Objectives The aim of the study was to determine whether longitudinal left ventricular (LV) function provides prognostic information in a large cohort of patients with systemic light-chain (AL) ...amyloidosis. Background AL amyloidosis is associated with a high incidence of cardiovascular events. Reduced myocardial longitudinal function is one of the hallmarks of myocardial involvement in this rare disease. Methods Two hundred six consecutive patients with biopsy-proven AL amyloidosis were investigated in this prospective observational study. Echocardiographic imaging parameters, mean tissue Doppler-derived longitudinal strain (LS), and two-dimensional global longitudinal strain (2D-GLS) of the LV, cardiac serological biomarkers, and comprehensive clinical disease characteristics were assessed. The primary endpoint was all-cause mortality or heart transplantation. Results After a median follow-up of 1207 days, LS and 2D-GLS were significant predictors of survival in AL amyloidosis. The cutoff values discriminating survivors from nonsurvivors were −10.65% for LS and −11.78% for 2D-GLS. In a multivariable echocardiographic Cox model, only diastolic dysfunction and 2D-GLS remained as independent predictors of survival. In comprehensive clinical models, 2D-GLS (p < 0.0001), diastolic dysfunction (p < 0.01), the pathologic free light chains (p < 0.05), cardiac troponin-T (cTnT) (p < 0.01), and the Karnofsky index (p < 0.001) remained as independent predictors. 2D-GLS delineated a superior prognostic value compared with that derived from pathologic free light chains or cTnT in patients evaluated before firstline chemotherapy (n = 113; p < 0.0001), and remained the only independent predictor besides the Karnofsky index in subjects with preserved LV ejection fraction (≥50%; n = 127; p < 0.01). LS and 2D-GLS both offered significant incremental information (p < 0.001) for the assessment of outcome compared with clinical variables (age, Karnofsky index, and New York Heart Association functional class) and serological biomarkers. Conclusions In the largest serial investigation reported so far, reduced LV longitudinal function served as an independent predictor of survival in AL amyloidosis and offered incremental information beyond standard clinical and serological parameters.
Abstract Objectives This study sought to evaluate myocardial perfusion reserve index (MPRI) and diastolic strain rate, both assessed by cardiac magnetic resonance (CMR) as a noninvasive tool for the ...detection of microvasculopathy. Background Long-term survival of cardiac allograft recipients is limited primarily by cancer and cardiac allograft vasculopathy (CAV). Besides epicardial CAV, diagnosed by coronary angiography, stenotic microvasculopathy was found to be an additional independent risk factor for survival after heart transplantation. Methods Sixty-three consecutive heart transplant recipients who underwent CMR, coronary angiography, and myocardial biopsy were enrolled. Stenotic vasculopathy in microvessels was considered in myocardial biopsies by immunohistochemistry and CAV was graded during coronary angiography according to International Society of Heart and Lung Transplantation criteria. In addition, by CMR microvasculopathy was assessed by myocardial perfusion reserve during pharmacologic hyperemia with adenosine and strain-encoded magnetic resonance using a modified spatial modulation of magnetization tagging pulse sequence in all patients. Results Decreasing MPRI and diastolic strain rates were observed in patients with decreasing microvessel luminal radius to wall thickness ratio and decreasing capillary density ( r = 0.45 and r = 0.61 for MPRI and r = 0.50 and r = 0.38 for diastolic strain rate, respectively; p < 0.005 for all). Using multivariable analysis, both MPRI and diastolic strain rate were robust predictors of stenotic microvasculopathy, independent of age, organ age, and CAV by International Society of Heart and Lung Transplantation criteria (hazard ratio: 0.07, p = 0.006 for MPRI; hazard ratio: 0.91, p = 0.002 for diastolic strain rate). Patients without stenotic microvasculopathy in the presence of no or mild CAV (n = 36) exhibited significantly higher median survival free of events, compared with patients with stenotic microvasculopathy in the presence of no or mild CAV (n = 18; p = 0.04 by log rank). Conclusions CMR represents a valuable noninvasive diagnostic tool, which may be used for the early detection of transplant microvasculopathy before the manifestation of CAV during surveillance coronary angiographic procedures.
Objectives This study evaluated the value of systolic and diastolic deformation indexes determined by strain-encoded imaging to predict persistent severe dysfunction at follow-up in patients after ...reperfused acute myocardial infarction (AMI) in comparison with late gadolinium enhancement (LGE). Background Animal studies suggest that regional diastolic function provides information about myocardial viability after AMI. However, data in humans are sparse. Methods Twenty-six patients underwent magnetic resonance imaging 3 ± 1 days after successfully reperfused ST-segment elevation myocardial infarction and at a follow-up of 6 months. Cine, strain-encoded, and LGE images were acquired. Peak systolic circumferential strain (Ecc ) and early diastolic strain rate (Ecc /s) were calculated for each segment at baseline and at follow-up. A cutoff Ecc value of −9% was used to define severe dysfunction at follow-up. Results A total of 312 segments were analyzed; 119 segments showed abnormal baseline function. Thirty-five segments showed severe dysfunction at follow-up, which was defined as Ecc at follow-up <9%. The area under the curve for Ecc /s was 0.82 (95% confidence interval CI: 0.72 to 0.89), for Ecc 0.74 (95% CI: 0.64 to 0.83), and for LGE 0.85 (95% CI: 0.77 to 0.92). A comparison of receiver-operating characteristic curves demonstrates that LGE is not significantly different than Ecc /s but is significantly different than Ecc (p = 0.32 vs. p < 0.05) for prediction of severe dysfunction at follow-up. Conclusions Regional diastolic function provides similar accuracy to predict persistent severe dysfunction at follow-up to LGE and is superior to regional systolic function in patients after AMI. Diastolic deformation indexes may serve as a new parameter for assessment of viability in patients after AMI. (SENC in AMI Study; NCT00752713 ).
Noninvasive Detection of Macrophage-Rich Atherosclerotic Plaque in Hyperlipidemic Rabbits Using “Positive Contrast” Magnetic Resonance Imaging Grigorios Korosoglou, Robert G. Weiss, Dorota A. ...Kedziorek, Piotr Walczak, Wesley D. Gilson, Michael Schär, David E. Sosnovik, Dara L. Kraitchman, Raymond C. Boston, Jeff W. M. Bulte, Ralph Weissleder, Matthias Stuber The purpose of our study was to identify macrophage-rich atherosclerotic plaque noninvasively by the combined use of monocrystalline iron-oxide nanoparticles (MION)-47 and inversion recovery with ON-resonant water suppression (IRON) magnetic resonance imaging (MRI). Experiments were conducted in 7 hyperlipidemic and 4 control rabbits, which received MION-47 and underwent serial IRON-MRI. After administration of MION-47, a striking signal enhancement was found in areas of plaque only in hyperlipidemic rabbits, which correlated with the number of macrophages determined by histology and allowed for the detection of macrophage-rich plaque with high accuracy. Thus, IRON-MRI is a promising approach for the noninvasive evaluation of atherosclerosis.
...hsTnT-orientated therapeutic strategies have not been implemented in the clinical realm so far. Possibly, and in light of the availability of a number of modern agents (including different P2Y12 ...inhibitors of different strengths, PCSK9 inhibitors with different low-density lipoprotein targets, high-density lipoprotein modifiers, and soluble receptor for advanced glycation endproducts modulating agents targeting vascular inflammation), cardiac biomarkers such as the hsTnT may present novel therapeutic targets in future interventional pharmacotherapy studies. ...patients with increased atherosclerotic burden, identified as high-risk candidates for future ACS, may undergo combined treatment with 1 or several of the above-mentioned agents.
To the Editor: In the present study we sought to investigate the predictive value of resting and inducible wall motion abnormalities (WMA) and of late gadolinium enhancement (LGE) for hard cardiac ...outcomes and for revascularization procedures in 3,138 patients undergoing dobutamine cardiac magnetic resonance (DCMR) in 2 tertiary centers (University Hospital Heidelberg; and German Heart Institute, Berlin) and during a long-term follow-up. Other events included clinically indicated revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Because the results of the magnetic resonance examination might have triggered revascularization procedures, patients with "early" revascularization procedures within 3 months after DCMR were censored.
Objectives This study sought to evaluate the diagnostic accuracy of strain-encoded cardiac magnetic resonance (SENC) for the detection of inducible ischemia during intermediate stress. Background ...High-dose dobutamine stress cardiac magnetic resonance (DS-CMR) is a well-established modality for the noninvasive detection of coronary artery disease (CAD). However, the assessment of cine scans relies on the visual interpretation of wall motion, which is subjective, and modalities that can objectively and quantitatively assess the time course of myocardial strain response during stress are lacking. Methods Stress-induced ischemia was assessed by wall motion analysis and by SENC in 80 patients with suspected or known CAD and in 18 healthy volunteers who underwent DS-CMR in a clinical 1.5-T scanner. Quantitative coronary angiography was used as the standard reference for the presence of CAD (≥50% diameter stenosis). Results On a patient level, 46 of 80 patients (58%) had CAD, including 20 with single-vessel, 18 with 2-vessel, and 8 with 3-vessel disease. During peak stress, SENC correctly detected ischemia in 45 versus 38 of 46 patients with CAD (7 additional correct findings for SENC), yielding significantly higher sensitivity than cine (98% vs. 83%, p < 0.05). No patients were correctly diagnosed by cine and missed by SENC. During intermediate stress, SENC showed diagnostic value similar to that provided by cine imaging only during peak dobutamine stress (sensitivity of 76% vs. 83%, specificity of 88% vs. 91%, and accuracy of 81% vs. 86%; p = NS for all). Quantification analysis demonstrated that strain rate response is a highly sensitive marker for the detection of inducible ischemia (area under the curve = 0.96; SE = 0.01; 95% confidence interval: 0.93 to 0.99) that precedes the development of inducible wall motion abnormalities and already significantly decreases with moderate 40% to 60% coronary lesions. Conclusions Using SENC, CAD can be detected during intermediate stress with similar accuracy to that provided by cine only during peak stress. By this approach, patient safety may be improved during diagnostic procedures within lower time spent (Strain-Encoded Cardiac Magnetic Resonance Imaging for Dobutamine Stress Testing; NCT00758654
Abstract Objectives The purpose of this study was to assess the potential of iterative image reconstruction (IR) of images for radiation dose reduction in coronary computed tomography angiography ...(CTA). Therefore, IR in combination with 30% tube current reduction was compared with standard scanning with filtered back projection (FBP) reconstruction. Background Lately, new IR techniques with advanced raw data processing have been introduced by different computed tomography vendors, thus allowing for either image noise reduction at unchanged radiation dose levels or radiation dose reductions at comparable image noise levels. Methods In this prospective, multicenter, multivendor noninferiority trial, we randomized 400 consecutive patients to 1 of 2 groups: a control group using standard FBP image reconstruction and standard tube current or an interventional group using IR technique and 30% tube current reduction. The primary endpoint was to demonstrate noninferiority in image quality (IQ) in the IR group. IQ was assessed on a 4-point scale (1, nondiagnostic IQ; 4, excellent IQ). Secondary endpoints included total radiation dose estimates and the rate of downstream testing during 30-day follow-up. Results Median IQ in the IR group was noninferior compared with the conventional FBP group (IR, 3.5 interquartile range: 3.0 to 4.0; FBP, 3.4 interquartile range: 2.8 to 4.0, p for noninferiority <0.016). The radiation exposure was significantly lower in the IR group (median dose-length-product 157 interquartile range: 114 to 239 mGy·cm vs. 222 interquartile range: 141 to 319 mGy·cm for IR vs. FBP, respectively, p < 0.0001). The rate of downstream testing did not differ significantly (7.7% vs. 7.9% for IR vs. FBP, respectively, p = 0.94). Conclusions Coronary CTA image quality is maintained with the combined use of a 30% reduced tube current and IR algorithms when compared with conventional FBP image reconstruction techniques and standard tube current. (Prospective Randomized Trial On RadiaTion Dose Estimates Of CT AngIOgraphy In PatieNts: NCT01453712 )
In this clinical vignette, we present the case of an 83-year-old female patient with acute limb ischemia, resulting from a large (1.8 × 2.8 cm) mobile thrombus in the descending aorta. The peripheral ...obstruction was treated with mechanical thrombectomy, whereas the intra-aortic thrombus was treated conservatively with clopidogrel and fondaparinux. (Level of Difficulty: Beginner.)
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Milder forms of plaque rupture with subsequent microembolization of atherothrombotic burden into the coronary circulation, however, may occur in patients with stable CAD or even in presumably healthy ...subjects. ...more than a decade ago, healed plaque destruction was observed in postmortem studies (3), whereas angioscopy studies demonstrated that silent plaque rupture is present in ~20% of patients with stable CAD (4).
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