C.P. Allaart

Risk stratification for ventricular arrhythmias in ischaemic cardiomyopathy: the value of non-invasive imaging

The introduction of the implantable cardioverter defibrillator (ICD) has had a major impact on survival and treatment of patients with ischaemic cardiomyopathy. However, only a third of patients receive appropriate ICD discharges during the first 3 years of follow-up, hence creating opportunities for improvement in patient care as well as for health care costs containment. Therefore, refinement of ICD implantation criteria is needed. Evaluation of pathophysiological substrates related to electrical instability with imaging modalities such as nuclear imaging, cardiac magnetic resonance imaging, and echocardiography might yield important prognostic information. This review discusses the currently available literature regarding the value of these imaging modalities for prediction of ventricular arrhythmias in patients with ischaemic cardiomyopathy.

patients with coronary stenosis and a fractional flow reserve of ≥ 0.75 measured in daily practice at the VU University Medical center

Objectives. The aim of this study was to analyse the rate of major adverse clinical events in patients with coronary artery disease and a fractional flow reserve (FFR) of ≥0.75 and deferred for coronary intervention in daily practice. Methods. From 1 January to 31 December 2006, FFR measurement was initiated in 122 patients (5%) out of 2444 patients referred for coronary angiography. In two patients FFR measurement failed and in one patient the FFR value could no longer be traced in the documents. Thus, 119 patients (84 men, 64 years, range 41-85) were included in the evaluation (145 lesions). Major adverse clinical events (death, myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG)) and the presence of angina were evaluated at follow-up. Furthermore a cost-effectiveness analysis was performed.Results. In 93 patients (76%) the FFR value was ≥0.75. Seventy of these 93 patients (76%) were treated with medication alone or underwent PCI for a different lesion (medical treatment group). Average duration of follow-up of all 119 patients was 22 months (range 4 days to 30 months). In the medical treatment group seven patients (10%) experienced a major adverse clinical event related to the FFR-evaluated lesion during follow-up. In this study population, the use of FFR measurement is cost-reducing provided that at least 65% of the patients in the medical treatment group has had a PCI with stent implantation when the use of FFR measurement is impossible. In this case, the decision to use PCI with stent implantation is purely based on the angiogram. Conclusions. In patients with a coronary stenosis based on visual assessment and an FFR of ≥0.75 deferral of PCI or CABG is safe in daily clinical practice and saves money. (Neth Heart J 2010;18:402-7.)

Don't judge the myocardium by its cover : The incremental value of cardiac magnetic resonance imaging in left ventricular hypertrophy

A 51-year-old female presenting with fatigue demonstrated cardiac enlargement on her chest x-ray. The electrocardiogram was normal (Fig. 1). However, echocardiography suggested asymmetrical hypertrophic cardiomyopathy. Cardiac magnetic resonance (CMR) imaging was performed for further evaluation. The cine images showed a maximum wall thickness of 28mm at the mid anterolateral segment (Fig. 2a; Supplementary movie 1). Due to the atypical

703 Abnormal left ventricular rotational direction predicts acute response to cardiac resynchronization therapy

Background: Left ventricular (LV) torsion is an essential component of cardiac contraction in normal heart function, but is impaired in patients with dilated cardiomyopathy. The aim of this study is to determine the predictive value of impaired torsion for the acute response to cardiac resynchronization therapy (CRT) in these patients. Methods: In 35 CRT candidates and 12 controls, basal and apical LV rotations were calculated using MRI tagging. Impaired torsion was quantified by the correlation between both rotations, where a negative value indicates normal torsion and a positive value indicates a torsion disorder: basal and apical rotations follow the same path. This value was called ‘Torcor’. In patients, LV pressure was measured under atrial-sensed ventricular stimulation, using different pacing combinations. Acute response to CRT was defined by >10% increase in invasively measured dP/dtmax from the best pacing configuration relative to baseline. Torcor was compared between responders, non-responders and controls, and ROC-analysis was performed. Results: Torcor was significantly higher in responders (n=18) than in non-responders (n=17) and controls (0.60±0.55, -0.45±0.55 and 0.68±0.22, resp., p<0.001), but was not significantly different between the non-responder and the control group (p=0.71). ROC analysis resulted in an area under the curve of 0.88, p<0.001, 95% CI: 0.76 to 1.00. The sensitivity and specificity for prediction of response were 83% at a cutoff-value of 0.11.