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Sep 30, 2009

Prognostic value of adenosine stress cardiovascular magnetic resonance in patients with low-risk chest pain

Stamatios Lerakis , Dalton S McLean , Athanasios V Anadiotis , Matthew Janik , John N Oshinski , Nikolaos Alexopoulos , Elisa Zaragoza-Macias , Emir Veledar and Arthur E Stillman


Background
Approximately 5% of patients with an acute coronary syndrome are discharged from the emergency room with an erroneous diagnosis of non-cardiac chest pain. Highly accurate non-invasive stress imaging is valuable for assessment of low-risk chest pain patients to prevent these errors. Adenosine stress cardiovascular magnetic resonance (AS-CMR) is an imaging modality with increasing application. The goal of this study was to evaluate the negative prognostic value of AS-CMR among low-risk acute chest pain patients.
Methods
We studied 103 patients, mean 56.7+/-12.3 years of age, with chest pain and no electrocardiographic evidence of ischemia and negative cardiac biomarkers of necrosis, who were admitted to the Cardiac Decision Unit of our institution. All patients underwent AS-CMR. A negative AS-CMR was defined as absence of all the following: regional wall motion abnormalities at rest; perfusion defects during stress (adenosine) and rest; and myocardial scar on late gadolinium enhancement images. The patients were followed for a mean of 277 (range 161-462) days. The primary end point was defined as the combination of cardiac death, nonfatal acute myocardial infarction, re-hospitalization for chest pain, obstructive coronary artery disease (>50% coronary stenosis on invasive angiography) and coronary revascularization.
Results
In 14 patients (13.6%), AS-CMR was positive. The remaining 89 patients (86.4%), who had negative AS-CMR, were discharged. No patient with negative AS-CMR reached the primary end-point during follow-up. The negative predictive value of AS-CMR was 100%.
Conclusions
AS-CMR holds promise as a useful tool to rule out significant coronary artery disease in patients with low-risk chest pain. Patients with negative AS-CMR have an excellent short and mid-term prognosis.
Journal of Cardiovascular Magnetic Resonance 2009, 11:37.

Sep 21, 2009

Magnetic resonance investigations in Brugada syndrome reveal unexpectedly high rate of structural abnormalities
Oronzo Catalano,*, Serena Antonaci, Guido Moro, Maria Mussida1, Mauro Frascaroli, Maurizia Baldi2, Franco Cobelli, Paola Baiardi, Janni Nastoli, Raffaella Bloise, Nicola Monteforte, Carlo Napolitano and Silvia G. Priori.
Aims: Recent data suggest that sub-clinical structural abnormalities may be part of the Brugada syndrome (BrS) phenotype, a disease traditionally thought to occur in the structurally normal heart. In this study, we carried out detailed assessment of cardiac morphology and function using cardiac magnetic resonance imaging (CMRI).
Methods and results: Thirty consecutive patients with BrS were compared with 30 sex- (26/4 male/female), body surface area- (±0.2 m2), and age-matched (±5 years) normal volunteers. CMRI exam included long- and short-axis ECG-gated breath-hold morphological T1-TSE sequences for fatty infiltration and cine-SSFP sequences for kinetic assessment. Fatty infiltration was not found in any subject. Patients with BrS compared with normal subjects showed higher incidence of mild right ventricle (RV) wall-motion abnormalities [15 (50%) vs. 5 (17%) subjects (P = 0.006) with reduced radial fractional shortening in more than two segments], reduction of outflow tract ejection fraction (49 ± 11% vs. 55 ± 10%; P = 0.032), enlargement of the inflow tract diameter (46 ± 4 vs. 41 ± 5 mm, P < 0.001 in short-axis; 46 ± 4 vs. 42 ± 5 mm, P = 0.001 in four-chamber long-axis view) and area (22 ± 2 vs. 20 ± 3 cm2; P = 0.050), and of global RV end-systolic volume (34 ± 10 vs. 30 ± 6 mL/m2; P = 0.031) but comparable outflow tract dimensions, global RV end-diastolic volume, left ventricle parameters, and atria areas.
Conclusion: CMRI detects a high prevalence of mild structural changes of the RV, and suggests further pathophysiological complexity in BrS. Prospective studies to assess the long-term evolution of such abnormalities are warranted.
Key Words: Brugada syndrome • Cardiac magnetic resonance imaging • Sudden cardiac death • SCN5A.

European Heart Journal 2009 30(18):2241-2248
Prediction of All-Cause Mortality From Global Longitudinal Speckle Strain
Comparison With Ejection Fraction and Wall Motion Scoring
Tony Stanton, MBChB, PhD; Rodel Leano, BS and Thomas H. Marwick, MBBS, PhD
From the School of Medicine, University of Queensland, Brisbane, Australia.

Background— Although global left ventricular systolic function is an important determinant of mortality, standard measures such as ejection fraction (EF) and wall motion score index (WMSI) have important technical limitations. The aim of this study was to compare global longitudinal speckle strain (GLS), an automated technique for measurement of long-axis function, with EF and WMSI for the prediction of mortality.
Methods and Results— Of 546 consecutive individuals undergoing echocardiography for assessment of resting left ventricular function, 91 died over a period of 5.2±1.5 years. In addition to Simpson biplane EF, WMSI was determined by 2 experienced readers and GLS was calculated from 3 standard apical views using 2D speckle tracking. The incremental value of EF, WMSI, and GLS to significant clinical variables was assessed in nested Cox models. Clinical factors associated with outcome (model 2=20.2) were age (hazard ratio [HR], 1.46; P<0.01), p="0.01)," p="0.03)" 2="34.9,">35% and those with and without wall motion abnormalities. A GLS –12% was found to be equivalent to an EF 35% for the prediction of prognosis. Intraobserver and interobserver variations for EF and GLS were similar.
Conclusions— GLS is a superior predictor of outcome to either EF or WMSI and may become the optimal method for assessment of global left ventricular systolic function.
Key Words: echocardiography • ventricular function • strain • mortality

Circ Cardiovasc Imaging.2009; 2: 353-355 .
Accuracy of Cardiac Magnetic Resonance of Absolute Myocardial Blood Flow With a High-Field System
Comparison With Conventional Field Strength

Timothy F. Christian, MD*,*, Stephen P. Bell, BS*, Lawrence Whitesell, BS, Michael Jerosch-Herold, PhD
Objectives: The aim of this study was to determine the accuracy of cardiac magnetic resonance (CMR) first pass (FP) perfusion measures of absolute myocardial blood flow (MBF) with a 3.0-T magnet and compare these measures with FP perfusion at 1.5-T with absolute MBF by labeled microspheres as the gold standard.
Background: First-pass magnetic resonance (MR) myocardial perfusion imaging can quantify MBF, but images are of low signal at conventional magnetic field strength due to the need for rapid acquisition.
Methods: A pig model was used to alter MBF in a coronary artery during FP CMR (intracoronary adenosine followed by ischemia). This produces an active zone with a range of MBF and a control zone. Microspheres were injected into the left atrium with concurrent reference sampling. FP MR perfusion imaging was performed at 1.5-T (n = 9) or 3.0-T (n = 8) with a saturation-recovery gradient echo sequence in short-axis slices during a bolus injection of 0.025 mmol/kg gadolinium–diethylenetriamine pentaacetic acid. Fermi function deconvolution was performed on active and control region of interest from short-axis slices with an arterial input function derived from the left ventricular cavity. These MR values of MBF were matched to microsphere values obtained from short-axis slices at pathology.
Results: Occlusion MBF was 0.21 ± 0.26 ml/min/g, adenosine MBF was 2.28 ± 0.99 ml/min/g, and control zone MBF was 0.70 ± 0.22 ml/min/g. The correlation of MR FP CMR with microsphere was close for both field strengths: 3.0-T, r = 0.98, p < 0.0001 and 1.5-T, r = 0.95, p < 0.0001. The 95% confidence limits of agreement were slightly narrower at 3.0-T (3.0-T = 0.49 ml/min/g, 1.5-T = 0.68 ml/min/g, p < 0.05). The FP CMR image characteristics were better at 3.0-T (noise and contrast enhancement were both superior at 3.0-T). In myocardial zones where MBF <0.50 ml/min/g, the correlation with microspheres was closer at 3.0-T (r = 0.55 at 1.5-T, r = 0.85 at 3.0-T).
Conclusions: Absolute MBF by FP perfusion imaging is accurate at both 1.5- and 3.0-T. Signal quality is better at 3.0-T, which might confer a benefit for estimating MBF in ischemic zones.

Key Words: cardiac imaging • CMR • coronary flow reserve • ischemia • myocardial perfusion
J Am Coll Cardiol Img, 2009; 2:1103-1110.

Sep 20, 2009

Will you care for a free Windows CMR Software?



For those of us who need a good CMR software for non commercial uses, a nice pick is Segment. It provides most of the features found in full fledged commercial packages and is upgraded many times a year. Thanks to Einar Heiberg at the Cardiac MR group, at Lund University, Sweden.

http://segment.heiberg.se/index.htm

Sep 17, 2009

Regadenason review


I have followed the work on this new agent in the last few years. I tried to test it in CMR perfusion but the company refused it initially. It was only tested with nuclear MPI. On a critical view: the symptoms are about the same as adenosine (ok, there is a statistical difference but I believe clinically irrelevant) but the ease of use really is something to cheer. It would fit CMR very nicely: one single bolus, no weight ajustement, short duration in minutes.

However, as it is, the price is almost prohibitive and it is not approved in all countries yet (at least not in Brazil so far).

If the prices go down (and there are 2 competitors coming along), maybe it will be useful. Otherwise, good old dipyridamole will continue ruling.

What a difference by what was reported in JACC


The results are not so optimistic as the latest article. The impact of CMR in our practices are not as wide as we think. More, much more work is needed.

Braziliam team looks at MDE in PH

A very well written article by a Brazilian team. Congratulations!

Br J Radiol. 2009 Apr 27. [Epub ahead of print]

Myocardial delayed enhancement in patients with pulmonary hypertension and right ventricular failure: evaluation by cardiac MRI.
Junqueira FP, Filho RM, Coutinho AC, Loureiro R, DE Pontes PV, Domingues RC, Dro Gasparetto EL.

Clinics Multi-Imagem, 2Clínica de Diagnóstico Por Imagem and 3Department of Radiology, University of Rio de Janeiro, Rio de Janeiro, Brazil.
In this study we evaluated patients with pulmonary arterial hypertension (PAH) and impaired right ventricular function. We used cardiac MRI for the detection of myocardial delayed enhancement (MDE) and its possible association with other clinical variables. 20 patients (6 males and 14 females, aged 44.5+/-11 years; 15 New York Heart Association class III, 5 class IV) with known PAH (13 idiopathic, 7 resulting from chronic pulmonary embolism) were evaluated for the detection of MDE. Short-axis cine images of the heart were made for ventricular function assessment using a steady-state free precession sequence. For MDE evaluation, a short-axis phase-sensitive inversion recovery sequence was performed 10 min after intravenous administration of 0.2 mmol kg(-1) gadodiamide. Right ventricle (RV) systolic dysfunction, RV enlargement and RV hypertrophy were present in 20 patients (RV ejection fraction, 21.5+/-7.2 %; RV diastolic diameter, 5.97+/-0.79 cm; RV wall thickness, 0.73+/-0.10 cm). 13 of the 20 patients (65%) were positive for MDE (10 anterior, 12 inferior). All 13 positive patients with MDE demonstrated small hyperintense areas at the insertion points of the RV free wall in the interventricular septum. We found no significant correlation between MDE and ejection fraction or other haemodynamic variables. In this study MDE correlated positively only with the duration of disease. We found that septal MDE can be present in patients with PAH and impaired ventricular function. However, further studies are necessary to investigate this possible association and its prognostic implication.

Sep 8, 2009

A trial to watch for


This will answer very important questions partially responded by MR-Impact. Let's eagerly wait for its results.

Trials. 2009 Jul 29;10:62.Click here to read Links
Clinical evaluation of magnetic resonance imaging in coronary heart disease: the CE-MARC study.
Greenwood JP, Maredia N, Radjenovic A, Brown JM, Nixon J, Farrin AJ, Dickinson C, Younger JF, Ridgway JP, Sculpher M, Ball SG, Plein S.

Division of Cardiovascular and Neuronal Remodelling, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds General Infirmary, Leeds, LS1 3EX, UK. j.greenwood@leeds.ac.uk

BACKGROUND: Several investigations are currently available to establish the diagnosis of coronary heart disease (CHD). Of these, cardiovascular magnetic resonance (CMR) offers the greatest information from a single test, allowing the assessment of myocardial function, perfusion, viability and coronary artery anatomy. However, data from large scale studies that prospectively evaluate the diagnostic accuracy of multi-parametric CMR for the detection of CHD in unselected populations are lacking, and there are few data on the performance of CMR compared with current diagnostic tests, its prognostic value and cost-effectiveness. METHODS/DESIGN: This is a prospective diagnostic accuracy cohort study of 750 patients referred to a cardiologist with suspected CHD. Exercise tolerance testing (ETT) will be preformed if patients are physically able. Recruited patients will then undergo CMR and single photon emission tomography (SPECT) followed in all patients by invasive X-ray coronary angiography. The order of the CMR and SPECT tests will be randomised. The CMR study will comprise rest and adenosine stress perfusion, cine imaging, late gadolinium enhancement and whole-heart MR coronary angiography. SPECT will use a gated stress/rest protocol. The primary objective of the study is to determine the diagnostic accuracy of CMR in detecting significant coronary stenosis, as defined by X-ray coronary angiography. Secondary objectives include an assessment of the prognostic value of CMR imaging, a comparison of its diagnostic accuracy against SPECT and ETT, and an assessment of cost-effectiveness. DISCUSSION: The CE-MARC study is a prospective, diagnostic accuracy cohort study of 750 patients assessing the performance of a multi-parametric CMR study in detecting CHD using invasive X-ray coronary angiography as the reference standard and comparing it with ETT and SPECT. TRIAL REGISTRATION: Current Controlled Trials ISRCTN77246133.

Sep 7, 2009

Location of LGE gives more information on non-ischaemic dilated cardiomyopathy

A difference between mid and epicardial LGE was found giving more prognostic information in non-ischaemic dilated cardiomyopathy.

Eur J Heart Fail. 2009 Jun;11(6):573-80. Epub 2009 Apr 21.

Patterns of late gadolinium enhancement are associated with ventricular stiffness in patients with advanced non-ischaemic dilated cardiomyopathy.
Choi EY, Choi BW, Kim SA, Rhee SJ, Shim CY, Kim YJ, Kang SM, Ha JW, Chung N.

Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Shinchon-dong 134, Seoul, South Korea 120-752.

AIMS: Despite the prognostic importance of ventricular filling and ventricular-arterial interaction in patients with advanced systolic heart failure, the structural determinants of these parameters have not been fully studied. We aimed to investigate whether patterns of late gadolinium enhancement (LGE) on cardiac magnetic resonance affect ventricular elastic properties or performance in patients with non-ischaemic dilated cardiomyopathy (DCM). METHODS AND RESULTS: Patients (n = 49) with markedly reduced systolic function (left ventricular (LV) ejection fraction <35%) due to longstanding non-ischaemic DCM underwent contrast-enhanced cardiac magnetic resonance after comprehensive echo-Doppler evaluations. The single beat-derived end-diastolic elastance, end-systolic elastance, arterial elastance, and dyssynchrony indices were measured by echo. On the basis of LGE patterns, patients could be divided into three groups: non-LGE (n = 18), non-midwall LGE (n = 13), and midwall LGE (n = 18). The midwall LGE group had lower LV systolic longitudinal velocity (4.6 +/- 1.7 for non-LGE vs. 4.3 +/- 1.2 for non-midwall LGE vs. 3.5 +/- 1.0 cm/s for midwall LGE, P = 0.025), higher end-diastolic elastance index (0.41 +/- 0.21 vs. 0.46 +/- 0.31 vs. 0.85 +/- 0.51 respectively, P = 0.008), and a more impaired ventriculoarterial coupling index (3.14 +/- 1.53 vs. 2.88 +/- 1.94 vs. 5.52 +/- 3.18, P = 0.006) than other subgroups. CONCLUSION: Patients with midwall LGE had a higher ventricular stiffness index and more impaired ventriculoarterial coupling when compared with other non-ischaemic DCM patients.

Sep 2, 2009


The Value of Cardiac Magnetic Resonance in
Patients With Acute Coronary Syndrome and
Normal Coronary Arteries


Introduction and objectives. A number of different conditions can present with symptoms similar to acute coronary syndrome (ACS): chest pain, electrocardiographic changes and elevated levels of markers of myocardial damage. Even after coronary angiography has been performed, differential diagnosis can be challenging. The aim of this study was to evaluate the usefulness of cardiacmagnetic resonance (CMR) for diagnosing conditions that present like ACS but in which the coronary arteries are normal.
Methods. The study involved 80 patients with suspected ACS and normal coronary arteries. Their mean age was 48±15 years and their mean troponin-T (TnT) level was 1.8±0.9 ng/ml. A CMR study, which involved T2- weighted imaging to detect edema and delayed contrastenhancement (DCE) imaging 10 minutes after gadolinium administration, was performed.
Results. In 51 patients (63%), the final diagnosis was acute myocarditis. In all these cases, DCE was observed in subepicardial and middle segments of the myocardium. The final diagnosis was acute myocardial infarction in 12 patients (15%), all of whom exhibited subendocardial or transmural DCE. In the 9 (11%) who exhibited abnormal contractility on baseline echocardiography with subsequent normalization, CMR did not show DCE, a finding that is characteristic of Takotsubo cardiomyopathy. In addition, 4 patients had a final diagnosis of pericarditis, while no diagnosis could be established in another 4.
Conclusions. The clinical presentation of acute myocarditis and Takotsubo syndrome can be similar to that of ACS. The presence and distribution of DCE on CMR are of great help in establishing a diagnosis.
Key words: Cardiac magnetic resonance. Myocarditis. Acute coronary syndrome. Takotsubo.
Rev Esp Cardiol. 2009;62(9):976-83

Sep 1, 2009

Congreso virtual de Cardiología!!!

"Estimados amigos del foro, los invito a participar del 6to Congreso Virtual de Cardiología de la Federación Argentina de Cardiología (FAC). Es totalmente gratuito. Pueden enviar trabajos o particiar en las mesas de discusión con panelistas de primer nuvel internacional."

VI Congreso Internacional de Cardiología por Internet
1ro. de Septiembre al 30 de Noviembre de 2009

Declarado de Interés Nacional
Res. Nº Res. Nº 363 - 361 - 04/2009
Presidencia de la Nación - Ministerio de Salud de la Nación Argentina.

Comienza hoy..


www.fac.org.ar/6cvc

Si aún no lo ha hecho, lo invitamos a inscribirse y a interactuar con los conferencistas y autores a través de los Foros de Discusión, donde los mensajes contarán con traducción.

Principales temas que se abordarán:

Cardiopatía Isquémica – RCP – Síndrome Metabólico – Dislipemias – Insuficiencia Cardíaca – Arritmias – Dispositivos electrónicos para el tratamiento de trastornos de la conducción – Enfermedad de Chagas – Hipertrofia ventricular – Investigación Clínica – HTA – Cirugía de revascularización – Angioplastia – Prótesis Endoluminales

Speakers internacionales que participarán en esta edición:

Dr. Paul A. Levine (EEUU); Dr. Adrian Baranchuk (EEUU); Dr. Andrés Ricardo Pérez Riera (Brasil); Dr. Jose Carlos Pachon (Brasil); Dr. Juan Carlos Chachques (Francia); Dr. Josep Brugada (España); Dr. Robert M. Lang (EEUU); Dr. Arturo Evangelista (España); Dr. Wilson Mathias (Brasil); Dr. James K. McCord (EEUU); Dr. Xavier Bosch (España); Dr. Michael A. Ross (EEUU); Dr. Juan José Badimon (EEUU); Dr. Richard D. Hurt (EEUU).

Idiomas oficiales: español, portugués e inglés

Programa científico: tendrá Unidades Temáticas que incluirán más de 250 conferencias a cargo de invitados especiales. Se desarrollarán simposios, ateneos, controversias, discusión de casos, cursos y presentación de trabajos de investigación.
Los participantes tendrán la posibilidad de acceder a audio y diapositivas de las sesiones más destacadas del CNC 2009, por ejemplo:

Más información: www.fac.org.ar/6cvc / 6cvc@fac.org.ar