1.16 to 2.49; p = 0.007) outcomes. The addition of ischemia and LGE led to improved model discrimination for the primary outcome (change in C statistic from 0.715 to 0.765; p = 0.02). The presence and extent of ischemia were associated with higher rates of use of downstream coronary angiography, revascularization, and cost of care spent on ischemia testing.
Conclusions
Stress CMR was effective in risk-stratifying patients with reduced LV ejection fractions. (Stress CMR Perfusion Imaging in the United States [SPINS] Study; NCT03192891).

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 02 Aug 2020; epub ahead of print
Ge Y, Antiochos P, Steel K, Bingham S, ... Simonetti OP, Kwong RY
JACC Cardiovasc Imaging: 02 Aug 2020; epub ahead of print | PMID: 32771575
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Abstract

Usefulness of Neuromuscular Co-morbidity, Left Bundle Branch Block, and Atrial Fibrillation to Predict the Long-Term Prognosis of Left Ventricular Hypertrabeculation/Noncompaction.

Stöllberger C, Hasun M, Winkler-Dworak M, Finsterer J

The prognosis of patients with left ventricular hypertrabeculation/noncompaction (LVHT) is assessed controversially. LVHT is associated with other cardiac abnormalities and with neuromuscular disorders (NMD). Aim of the study was to assess cardiac and neurological findings as predictors of mortality rate in adult LVHT-patients. Included were patients with LVHT diagnosed between 1995 and 2019 in 1 echocardiographic laboratory. Patients underwent a baseline cardiologic examination and were invited for a neurological investigation. In January 2020, their survival status was assessed. End points were death or heart transplantation. LVHT was diagnosed by echocardiography in 310 patients (93 female, aged 53 ± 18 years) with a prevalence of 0.4%/year. A neurologic investigation was performed in 205 patients (67%). A specific NMD was found in 33 (16%), NMD of unknown etiology in 123 (60%) and the neurological investigation was normal in 49 (24%) patients. During follow-up of 84 ± 71 months, 59 patients received electronic devices, 105 patients died, and 6 underwent heart transplantation. The mortality was 4.7%/year, the rate of heart transplantation/death 5%/year. By multivariate analysis, the following parameters were identified to elevate the risk of mortality/heart transplantation: increased age (p = 0.005), inpatient (p = 0.001), presence of a specific NMD (p = 0.0312) or NMD of unknown etiology (p = 0.0365), atrial fibrillation (p = 0.0000), ventricular premature complexes (p = 0.0053), exertional dyspnea (p = 0.0023), left bundle branch block (p = 0.0201), and LVHT of the posterior wall (p = 0.0158). In conclusion, LVHT patients should be systematically investigated neurologically since neurological co-morbidity has a prognostic impact.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jul 2020; 128:168-173
Stöllberger C, Hasun M, Winkler-Dworak M, Finsterer J
Am J Cardiol: 31 Jul 2020; 128:168-173 | PMID: 32650915
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Abstract

Progression of Normal Flow Low Gradient \"Severe\" Aortic Stenosis With Preserved Left Ventricular Ejection Fraction.

Chadha G, Bohbot Y, Lachambre P, Rusinaru D, ... Vanoverschelde JL, Tribouilloy C

Normal-flow low-gradient severe aortic stenosis (NF-LG-SAS), defined by an aortic valve area (AVA) <1 cm², mean pressure gradient (MPG) <40 mm Hg and indexed stroke volume ≥35 ml/m², is the most prevalent form of low-gradient aortic stenosis (AS) with preserved ejection fraction (PEF). However, the true severity of AS in these patients is controversial. The aim of this Doppler echocardiographic study was to investigate changes over time in the hemodynamic severity of patients with NF-LG-SAS with PEF. We retrospectively identified 96 patients who had 2 Doppler echocardiographic examinations without an intervening event. After a median follow-up of 25 (interquartile range 15 to 52) months, progression was observed, with increased transaortic MPG (from 28 [25 to 33] to 39 [34 to 50] mm Hg; p<0.001), peak aortic jet velocity (from 3.46 [3.20 to 3.64] to 4.01 [3.70 to 4.39] m/s; p<0.001), and decreased AVA (from 0.87 [0.82 to 0.94] to 0.72 [0.62 to 0.81] cm²; p<0.001). Median annual rates of progression were 4.3 (1.7 to 8.1) mm Hg/year, 0.25 (0.08 to 0.44) m/s/year, and -0.05 (-0.10 to -0.02) cm²/year, respectively. There was no significant change in left ventricular ejection fraction over time (p = 0.74). At follow-up, 46 patients (48%) acquired the features of classical high-gradient severe AS (MPG ≥40 mm Hg). This study shows that most patients with NF-LG-SAS with PEF exhibit significant hemodynamic progression of AS severity without EF impairment. These findings suggest that NF-LG-SAS with PEF is an \"intermediate\" stage between moderate AS and classical high-gradient severe AS requiring close monitoring.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jul 2020; 128:151-158
Chadha G, Bohbot Y, Lachambre P, Rusinaru D, ... Vanoverschelde JL, Tribouilloy C
Am J Cardiol: 31 Jul 2020; 128:151-158 | PMID: 32650909
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Abstract

Characteristics and Implications of Left Atrial Calcium on Cardiac Computed Tomography in Patients With Earlier Mitral Valve Operation.

Choi JY, Suh YJ, Kim YJ, Lee SH, ... Ha JW, Shim CY

Left atrial calcium (LAC) is often observed in patients who have undergone mitral valve (MV) surgery, but little is known about its characteristics and clinical implications. Therefore, we sought to investigate the structural and hemodynamic significance of LAC and its association with clinical outcomes. We investigated 327 patients with repaired or prosthetic MV who underwent cardiac CT from 2010 to 2017. The degree of LAC was analyzed and classified into three groups: group 1 (no LAC), group 2 (mild-to-moderate LAC), and group 3 (severe LAC). Clinical and echocardiographic characteristics and clinical outcomes were compared in three groups. LAC was seen in 79 (24.2%) patients. Groups 2 and 3 showed more prevalent atrial fibrillation, a rheumatic etiology, a higher number of previous surgeries, a larger LA volume index, and higher pulmonary artery systolic pressure than group 1. Paravalvular leakage of the MV increased progressively according to severity of LAC (15.4% in group 1, 39.3% in group 2, and 66.7% in group 3, p <0.001). Event-free survival rate for major adverse cardiovascular adverse events (log rank p = 0.033) and all-cause mortality (log rank p <0.001) were significantly different according to LAC group. In Cox regression analyses, presence of severe LAC was an independent predictor of all-cause mortality (hazard ratio: 4.44, 95% confidence interval: 1.71 to 11.58, p = 0.002). LAC on cardiac CT is not uncommon and reflects more advanced LA remodeling and a stiff LA. The presence and severity of LAC are associated with a worse clinical outcome after MV surgery.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jul 2020; 128:60-66
Choi JY, Suh YJ, Kim YJ, Lee SH, ... Ha JW, Shim CY
Am J Cardiol: 31 Jul 2020; 128:60-66 | PMID: 32650925
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Abstract

Color Doppler Splay: A Clue to the Presence of Significant Mitral Regurgitation.

Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
Background
The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal \"splay\" of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign.
Methods
Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR.
Results
Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it.
Conclusions
The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 21 Jul 2020; epub ahead of print
Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
J Am Soc Echocardiogr: 21 Jul 2020; epub ahead of print | PMID: 32712051
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Abstract

Value of Vascular and Non-Vascular Pattern on Computed Tomography Perfusion in Patients With Acute Isolated Aphasia.

Rudilosso S, Rodríguez A, Amaro S, Obach V, ... Urra X, Chamorro Á
Background and purpose
Acute onset aphasia may be due to stroke but also to other causes, which are commonly referred to as stroke mimics. We hypothesized that, in patients with acute isolated aphasia, distinct brain perfusion patterns are related to the cause and the clinical outcome. Herein, we analyzed the prognostic yield and the diagnostic usefulness of computed tomography perfusion (CTP) in patients with acute isolated aphasia.
Methods
From a single-center registry, we selected a cohort of 154 patients presenting with acute isolated aphasia who had a whole-brain CTP study available. We collected the main clinical and radiological data. We categorized brain perfusion studies on CTP into vascular and nonvascular perfusion patterns and the cause of aphasia as ischemic stroke, transient ischemic attack, stroke mimic, and undetermined cause. The primary clinical outcome was the persistence of aphasia at discharge. We analyzed the sensitivity, specificity, positive and negative predictive values of perfusion patterns to predict complete clinical recovery and ischemic stroke on follow-up imaging.
Results
The cause of aphasia was an ischemic stroke in 58 patients (38%), transient ischemic attack in 3 (2%), stroke mimic in 68 (44%), and undetermined in 25 (16%). CTP showed vascular and nonvascular perfusion pattern in 62 (40%) and 92 (60%) patients, respectively. Overall, complete recovery occurred in 116 patients (75%). A nonvascular perfusion pattern predicted complete recovery (sensitivity 75.9%, specificity 89.5%, positive predictive value 95.7%, and negative predictive value 54.8%), and a vascular perfusion pattern was highly predictive of ischemic stroke (sensitivity 94.8%, specificity 92.7%, positive predictive value 88.7%, and negative predictive value 96.7%). The 3 patients with ischemic stroke without a vascular perfusion pattern fully recovered at discharge.
Conclusions
CTP has prognostic value in the workup of patients with acute isolated aphasia. A nonvascular pattern is associated with higher odds of full recovery and may prompt the search for alternative causes of the symptoms.



Stroke: 19 Jul 2020:STROKEAHA120028821; epub ahead of print
Rudilosso S, Rodríguez A, Amaro S, Obach V, ... Urra X, Chamorro Á
Stroke: 19 Jul 2020:STROKEAHA120028821; epub ahead of print | PMID: 32684143
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Abstract

Left ventricular myocardial deformation as measure of hemodynamic burden in congenital valvular aortic stenosis.

Reddy SC, Zhang J, Jani V, Wolfe SB, ... Kutty S, Pignatelli RH
Background
Changes in 2D echocardiography (2DE) speckle tracking imaging (STI) derived left ventricular (LV) strain (S) and strain rate (SR) precedes diminution of LV ejection fraction (LVEF) in adult valvular aortic stenosis (AS). We prospectively examined whether 2DE-STI derived multidirectional LV S and SR correlate with AS severity in children using LV mass index (MI) as the principal outcome variable.
Methods
52 children (10.4 ± 7.3 years) with isolated congenital AS were included; 13 mild (2.5 m/s < V < 3.0 m/s), 25 moderate (3.0 m/s < V < 4.0 m/s), and 14 severe (V > 4.0 m/s). 2DE including Doppler and STI longitudinal strain (LS), strain rate (LSR), circumferential strain (CS), and strain rate (CSR) were measured. Univariate and multivariable linear regressions identified correlations between LVMI and strain indices.
Results
Three clinical and 2DE variables, and four strain indices were independently associated with LVMI. LVMI correlated positively with systolic blood pressure and aortic regurgitation, and negatively with LVEF. LVMI correlated positively with LSR (four-chamber) and CSR (basal), and negatively with segmental CS in the inferior (basal) and anteroseptal (distal) segments. LVMI showed significant inverse association with GLS (P = .05), GLSR (P < .001), CS (P < .005), CSR (P < .0001), RSR (P < .001), independent of AS severity.
Conclusions
Independent of clinical and 2DE findings including contemporaneous Doppler estimates of AS gradient, both longitudinal and circumferential strain indices correlate with LVMI as a measure of cumulative hemodynamic burden. This association implies subclinical LV dysfunction.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 13 Jul 2020; epub ahead of print
Reddy SC, Zhang J, Jani V, Wolfe SB, ... Kutty S, Pignatelli RH
Int J Cardiol: 13 Jul 2020; epub ahead of print | PMID: 32679139
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Abstract

Prevalence and Outcome of Potential Candidates for Left Atrial Appendage Closure After Stroke With Atrial Fibrillation: WATCH-AF Registry.

Ong E, Meseguer E, Guidoux C, Lavallée PC, ... Nighoghossian N, Amarenco P
Background and purpose
As a result of contraindications (eg, frailty, cognitive impairment, comorbidities) or patient refusal, many patients with stroke and atrial fibrillation cannot be discharged on oral anticoagulant. Among them, the proportion of potential candidates for left atrial appendage closure (LAAC) and their 12-month outcome is not well known.
Methods
The prospective WATCH-AF registry (Warfarin Aspirin Ten-A Inhibitors and Cerebral Infarction and Hemorrhage and Atrial Fibrillation) enrolled consecutive patients admitted within 72 hours of an acute stroke associated with atrial fibrillation in 2 stroke centers. Scales to evaluate stroke severity, disability, functional independence, risk of fall, cognition, ischemic and hemorrhagic risk-stratification, and comorbidities were systematically collected at admission, discharge, 3, 12 months poststroke. The 2 main end points were death or dependency (modified Rankin Scale score >3) and recurrent stroke (brain infarction and brain hemorrhage).
Results
Among 400 enrolled patients (370 with brain infarction, 30 with brain hemorrhage), 31 died before discharge and 57 (14.3%) were possible European Heart Rhythm Association/European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Rhythm Society candidates for LAAC. At 12 months, the rate of death or dependency was 17.9%, and the rate of stroke recurrence was 9.8% in the 274/400 (68.5%) patients discharged on a long-term oral anticoagulant strategy, as compared with 17.5% and 24.7%, respectively, in 57 patients candidate for LAAC. As compared with patients on a long-term oral anticoagulant strategy, there was a 2-fold increase in the risk of stroke recurrence in the group with an indication for LAAC (adjusted hazard ratio, 2.58 [95% CI, 1.40-4.76]; P=0.002).
Conclusions
Fourteen percent of patients with stroke associated with atrial fibrillation were potential candidates for LAAC. The 12-month stroke risk of these candidates was 3-fold the risk of anticoagulated patients.



Stroke: 08 Jul 2020:STROKEAHA120029267; epub ahead of print
Ong E, Meseguer E, Guidoux C, Lavallée PC, ... Nighoghossian N, Amarenco P
Stroke: 08 Jul 2020:STROKEAHA120029267; epub ahead of print | PMID: 32640939
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Abstract

Accuracy of contrast-enhanced computed tomography for thrombus detection prior to atrial fibrillation ablation and role of novel Left Atrial Appendage Enhancement Index in appendage flow assessment.

Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Aims
To evaluate diagnostic accuracy of different protocols of contrast enhanced computed tomography venogram (CTV) for LAA thrombus detection in patients undergoing AF ablation and study the correlation of the novel LAA enhancement index (LAA-EI) to LAA flow velocity obtained using transesophageal echocardiography (TEE).
Methods
Study comprised of patients undergoing CTV and TEE on the same day from October 2016 to December 2017. Three CTV scanning protocols (described in results), were evaluated wherein ECG gating was used only for those with sinus rhythm on day of CTV. LAA-EI was calculated as Hounsfield Unit (HU) in the LAA divided by the HU unit in the center of the LA. The diagnostic accuracy for CTV was calculated in comparison to TEE. The LAA-EI was compared to LAA emptying velocities as obtained from TEE.
Results
590 patients with 45.6% non-ECG-gated without delayed imaging, 26.9% non-ECG-gated with delayed imaging and 27.5% ECG-gated with delayed imaging, were included in the study. All three protocols had 100% negative predictive value with improvement in specificity from 61.8% to 98.1% upon adding delayed imaging. The LAA-EI correlated significantly with reduced LAA flow velocities (r = 0.45, p < .0001). The mean LAA emptying velocity in patients with LAA-EI of ≤ 0.6 was significantly lower than in those with LAA-EI of >0.6 (36.2 cm/s [95% CI: 32.6-39.7] vs, (58 cm/s [95% CI 55.3-60.8]), respectively (p < .0001).
Conclusion
CTV with delayed imaging (with or without ECG gating) is highly specific in ruling out LAA thrombus. The novel LAA-EI can detect low LAA flow velocities.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 02 Jul 2020; epub ahead of print
Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Int J Cardiol: 02 Jul 2020; epub ahead of print | PMID: 32629004
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Abstract

Volume-Outcome Association of Mitral Valve Surgery in the United States.

Badhwar V, Vemulapalli S, Mack MA, Gillinov AM, ... Gammie JS, Shahian DM
Importance
Early surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking.
Objective
To assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation.
Design, setting, and participants
This multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services.
Main outcomes and measures
The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure.
Results
A total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50).
Conclusions and relevance
National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.



JAMA Cardiol: 30 Jun 2020; epub ahead of print
Badhwar V, Vemulapalli S, Mack MA, Gillinov AM, ... Gammie JS, Shahian DM
JAMA Cardiol: 30 Jun 2020; epub ahead of print | PMID: 32609292
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Abstract

Transluminal attenuation gradient derived from coronary CT angiography to predict ischemia in SPECT myocardial perfusion imaging: Effect of coronary cross-sectional area.

von Felten E, Benz DC, Benetos G, Giannopoulos AA, ... Kaufmann PA, Pazhenkottil AP
Background
Coronary computed tomography angiography (CCTA)-based transluminal attenuation gradient (TAG) was suggested to determine the functional significance of a stenosis. However, evidence that TAG acquired by wide-volume scanners can assess the hemodynamic significance of stenosis assessed by single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is lacking. Moreover, coronary cross-sectional area may influence TAG. Hence, we aimed at assessing the diagnostic value of TAG to predict ischemia in SPECT-MPI and the correlation between TAG and the transluminal cross-sectional area gradient (TCG).
Methods
Patients undergoing CCTA and SPECT-MPI for suspected coronary artery disease were included. TAG and TCG were calculated measuring the mean vessel attenuation and the cross-sectional area along major coronary vessels at 5-mm intervals.
Results
A total of 255 coronary arteries of 87 patients were included. TAG and TCG did not discriminate between coronary arteries with or without ischemia as assessed by SPECT-MPI (p = .44 and p = .25, respectively). The area under the curve to predict ischemia was not increased by adding TAG (0.88, 95% CI 0.83-0.92) or TCG (0.87, 95% CI 0.81-0.90) to CCTA alone (0.85, 95% CI 0.80-0.89). There was a significant correlation between TAG and TCG (r = 0.43; p < .001).
Conclusions
CCTA-derived TAG and TCG do not offer any value in predicting ischemia assessed by SPECT-MPI. TAG is partly affected by differences in the coronary luminal area.



J Nucl Cardiol: 30 Jun 2020; epub ahead of print
von Felten E, Benz DC, Benetos G, Giannopoulos AA, ... Kaufmann PA, Pazhenkottil AP
J Nucl Cardiol: 30 Jun 2020; epub ahead of print | PMID: 32613474
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Abstract

Improvement of the prognosis assessment of severe tricuspid regurgitation by the use of a five-grade classification of severity.

Peugnet F, Bohbot Y, Chadha G, Delpierre Q, ... Beyls C, Tribouilloy C

It is well known that some patients present with \"more than severe\" tricuspid regurgitation (TR). We aimed to assess the prognosis of these very severe TR patients. We defined very severe TR using 3 simple echocardiographic parameters: a coaptation gap≥10mm, a laminar TR flow and a systolic reversal of the hepatic vein flow. We included 259 consecutive patients (76 ± 13 years; 46% men) with moderate-to-severe TR (n = 114) and severe TR (n = 145). The primary end point was the combination of hospitalisation for right heart failure (RHF) and cardiovascular mortality. Median follow-up was 24(7 to 47) months. In patients with severe TR, 52 (36%) met the definition of very severe TR. These patients were younger, had more history of RHF and were more frequently treated with loop diuretics than those with moderate-to-severe TR (all p < 0.001). Four-year event-free survival rates were 68 ± 5%, for moderate-to-severe TR, 48 ± 6% for severe TR and only 35 ± 7% for very-severe TR (p < 0.001). On multivariable analysis, after adjustment for outcome predictors including age, comorbidity, RHF, TR etiology, left and right ventricular dysfunction, and tricuspid valve surgery, patients with very severe TR had a worsened prognosis than those with moderate-to-severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.43 [1.18 to 5.53]; p = 0.002) and than those with severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.23 [1.06 to 5.56]; p = 0.015). In conclusion, very severe TR is frequent in patients with severe TR, corresponds to a more advanced stage of the disease and is associated with poor outcomes. Therefore, the use of a 5-grade classification of TR severity is justified in routine clinical practice. (ID-RCB: 2017-A03233-50).

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 29 Jun 2020; epub ahead of print
Peugnet F, Bohbot Y, Chadha G, Delpierre Q, ... Beyls C, Tribouilloy C
Am J Cardiol: 29 Jun 2020; epub ahead of print | PMID: 32741538
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Abstract

Redefining Adverse and Reverse Left Ventricular Remodeling by Cardiovascular Magnetic Resonance Following ST-Segment-Elevation Myocardial Infarction and Their Implications on Long-Term Prognosis.

Bulluck H, Carberry J, Carrick D, McEntegart M, ... Oldroyd KG, Berry C
Background
Cut off values for change in left ventricular end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) by cardiovascular magnetic resonance following ST-segment-elevation myocardial infarction have recently been proposed and 4 patterns of LV remodeling were described. We aimed to assess their long-term prognostic significance.
Methods
A prospective cohort of unselected patients with ST-segment-elevation myocardial infarction with paired acute and 6-month cardiovascular magnetic resonance, with the 5-year composite end point of all-cause death and hospitalization for heart failure was included. The prognosis of the following groups (group 1: reverse LV remodeling [≥12% decrease in LVESV]; group 2: no LV remodeling [changes in LVEDV and LVESV <12%]; group 3: adverse LV remodeling with compensation [≥12% increase in LVEDV only]; and group 4: adverse LV remodeling [≥12% increase in both LVESV and LVEDV]) was compared.
Results
Two hundred eighty-five patients were included with a median follow-up was 5.8 years. The composite end point occurred in 9.5% in group 1, 12.3% in group 2, 7.1% in group 3, and 24.2% in group 4. Group 4 had significantly higher cumulative event rates of the composite end point (log-rank test, =0.03) with the other 3 groups showing similar cumulative event rates (log-rank test, =0.51). Cox proportional hazard for group 2 (hazard ratio, 1.3 [95% CI, 0.6-3.1], =0.53) and group 3 (hazard ratio, 0.6 [95% CI, 0.2-2.3], =0.49) were not significantly different but was significantly higher in group 4 (hazard ratio, 3.0 [95% CI, 1.2-7.1], =0.015) when compared with group 1.
Conclusions
Patients with ST-segment-elevation myocardial infarction developing adverse LV remodeling at 6 months, defined as ≥12% increase in both LVESV and LVEDV by cardiovascular magnetic resonance, was associated with worse long-term clinical outcomes than those with adverse LV remodeling with compensation, reverse LV remodeling, and no LV remodeling, with the latter 3 groups having similar outcomes in a cohort of stable reperfused patients with ST-segment-elevation myocardial infarction. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02072850.



Circ Cardiovasc Imaging: 29 Jun 2020; 13:e009937
Bulluck H, Carberry J, Carrick D, McEntegart M, ... Oldroyd KG, Berry C
Circ Cardiovasc Imaging: 29 Jun 2020; 13:e009937 | PMID: 32689822
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This program is still in alpha version.