Ana Martín-García

Dynamic Edematous Response of the Human Heart to Myocardial Infarction: Implications for Assessing Myocardial Area at Risk and Salvage

Background: Clinical protocols aimed to characterize the post–myocardial infarction (MI) heart by cardiac magnetic resonance (CMR) need to be standardized to take account of dynamic biological phenomena evolving early after the index ischemic event. Here, we evaluated the time course of edema reaction in patients with ST-segment–elevation MI by CMR and assessed its implications for myocardium-at-risk (MaR) quantification both in patients and in a large-animal model. Methods: A total of 16 patients with anterior ST-segment–elevation MI successfully treated by primary angioplasty and 16 matched controls were prospectively recruited. In total, 94 clinical CMR examinations were performed: patients with ST-segment–elevation MI were serially scanned (within the first 3 hours after reperfusion and at 1, 4, 7, and 40 days), and controls were scanned only once. T2 relaxation time in the myocardium (T2 mapping) and the extent of edema on T2-weighted short-tau triple inversion-recovery (ie, CMR-MaR) were evaluated at all time points. In the experimental study, 20 pigs underwent 40-minute ischemia/reperfusion followed by serial CMR examinations at 120 minutes and 1, 4, and 7 days after reperfusion. Reference MaR was assessed by contrast-multidetector computed tomography during the index coronary occlusion. Generalized linear mixed models were used to take account of repeated measurements. Results: In humans, T2 relaxation time in the ischemic myocardium declines significantly from early after reperfusion to 24 hours, and then increases up to day 4, reaching a plateau from which it decreases from day 7. Consequently, edema extent measured by T2-weighted short-tau triple inversion-recovery (CMR-MaR) varied with the timing of the CMR examination. These findings were confirmed in the experimental model by showing that only CMR-MaR values for day 4 and day 7 postreperfusion, coinciding with the deferred edema wave, were similar to values measured by reference contrast-multidetector computed tomography. Conclusions: Post-MI edema in patients follows a bimodal pattern that affects CMR estimates of MaR. Dynamic changes in post–ST-segment–elevation MI edema highlight the need for standardization of CMR timing to retrospectively delineate MaR and quantify myocardial salvage. According to the present clinical and experimental data, a time window between days 4 and 7 post-MI seems a good compromise solution for standardization. Further studies are needed to study the effect of other factors on these variables.

Effect of Ischemia Duration and Protective Interventions on the Temporal Dynamics of Tissue Composition After Myocardial Infarction

Rationale: The impact of cardioprotective strategies and ischemia duration on postischemia/reperfusion (I/R) myocardial tissue composition (edema, myocardium at risk, infarct size, salvage, intramyocardial hemorrhage, and microvascular obstruction) is not well understood. Objective: To study the effect of ischemia duration and protective interventions on the temporal dynamics of myocardial tissue composition in a translational animal model of I/R by the use of state-of-the-art imaging technology. Methods and Results: Four 5-pig groups underwent different I/R protocols: 40-minute I/R (prolonged ischemia, controls), 20-minute I/R (short-duration ischemia), prolonged ischemia preceded by preconditioning, or prolonged ischemia followed by postconditioning. Serial cardiac magnetic resonance (CMR)-based tissue characterization was done in all pigs at baseline and at 120 minutes, day 1, day 4, and day 7 after I/R. Reference myocardium at risk was assessed by multidetector computed tomography during the index coronary occlusion. After the final CMR, hearts were excised and processed for water content quantification and histology. Five additional healthy pigs were euthanized after baseline CMR as reference. Edema formation followed a bimodal pattern in all 40-minute I/R pigs, regardless of cardioprotective strategy and the degree of intramyocardial hemorrhage or microvascular obstruction. The hyperacute edematous wave was ameliorated only in pigs showing cardioprotection (ie, those undergoing short-duration ischemia or preconditioning). In all groups, CMR-measured edema was barely detectable at 24 hours postreperfusion. The deferred healing-related edematous wave was blunted or absent in pigs undergoing preconditioning or short-duration ischemia, respectively. CMR-measured infarct size declined progressively after reperfusion in all groups. CMR-measured myocardial salvage, and the extent of intramyocardial hemorrhage and microvascular obstruction varied dramatically according to CMR timing, ischemia duration, and cardioprotective strategy. Conclusions: Cardioprotective therapies, duration of index ischemia, and the interplay between these greatly influence temporal dynamics and extent of tissue composition changes after I/R. Consequently, imaging techniques and protocols for assessing edema, myocardium at risk, infarct size, salvage, intramyocardial hemorrhage, and microvascular obstruction should be standardized accordingly.

Platelet count and mean platelet volume predict outcome in adults with Eisenmenger syndrome

Objectives Although a significant proportion of patients with cyanotic congenital heart disease are thrombocytopaenic, its prevalence and clinical significance in adults with Eisenmenger syndrome (ES) is not well studied. Accordingly, we examined the relationship of thrombocytopaenia and mean platelet volume (MPV) to bleeding or thrombotic complications and survival in a contemporary cohort of patients with ES, including patients with Down syndrome. Methods Demographics, laboratory and clinical data were analysed from 226 patients with ES under active follow-up over 11 years. Results Age at baseline was 34.6±11.4 years and 34.1% were men. Mean platelet count and MPV were 152.6±73.3×109/L and 9.6±1.2 fL, respectively. A strong inverse correlation was found between platelet count and haemoglobin concentration and MPV. During the study, there were 39 deaths, and 21 thrombotic and 43 bleeding events. On univariate Cox regression analysis, patients with a platelet count <100×109/L had a twofold increased mortality (HR 2.10, 95% CI 1.10 to 4.01, p=0.024). Platelet count was not associated with an increased risk of thrombosis. However, there was a threefold increased thrombotic risk with MPV >9.5 fL (HR 3.50, 95% CI 1.28 to 9.54, p=0.015). Patients with either severe secondary erythrocytosis (>220g/L) or anaemia (<130g/L) were at higher risk of thrombotic events (HR 3.93, 95% CI 1.60 to 9.67, p=0.003; and HR 4.75, 95% CI 1.03 to 21.84, p=0.045, respectively). Conclusions Thrombocytopaenia significantly increased the risk of mortality in ES. Furthermore, raised MPV, severe secondary erythrocytosis and anaemia, but not platelet count, were associated with an increased risk of thrombotic events in our adult cohort.

Tako-tsubo Syndrome in Men: Rare, but With Poor Prognosis

INTRODUCTION AND OBJECTIVES Tako-tsubo syndrome is a potentially serious disease during the acute phase. It mimics myocardial infarction, but with no potentially causative coronary lesions. The aim of this study was to analyze the clinical course and outcome of patients with tako-tsubo syndrome by sex. METHODS We analyzed the characteristics of patients included in the RETAKO registry from 2003 to 2015, a multicenter registry with participation of 32 Spanish hospitals. RESULTS Of 562 patients included, 493 (87.7%) were women. Chest pain was less frequent as an initial symptom in men than in women (43 [66.2%] vs 390 [82.8%]; P < .01). The prognosis was worse in men, with higher in-hospital mortality (3 [4.4%] vs 1 [0.2%]; P < .01), longer intensive care stay (4.2 ± 3.7 vs 3.2 ± 3.2 days; P = .03) and a higher frequency of severe heart failure (22 [33.3%] vs 95 [20.3%]; P = .02). However, dynamic obstruction at the left-ventricular outflow tract occurred exclusively in women (39 [7.9%] vs 0 [0.0%]; P = .02). The incidence of functional mitral regurgitation was also higher in women (52 [10.6%] vs 2 [2.9%]; P = .04). CONCLUSIONS Tako-tsubo syndrome shows wide differences by sex in terms of its incidence, presentation, and outcomes. Prognosis is worse in men.

Measuring the aorta in the era of multimodality imaging: still to be agreed

Thoracic aortic dilatation is associated with major vascular complications with fatal consequences, such as dissection and aortic rupture. We can predict the risk of rupture or dissection based on aortic size (1,2). Broad spectrum of aortic complications benefits from different cardiac imaging techniques: transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, aortic dilatation is one of the most frequent clinical entities for request in cardiac imaging laboratories, both for the initial diagnosis and the monitoring and establishment of the optimal timing for surgery.

Severely complicated emergency blind pericardiocentesis: Evidence from multimodality imaging

Figure 1 Multimodality imaging of the path of the pericardiocentesis catheter crossing the aortic valve to the ascending aorta. (A) Two-dimensional transesophageal echocardiogram, left ventricular outflow tract projection; (B) computed tomography curved format reconstruction along the catheter; (C) three-dimensional volume-rendered computed tomography reconstruction of the catheter insertion point and its relationship with the anterior descending artery.

Response by Fernández-Jiménez et al to Letters Regarding Article, “Dynamic Edematous Response of the Human Heart to Myocardial Infarction: Implications for Assessing Myocardial Area at Risk and Salvage”

We are grateful to Stiermaier et al, Sacha and Feusette, and Bulluck and Hausenloy for their interest and comments on our article,1 in which we showed that myocardial edema in the week after ST-segment–elevation myocardial infarction in humans is a bimodal phenomenon. We concur with Stiermaier et al on the implications of our findings, and the need to put these data into perspective. Indeed, in the discussion of our paper, we speculated on the potential explanations for divergent findings in the literature. It is important to note that our clinical study was specifically designed to validate the hypothesis generated in previous experimental studies,2,3 and thus the timing for each cardiac magnetic resonance (CMR) was exquisitely chosen. Thus, we first analyzed the dynamics of the initial wave of edema (online-only Data Supplement Figure I from Fernandez-Jimenez et al)1 to define the optimal timing for the first CMR scan in patients and not miss the initial wave of edema. The fact that this initial wave of edema peaks very early, and is significantly attenuated …

Current Status of Cardio-Oncology in Spain: A National Multidisciplinary Survey

Supplementary material _____________________________________________________________________________ Current Status of Cardio-Oncology in Spain: A National Multidisciplinary Survey _____________________________________________________________________________ Current Status of Cardio-Oncology in Spain: A National Multidisciplinary Survey National Cardio-oncology Working Group To allow us to evaluate the current status of cardio-oncology in Spain, please, answer the following questions:

P2442Assessment of iron overload and cardiac disease in patients with transfusion-dependent myelodysplastic syndromes with cardiac magnetic resonance new sequences

P2443 – Table 1. Multivariate analysis Group 1 (n=6113) Group 2 (n=1922) Group 3 (n=1390) OR [CI95] p-value OR [CI95] p-value OR [CI95] p-value Invasive strategy 0.2 [0.1–0.4] <0.001 IH beta-blockers 0.3 [0.1–0.6] 0.003 IH beta-blockers 0.4 [0.2–0.8] 0.005 Invasive strategy 0.1 [0.1–0.2] <0.001 IH ACEi 0.5 [0.2–0.9] 0.039 IH spironolactone 0.5 [0.3–0.9] 0.024 Invasive strategy 0.2 [0.1–0.3] <0.001 ACEi, angiotensin conversion enzyme inhibitors; IH, In Hospital. P2443 | BEDSIDE Beta blocker therapy a major protector in patients with acute coronary syndromes and moderately reduced ejection fraction patients: a nationwide retrospective study F. Montenegro Sa, C. Ruivo, L. Graca Santos, A. Antunes, J. Morais on behalf of Portuguese Registry Of Acute Coronary Syndrome Investigators. Hospital Santo Andre, Cardiology, Leiria, Portugal Introduction: Beta blockers are an established therapy for heart failure (HF) patients with ejection fraction (EF) <40% as well as part of the cocktail for patients with ACS irrespective of left ventricular dysfunction. HF with moderately reduced EF (40–49% mrEF) is a newly defined entity, without specific therapy indications. Aim: To compare which therapeutic decisions have a positive impact on inhospital mortality, in patients with ACS stratified according to ejection fraction. Methods: The authors analyzed a cohort of patients with ACS enrolled in a multicenter national registry between 2010 and 2016, and stratified according to their EF. Patients with previously known HF or with no echocardiography EF estimation were excluded. 9429 patients were included and classified in three groups; Group1: EF>50%, (n=6113, 65%); Group 2: EF 40–49% (n=1922, 20%); Group 3 (3) EF<40% (n=1390, 15%). To exclude confounding factors, a multivariate logistic regression analysis was performed, including pharmacological treatment and also pre-hospital, clinical and laboratorial data, ACS classification and coronary anatomy when known. Results: Overall mortality was 2.8% (n=263): Group1: 0.9% (n=53), Group 2: 2.4% (n=37) and Group 3: 11.4% (n=159), p-value <0.001. Multivariate analysis results are shown in the table. After multivariate analysis, in-hospital beta blockers administration had a positive impact in prognosis for group 2 and 3. Conclusion: Post-ACS mrEF patients seem to be an intermediate risk group in which beta blocker administration had a positive impact on survival. An invasive strategy was a survival predictor for all groups, regardless of EF. P2444 | BEDSIDE Prediction of heart failure and atrial fibrillation using the CHARGE-AF and ARIC risk scores S. Ramkumar1, H. Yang2, Y. Wang2, M. Nolan2, K. Negishi2, T.H. Marwick1. 1Baker IDI Heart and Diabetes Institute, Melbourne, Australia; 2Menzies Research Institute, Hobart, Australia Introduction: The CHARGE-AF is a clinical score which gives an assessment of 5 year risk of developing atrial fibrillation (AF). Heart failure (HF) shares a similar risk factor profile to atrial fibrillation. AF risk assessment tools such as the CHARGE-AF score share similar characteristics to other HF risk scores such as the ARIC score. Aim: We aimed to compare the CHARGE-AF score to the ARIC score in prediction of HF and AF in patients with risk factors. Methods: A community based study of 503 participants (mean±SD age 70.8±4.7yrs, male 48% with median±IQR follow up 12 months±3) ≥65 years were recruited if they had presence of 1 or more risk factor for HF (hypertension (HTN), diabetes mellitus (DM), obesity, previous chemotherapy, previous history of ischaemic heart disease (IHD)). HF and AF risk was assessed using the CHARGEAF and ARIC scores. Baseline ECG and echocardiography was performed in all participants. HF with reduced or preserved ejection fraction was diagnosed as per ESC guidelines. AF was diagnosed by local doctors during the follow up period, by 12 lead ECG during outpatient clinics or using a single lead portable ECG monitoring device (Remon, Semacare, China). Receiver operator characteristic (ROC) curves were compared between both scores using the Hanley and McNeil method. Results: The baseline median CHARGE-AF and ARIC scores were 7.5% (3.8– 11.3%) and 5.9% (2.6–9.3%) respectively. During the follow up period 55 patients developed HF. 173/503 participants completed portable ECG monitoring follow up and 43 (25%) were diagnosed with subclinical AF. Patients with HF were older with higher rates of DM, HTN and IHD (p<0.05). Patients with AF were older, more likely to be male and had higher baseline CHARGE-AF score (p<0.05). In patients with HF and AF, echocardiography showed impaired global longitudinal strain and increased left atrial volume (p<0.05). For HF, there was modest discriminative ability using both CHARGE-AF and ARIC scores and no significant Table 1. Receiver Operator Characteristic (ROC) curves comparing CHARGE-AF and ARIC for heart failure and atrial fibrillation AUC (CHARGE-AF) 95% CI AUC (ARIC) 95% CI Comparison of AUC p value p value p value Heart Failure 0.65 0.58–0.73 0.65 0.58–0.73 0.89

Simultaneous Percutaneous Closure of Left Atrial Appendage and Atrial Septal Defect After Mitral Valve Replacement.

A 66-year-old woman with a history of atrial fibrillation and previous mitral valve replacement (MVR) underwent new MVR because of dysfunction. After surgery, she was admitted because of recurrent cardioembolic strokes despite optimal treatment with warfarin. Aspirin was added, but the patient had a