Alfonso H. Waller

Osteopontin in cardiovascular disease: a potential therapeutic target.

Osteopontin (OPN), also known as 44kDa bone phosphoprotein, sialoprotein I, secreted phosphoprotein I, 2ar, uropontin, and early T-lymphocyte activation-1 (Eta-1), is a multifunctional protein. OPN has been found to be expressed in various cell types and species with many physiologic and pathologic functions. OPN has emerged as a potential biomarker and mediator in cardiovascular disease. In this review, we will discuss the roles of OPN in cardiovascular disease, specifically in vascular and valvular heart disease, myocardial infarction and heart failure.

Comparison of efficacy and safety of intracoronary sodium nitroprusside and intravenous adenosine for assessing fractional flow reserve.

The purpose of this study was to compare the efficacy and safety of intracoronary (IC) nitroprusside and intravenous adenosine (IVA) for assessing fractional flow reserve (FFR).

Evaluation of Known or Suspected Cardiac Sarcoidosis.

Sarcoidosis is a multisystem disorder of unknown cause, and cardiac sarcoidosis affects at least 25% of patients and accounts for substantial mortality and morbidity from this disease. Cardiac sarcoidosis may present with heart failure, left ventricular systolic dysfunction, AV block, atrial or ventricular arrhythmias, and sudden cardiac death. Cardiac involvement can be challenging to detect and diagnose because of the focal nature of the disease, as well as the fact that clinical criteria have limited diagnostic accuracy. Nevertheless, the diagnosis of cardiac sarcoidosis can be enhanced by integrating both clinical and imaging findings. This article reviews the various roles that different imaging modalities provide in the evaluation and management of patients with known or suspected cardiac sarcoidosis.

Quantifying myocardial inflammation using F18-fluorodeoxyglucose positron emission tomography in cardiac sarcoidosis.

Sarcoidosis is a disease of unknown etiology which is characterized by the formation of non-caseating granulomas in multiple organs. Cardiac involvement in sarcoidosis, which occurs in at least one in four patients, is associated with a worse prognosis and significant morbidity from conduction abnormalities, arrhythmias, and congestive heart failure. Nevertheless, the diagnosis of cardiac sarcoidosis (CS) is often challenging, and relies on integrating both clinical and imaging findings. In addition to diagnosis, advanced imaging techniques such as cardiac magnetic resonance imaging (CMR) and cardiac positron emission tomography (PET) are now also being used to determine the risk of future adverse events, to identify which patients are most likely to benefit from immunosuppressive therapy, and to monitor response to therapy. Cardiac PET imaging for CS includes a rest myocardial perfusion imaging scan (using either NAmmonia or Rubidium) and an F-fluorodeoxyglucose (FDG) scan to identify areas of myocardial inflammation. Interpretation of the cardiac PET study is performed using a qualitative assessment with the perfusion and FDG images being simultaneously displayed (see Figure 1 for example). Rest myocardial perfusion defects may represent areas of scar related to fibrosis or areas of decreased perfusion from inflammation causing compression of the microvasculature. Following suppression of glucose uptake from the normal myocardium, and in the absence of coronary heart disease, which can be associated with hibernating myocardium, focal areas of FDG uptake represent active myocardial inflammation. Importantly, such abnormalities are not only useful for establishing the diagnosis of CS, but provide important prognostic information regarding a patient’s future risk of death or ventricular tachycardia. However, a limitation of FDG PET scans is that diffuse uptake of FDG may be visualized which is non-specific and due to either incomplete suppression of FDG from normal areas of myocardium vs diffuse inflammation. Such results—which despite ideal patient preparation occur *10%-15% of the time—may lead to inconclusive study results. However, there are no established quantitative methods that can reliably distinguish patients with diffuse FDG from inflammation related to CS from those who have benign uptake. Tahara et al have shown that heterogeneous myocardial FDG uptake is more common in CS patients and further data are needed regarding the discriminatory performance of this parameter among patients who have inconclusive FDG scans. To date, there is relatively little data on quantitative assessment of CS by PET imaging—with some studies evaluating the intensity of FDG uptake and only one prior study evaluating the extent of myocardial inflammation. The intensity of FDG uptake on PET can be measured by standardized uptake value (SUV), where a reader identifies voxels with FDG uptake, and the voxel with the highest intensity of FDG is used to define the SUVmax. The extent of FDG (e.g., SUV volume or volume of inflammation) can be measured by identifying voxels with an SUV intensity above a pre-defined threshold value. In this issue of the Journal of Nuclear Cardiology, Ahmadian et al propose a new method to quantify the Reprint requests: Ron Blankstein, MD, Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, 75 Francis Street – Room Shapiro 5096, Boston, MA 02115; rblankstein@mgh. harvard.edu; rblankstein@partners.org J Nucl Cardiol 2014;21:940–3. 1071-3581/

New index for assessing the chronotropic response in patients with end‐stage liver disease who are undergoing dobutamine stress echocardiography

34.00 Copyright 2014 American Society of Nuclear Cardiology.

Instantaneous Wave-Free Ratio and Fractional Flow Reserve: Close, But Not Close Enough!

The inability to achieve 85% of the maximum predicted heart rate (MPHR) on dobutamine stress echocardiography (DSE) is defined as chronotropic incompetence and is a predictor of major cardiac events after orthotopic liver transplantation (OLT). The majority of patients with end‐stage liver disease (ESLD) receive beta‐blockers for the prevention of variceal bleeding. In these patients, it is impossible to determine whether chronotropic incompetence is secondary to cirrhosis‐related autonomic dysfunction or is merely a beta‐blocker effect. We evaluated the usefulness of the maximum achieved heart rate (MAHR) and the heart rate reserve (HRR) in the detection of chronotropic incompetence in ESLD patients on beta‐blocker therapy before DSE. We also evaluated the usefulness of a new index, the modified heart rate reserve (MHRR), in diagnosing chronotropic incompetence and predicting major cardiovascular adverse events after OLT. The study population consisted of 284 ESLD patients. The mean values of MAHR (expressed as a percentage of 85% of MPHR) and HRR were significantly lower for patients on beta‐blockers versus patients off beta‐blockers [97.1% versus 101.6% (t = 5.01, P < 0.001) and 71.7% versus 77.3% (t = 4.03, P < 0.001), respectively], whereas the values of MHRR were similar in patients on beta‐blockers and patients off beta‐blockers [102.3% versus 102.1% (t = 0.04, P = 0.97)]. A regression analysis showed a significant association of MAHR (P < 0.001) and HRR (P < 0.001) with beta‐blockers, whereas MHRR was not associated with beta‐blocker treatment (P = 0.92). MAHR and HRR were found to have no value for diagnosing chronotropic incompetence in ESLD patients. MHRR was not affected by beta‐blocker therapy. Patients who developed heart failure (HF) and myocardial infarction (MI) after OLT had significantly lower MHRR values according to pretransplant DSE. MHRR was significantly associated with the subsequent development of HF (P = 0.01) and MI (P = 0.01) after OLT. MHRR may be useful for the determination of the target heart rate for stress testing, the diagnosis of chronotropic incompetence, and the prediction of adverse cardiac events after OLT. Liver Transpl 18:355–360, 2012.

Myocardial blood flow quantification for evaluation of coronary artery disease by positron emission tomography, cardiac magnetic resonance imaging, and computed tomography.

We were greatly interested by the study of Sen et al. ([1][1]), which proposes the revolutionary, vasodilator-independent index to assess significance of coronary artery stenosis—instantaneous wave-free ratio (iFR). The investigators identified a period during a cardiac cycle when intracoronary

In-Hospital Outcomes and Complications of Coronary Artery Bypass Grafting in the United States Between 2008 and 2012

The noninvasive detection of the presence and functional significance of coronary artery stenosis is important in the diagnosis, risk assessment, and management of patients with known or suspected coronary artery disease. Quantitative assessment of myocardial perfusion can provide an objective and reproducible estimate of myocardial ischemia and risk prediction. Positron emission tomography, cardiac magnetic resonance, and cardiac computed tomography perfusion are modalities capable of measuring myocardial blood flow and coronary flow reserve. In this review, we will discuss the technical aspects of quantitative myocardial perfusion imaging with positron emission tomography, cardiac magnetic resonance imaging, and computed tomography, and its emerging clinical applications.

Comparison of Echocardiography, Cardiac Magnetic Resonance, and Computed Tomographic Imaging for the Evaluation of Left Ventricular Myocardial Function: Part 2 (Diastolic and Regional Assessment)

OBJECTIVE To investigate the frequency and predictors of in-hospital complications among patients undergoing coronary artery bypass grafting (CABG) in the United States. DESIGN Retrospective national database analysis SETTINGS: United States hospitals. PARTICIPANTS A weighted sample of 1,910,236 patients undergoing CABG surgery identified from the National (Nationwide) Inpatient Sample from 2008 to 2012. INTERVENTIONS CABG surgery MEASUREMENTS AND MAIN RESULTS: The number of CABG surgeries decreased from 436,275 in 2008 to 339,749 in 2012. The Deyo comorbidity index showed a steady increase from 2008 to 2012. The rate of in-hospital mortality decreased from 2.7% in 2008 to 2.2% in 2012 (p<0.001). The most common in-hospital complication was postoperative hemorrhage (30.4%), followed by cardiac (11.34%) and respiratory complications (2.3%). During the 5-year period, the rates of in-hospital cardiac, respiratory and infectious complications decreased (p<0.001), while the rate of postoperative hemorrhage showed a 35.8% relative increase in 2012 compared to 2008. CONCLUSION The annual number of CABG surgeries is declining in the United States. While the burden of comorbidities is increasing, the rates of mortality and most in-hospital complications are improving. The increasing rate of postoperative bleeding necessitates the need to develop strategies to improve the risk of bleeding in this patient population.

Real-time three-dimensional transoesophageal echocardiography enables preoperative pulmonary valvulopathy assessment

Assessing left ventricular diastolic and regional function is a crucial part of the cardiovascular evaluation. Diastolic function is as important as systolic function for left ventricular performance because it is the determinant of the ability of the left atrium and ventricle to fill at relatively low pressures. Additionally, diastolic function plays an important role in the management and prognosis of patients with symptoms and signs of heart failure. Technical advances in the imaging modalities have allowed a comprehensive noninvasive assessment of global and regional cardiac mechanics and precise estimation of cardiovascular hemodynamics. In this review, we will discuss and compare clinically available techniques and novel approaches using echocardiography, cardiac magnetic resonance, and computed tomography for the assessment of diastolic and regional left ventricular function.