Right ventricular (RV) volume measurements with cardiovascular magnetic resonance (CMR) is considered the gold standard, but acquisition and analysis remain time-consuming. The aim of our study was ...therefore to investigate the accuracy and performance of a semi-quantitative assessment of RV function in CMR, compared to the standard quantitative approach. Seventy-five subjects with pulmonary hypertension (15), anterior myocardial infarction (15), inferior myocardial infarction (15), Brugada syndrome (15) and normal subjects (15) underwent cine CMR. RV end-systolic and end-diastolic volumes were determined to calculate RV ejection fraction (EF). Four-chamber cine images were used to measure tricuspid annular plane systolic excursion (TAPSE). RV fractional shortening (RVFS) was calculated by dividing TAPSE by the RV end-diastolic length. RV EF correlated significantly with TAPSE (r = 0.62, p < 0.01) and RVFS (r = 0.67, p < 0.01). Sensitivity to predict RV dysfunction was comparable between TAPSE and RVFS, with higher specificity for RVFS, but comparable areas under the ROC curve. Intra- and inter-observer variability of RV EF was better than TAPSE (3%/4% versus 7%/15%, respectively). For routine screening in clinical practice, TAPSE and RVFS seem reliable and easy methods to identify patients with RV dysfunction. The 3D volumetric approach is preferred to assess RV function for research purposes or to evaluate treatment response.
Symptomatic severe aortic stenosis (AS) is a class I indication for replacement in patients when left ventricular ejection fraction (LVEF) is preserved. However, symptom reporting is often equivocal ...and decision making can be challenging. We aimed to quantify myocardial deformation using cardiovascular magnetic resonance (CMR) in patients classified by symptom severity.
Forty-two patients with severe AS referred to heart valve clinic were studied using tagged CMR imaging. All had preserved LVEF. Patients were grouped by symptoms as either "none/mild" (n=21, NYHA class I, II) or "significant" (n=21, NYHA class III, IV, angina, syncope) but were comparable for age (72.8±5.4
. 71.0±6.8 years old, P=0.345), surgical risk (EuroSCORE II: 1.90±1.7
. 1.31±0.4, P=0.302) and haemodynamics (peak aortic gradient: 55.1±20.8
. 50.4±15.6, P=0.450). Thirteen controls matched in age and LVEF were also studied. LV circumferential strain was calculated using inTag
software and longitudinal strain using feature tracking analysis.
Compared to healthy controls, patients with severe AS had significantly worse longitudinal and circumferential strain, regardless of symptom status. Patients with "significant" symptoms had significantly worse peak longitudinal systolic strain rates (-83.352±24.802%/s
. -106.301±43.276%/s, P=0.048) than those with "no/mild" symptoms, with comparable peak longitudinal strain (PLS), peak circumferential strain and systolic and diastolic strain rates.
Patients with severe AS who have no or only mild symptoms exhibit comparable reduction in circumferential and longitudinal fibre function to those with significant symptoms, in whom AVR is clearly indicated. Given these findings of equivalent subclinical dysfunction, reportedly borderline symptoms should be handled cautiously to avoid potentially adverse delays in intervention.
In patients with chronic ischemic myocardial dysfunction, late gadolinium enhancement CMR (LGE-CMR) accurately depicts the regional extent of fibrosis and predicts functional recovery after ...revascularization. We hypothesized that the predictive accuracy of LGE-CMR could be optimized by not only taking into account the transmural extent of hyperenhancement but also the amount of residual, non-enhanced viable myocardium, and procedure related necrosis. We studied 45 patients with chronic ischemic left ventricular dysfunction, who underwent cine and LGE-CMR 1 month before and 3 months after surgical or percutaneous revascularization. Segmental and global function, scar, presence of a significant residual viable rim (defined as ≥4.5 mm), and procedure related necrosis were fully quantified using standardized methods and objective thresholds. Sixty percent of segments without hyperenhancement showed functional improvement at follow-up. No improvement was observed in segments with > 75% segmental extent of hyperenhancement (SEH), while segments with 1-25%, 26-50%, and 51-75% SEH were 4, 8, and 20 times less likely to improve (multilevel analysis, p < 0.001). Thickness of the viable rim largely paralleled total wall thickness; therefore, the presence of a significant viable rim did not provide additional diagnostic value beyond SEH. Procedure related necrosis was found in 12 (27%) patients. The presence of procedure related necrosis was the only (negative) predictor of changes in left ventricular volumes and ejection fraction. In conclusion, we found that functional outcome after revascularization was influenced by both transmural extent of hyperenhancement and procedure related necrosis. However, the presence of a significant residual, viable rim was of no additional diagnostic value.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: Microvascular obstruction commonly affects patients with acute ST-segment elevation myocardial infarction (STEMI) and is associated with adverse outcomes. OBJECTIVE: To determine whether ...a therapeutic strategy involving low-dose intracoronary fibrinolytic therapy with alteplase infused early after coronary reperfusion will reduce microvascular obstruction. DESIGN, SETTING, AND PARTICIPANTS: Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the United Kingdom within 6 hours of STEMI due to a proximal–mid-vessel occlusion of a major coronary artery were randomized in a 1:1:1 dose-ranging trial design. Patient follow-up to 3 months was completed on April 12, 2018. INTERVENTIONS: Participants were randomly assigned to treatment with placebo (n = 151), alteplase 10 mg (n = 144), or alteplase 20 mg (n = 145) by manual infusion over 5 to 10 minutes. The intervention was scheduled to occur early during the primary PCI procedure, after reperfusion of the infarct-related coronary artery and before stent implant. MAIN OUTCOMES AND MEASURES: The primary outcome was the amount of microvascular obstruction (% left ventricular mass) demonstrated by contrast-enhanced cardiac magnetic resonance imaging (MRI) conducted from days 2 through 7 after enrollment. The primary comparison was the alteplase 20-mg group vs the placebo group; if not significant, the alteplase 10-mg group vs the placebo group was considered a secondary analysis. RESULTS: Recruitment stopped on December 21, 2017, because conditional power for the primary outcome based on a prespecified analysis of the first 267 randomized participants was less than 30% in both treatment groups (futility criterion). Among the 440 patients randomized (mean age, 60.5 years; 15% women), the primary end point was achieved in 396 patients (90%), 17 (3.9%) withdrew, and all others were followed up to 3 months. In the primary analysis, the mean microvascular obstruction did not differ between the 20-mg alteplase and placebo groups (3.5% vs 2.3%; estimated difference, 1.16%; 95% CI, −0.08% to 2.41%; P = .32) nor in the analysis of 10-mg alteplase vs placebo groups (2.6% vs 2.3%; estimated difference, 0.29%; 95% CI, −0.76% to 1.35%; P = .74). Major adverse cardiac events (cardiac death, nonfatal MI, unplanned hospitalization for heart failure) occurred in 15 patients (10.1%) in the placebo group, 18 (12.9%) in the 10-mg alteplase group, and 12 (8.2%) in the 20-mg alteplase group. CONCLUSIONS AND RELEVANCE: Among patients with acute STEMI presenting within 6 hours of symptoms, adjunctive low-dose intracoronary alteplase given during the primary percutaneous intervention did not reduce microvascular obstruction. The study findings do not support this treatment. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02257294
Percutaneous alcohol septal ablation (ASA) is an established technique for the relief of refractory symptoms in patients with obstructive hypertrophic cardiomyopathy. Most subjects develop right ...bundle branch block (RBBB) after ASA, but it is not known whether these patients have similar infarct characteristics, which may influence left ventricular (LV) pressure gradient reduction and reverse remodeling, compared with those without RBBB. Twenty-seven consecutive patients (15 men, 12 women; mean age 62 ± 16 years) were studied with electrocardiography and cardiac magnetic resonance imaging at baseline and 1 and 6 months (n = 25) after ASA. Infarct size and location were determined at 1 month by delayed contrast-enhanced cardiac magnetic resonance imaging. The 17 subjects who developed RBBB tended to have larger infarcts (creatine kinase-MB 251 ± 92 vs 148 ± 97 IU, p = 0.03; cardiac magnetic resonance imaging mass 22.5 ± 9.3 vs 16.6 ± 8.3 g, p = 0.1) and were more likely to have sustained anterior and inferior septal transmural infarctions (9 of 17 vs 1 of 10, p = 0.03) than those without RBBB. Those who developed RBBB had greater LV mass reductions at 6 months (46 ± 26 vs 29 ± 13 g, p = 0.04) despite similar reductions in LV pressure gradients (64 ± 31 vs 56 ± 32 mm Hg). In conclusion, patients who develop RBBB after ASA tend to have more extensive transmural septal infarctions and greater reverse remodeling than those without RBBB.
Reply Kelly, Damian J.; Gershlick, Anthony H.; Greenwood, John P. ...
Journal of the American College of Cardiology,
10/2015, Letnik:
66, Številka:
15
Journal Article
Surgery is recommended for severe aortic stenosis (area less than 1.0 cm2 or 0.6 cm2.m-2 (aortic valve area corrected for body surface area) in the following situations: firstly, an abnormal response ...to exercise-if symptoms develop, if systolic blood pressure falls or a blunted systolic blood pressure response (less than 20 mm Hg) occurs when exercise capacity is poor; secondly, moderate to severe calcification of the valve, peak aortic velocity more than 400 cm/s, and a rate of progression more than 30 cm/s per year; thirdly, impaired left ventricular systolic function (ejection fraction less than 50%).
Background: The main symptoms of chronic heart failure are breathlessness and fatigue on exertion. Abnormalities of skeletal muscle cause early metabolic distress on exercise, with resultant ...ergoreceptor stimulation causing increased ventilation. The aim of this study is to determine the extent of enhanced ergoreflex activity in chronic heart failure in the leg.
Methods: Ten patients with chronic stable heart failure (New York Heart Association class II–III) and nine healthy age-matched controls performed two bouts of ankle dorsiflexion. On one occasion a cuff was inflated round the thigh to suprasystolic levels for 3 min immediately post-exercise: regional circulatory occlusion. Recovery with regional circulatory occlusion was compared to recovery without it.
Results: Systolic and diastolic blood pressure and ventilation were higher after 3 min post-exercise regional circulatory occlusion than after 3 min control recovery in the patient group (184±13.3 vs 165±12.5 mmHg,
P<0.01, 94±4.7 vs 86±3.5 mmHg,
P<0.05, 9.8±0.7 vs 7.9±0.36 l/min,
P<0.01). Systolic and diastolic blood pressure were higher after post-exercise regional circulatory occlusion than after control recovery in the control group (149±7.8 vs 138±5.7 mmHg,
P<0.01, 86±3.3 vs 82±2.5 mmHg,
P<0.05), but this was not the case for ventilation (8.1±0.62 vs 8.1±0.62 l/min). Ergoreflex activity was greater in the patient group than in the controls for systolic blood pressure (91 vs 48%,
P<0.001), diastolic blood pressure (86 vs 49%,
P<0.05) and ventilation (39 vs −1%,
P<0.05).
Conclusions: Ergoreceptor stimulation contributes to an increased ventilation and blood pressure response to leg exercise in chronic heart failure patients, perhaps contributing to dyspnoea and exercise limitation. Peripheral factors such as skeletal muscle abnormalities contribute to the pathogenesis of symptoms in chronic heart failure.
The diagnosis of type 2 diabetes (T2D) in younger adults, an increasingly common public health issue, is associated with a higher risk of cardiovascular complications and mortality, which may be due ...to a more adverse cardiovascular risk profile in individuals diagnosed at a younger age.
To investigate the association between age at diagnosis and the cardiovascular risk profile in adults with T2D.
A pooled dataset was used, comprised of data from five previous studies of adults with T2D, including 1409 participants of whom 196 were diagnosed with T2D under the age of 40 years. Anthropometric and blood biomarker measurements included body weight, body mass index (BMI), waist circumference, body fat percentage, glycaemic control (HbA1c), lipid profile and blood pressure. Univariable and multivariable linear regression models, adjusted for diabetes duration, sex, ethnicity and smoking status, were used to investigate the association between age at diagnosis and each cardiovascular risk factor.
A higher proportion of participants diagnosed with T2D under the age of 40 were female, current smokers and treated with glucose-lowering medications, compared to participants diagnosed later in life. Participants diagnosed with T2D under the age of 40 also had higher body weight, BMI, waist circumference and body fat percentage, in addition to a more adverse lipid profile, compared to participants diagnosed at an older age. Modelling results showed that each one year reduction in age at diagnosis was significantly associated with 0.67 kg higher body weight 95% confidence interval (CI): 0.52-0.82 kg, 0.18 kg/m
higher BMI (95%CI: 0.10-0.25) and 0.32 cm higher waist circumference (95%CI: 0.14-0.49), after adjustment for duration of diabetes and other confounders. Younger age at diagnosis was also significantly associated with higher HbA1c, total cholesterol, low-density lipoprotein cholesterol and triglycerides.
The diagnosis of T2D earlier in life is associated with a worse cardiovascular risk factor profile, compared to those diagnosed later in life.
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