Chiara Bucciarelli-Ducci

New Universal Definition of Myocardial Infarction: Applicable After Complex Percutaneous Coronary Interventions?

OBJECTIVES This study aimed to characterize myocardial infarction after percutaneous coronary intervention (PCI) based on cardiac marker elevation as recommended by the new universal definition and on the detection of late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR). It is also assessed whether baseline inflammatory biomarkers are higher in patients developing myocardial injury. BACKGROUND Cardiovascular magnetic resonance accurately assesses infarct size. Baseline C-reactive protein (CRP) and neopterin predict prognosis after stent implantation. METHODS Consecutive patients with baseline troponin (Tn) I within normal limits and no LGE in the target vessel underwent baseline and post-PCI CMR. The Tn-I was measured until 24 h after PCI. Serum high-sensitivity CRP and neopterin were assessed before coronary angiography. RESULTS Of 45 patients, 64 (53 to 72) years of age, 33% developed LGE with infarct size of 0.83 g (interquartile range: 0.32 to 1.30 g). A Tn-I elevation >99% upper reference limit (i.e., myocardial necrosis) (median Tn-I: 0.51 μg/l, interquartile range: 0.16 to 1.23) and Tn-I > 3× upper reference limit (i.e., type 4a myocardial infarction [MI]) occurred in 58% and 47% patients, respectively. LGE was undetectable in 42% and 43% of patients with periprocedural myocardial necrosis and type 4a MI, respectively. Agreement between LGE and type 4a MI was moderate (kappa = 0.45). The levels of CRP or neopterin did not significantly differ between patients with or without myocardial injury, detected by CMR or according to the new definition (p = NS). CONCLUSIONS This study reports the lack of substantial agreement between the new universal definition and CMR for the diagnosis of small-size periprocedural myocardial damage after complex PCI. Baseline levels of CRP or neopterin were not predictive for the development of periprocedural myocardial damage.

Variability of myocardial perfusion dark rim Gibbs artifacts due to sub-pixel shifts

BackgroundGibbs ringing has been shown as a possible source of dark rim artifacts in myocardial perfusion studies. This type of artifact is usually described as transient, lasting a few heart beats, and localised in random segments of the myocardial wall. Dark rim artifacts are known to be unpredictably variable. This article aims to illustrate that a sub-pixel shift, i.e. a small displacement of the pixels with respect to the endocardial border, can result in different Gibbs ringing and hence different artifacts. Therefore a hypothesis for one cause of dark rim artifact variability is given based on the sub-pixel position of the endocardial border. This article also demonstrates the consequences for Gibbs artifacts when two different methods of image interpolation are applied (post-FFT interpolation, and pre-FFT zero-filling).ResultsSub-pixel shifting of in vivo perfusion studies was shown to change the appearance of Gibbs artifacts. This effect was visible in the original uninterpolated images, and in the post-FFT interpolated images. The same shifted data interpolated by pre-FFT zero-filling exhibited much less variability in the Gibbs artifact. The in vivo findings were confirmed by phantom imaging and numerical simulations.ConclusionUnless pre-FFT zero-filling interpolation is performed, Gibbs artifacts are very dependent on the position of the subendocardial wall within the pixel. By introducing sub-pixel shifts relative to the endocardial border, some of the variability of the dark rim artifacts in different myocardial segments, in different patients and from frame to frame during first-pass perfusion due to cardiac and respiratory motion can be explained. Image interpolation by zero-filling can be used to minimize this dependency.

Measurement of myocardial frequency offsets during first pass of a gadolinium-based contrast agent in perfusion studies

MRI of myocardial perfusion observed with an extracellular contrast agent has proven valuable for the detection of coronary artery disease. During contrast enhancement transient dark rim artifacts are sometimes visible, complicating diagnosis and quantification. In this work a quantification of the frequency offsets caused solely by the first pass of Gd‐DTPA in a typical perfusion setup was made in vivo and compared with both phantom work and numerical simulations data. The results show that numerically simulated and phantom data agree well with in vivo frequency offsets. During the first pass main field distortion occurs mainly in the subendocardium, and the same pattern is always observed: positive for posterior/anterior regions, negative for septal/lateral regions (from −69 to 85 Hz). The larger myocardial frequency offsets were measured for patients with greater angles between the long axis of the heart and the direction of the main field. From these results it would appear that the frequency offsets are too weak to cause dark rim artifacts due simply to intravoxel dephasing in a typical perfusion sequence. However, when added to other sources of off‐resonance it can cause dark rims in particular regions of the myocardium wall in balanced‐SSFP sequences. Magn Reson Med 60:860–870, 2008.

Images in cardiovascular medicine: Perfusion cardiovascular magnetic resonance in a child with ischemic heart disease: potential advantages over nuclear medicine.

19-month-old boy presented with acute cardiac failureand was found to have an anomalous origin and courseof the left coronary artery (LCA). It arose from the anterioraortic sinus and was compressed between the aorta and thepulmonary artery. He underwent placement of a left internalmammary artery graft to the left anterior descending coronaryartery and made a good recovery. At 2A 19-month-old boy presented with acute cardiac failure and was found to have an anomalous origin and course of the left coronary artery (LCA). It arose from the anterior aortic sinus and was compressed between the aorta and the pulmonary artery. He underwent placement of a left internal mammary artery graft to the left anterior descending coronary artery and made a good recovery. At 2\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{1}{2}\) \end{document} years of age, he had mild limitation of physical exertion. Cardiac catheterization showed the left internal mammary artery graft to be occluded and the proximal course of the LCA origin to be significantly narrowed (Figure 1). Serial technetium-99m single-photon emission computed tomography (SPECT) myocardial perfusion scans showed ongoing inducible ischemia in the anterior and anterolateral walls (Figure 2). He consequently underwent surgical enlargement of the LCA origin with a good final result. Figure 1. Invasive coronary angiography/aortogram at 2![Formula][1] years of age showing a proximal stenosis of the native left main stem coronary artery (black arrow). Figure 2. Technetium-99m–tetrofosmin perfusion scintigraphy performed at 5 years of age showing significant perfusion abnormalities in the anteroapical and anterolateral regions (white arrowheads). By 7\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{1}{2}\) \end{document} years of age, he had developed significantly reduced exercise tolerance, chest pain on exercise, and shortness of breath. … [1]: F1/embed/tex-math-2.gif

Images in cardiovascular medicine. The complex pathophysiology of acute myocardial infarction imaged by cardiovascular magnetic resonance: infarction, edema, microvascular obstruction, and inducible ischemia.

A 61-year-old man, an ex-smoker with a history of hypercholesterolemia, presented with crushing central chest pain radiating to the left arm, nausea, and cold sweat after consuming up to 2 g of recreational cocaine. ECG revealed Q waves in V1 through V3 with associated marginal ST-segment elevation of <1 mm (Figure 1). His troponin I level was 13.7 μg/L (normal range 0 to 0.04 μg/L). The patient was treated with dual antiplatelet therapy in addition to low-molecular-weight heparin and a calcium antagonist. He was referred for invasive coronary angiography, which demonstrated proximal occlusion of the left anterior descending artery (Figure 2) associated with anterior akinesia on ventriculography. To assess viability in this territory, myocardial perfusion scintigraphy and cardiovascular magnetic resonance (CMR) were requested. The myocardial perfusion scintigraphy images showed extensive full-thickness, anterior myocardial infarction involving the apex and the adjacent septum with evidence of peri-infarct ischemia in the basal anteroseptal segment (Figure 3). Gadolinium contrast-enhanced CMR imaging confirmed the anterior wall and septal akinesia (Movies I and …A 61-year-old man, an ex-smoker with a history of hypercholesterolemia, presented with crushing central chest pain radiating to the left arm, nausea, and cold sweat after consuming up to 2 g of recreational cocaine. ECG revealed Q waves in V1 through V3 with associated marginal ST-segment elevation of <1 mm (Figure 1). His troponin I level was 13.7 μg/L (normal range 0 to 0.04 μg/L). The patient was treated with dual antiplatelet therapy in addition to low-molecular-weight heparin and a calcium antagonist. He was referred for invasive coronary angiography, which demonstrated proximal occlusion of the left anterior descending artery (Figure 2) associated with anterior akinesia on ventriculography. To assess viability in this territory, myocardial perfusion scintigraphy and cardiovascular magnetic resonance (CMR) were requested. The myocardial perfusion scintigraphy images showed extensive full-thickness, anterior myocardial infarction involving the apex and the adjacent septum with evidence of peri-infarct ischemia in the basal anteroseptal segment (Figure 3). Gadolinium contrast-enhanced CMR imaging confirmed the anterior wall and septal akinesia (Movies I and …

The Complex Pathophysiology of Acute Myocardial Infarction Imaged by Cardiovascular Magnetic Resonance Infarction, Edema, Microvascular Obstruction, and Inducible Ischemia

A 61-year-old man, an ex-smoker with a history of hypercholesterolemia, presented with crushing central chest pain radiating to the left arm, nausea, and cold sweat after consuming up to 2 g of recreational cocaine. ECG revealed Q waves in V1 through V3 with associated marginal ST-segment elevation of <1 mm (Figure 1). His troponin I level was 13.7 μg/L (normal range 0 to 0.04 μg/L). The patient was treated with dual antiplatelet therapy in addition to low-molecular-weight heparin and a calcium antagonist. He was referred for invasive coronary angiography, which demonstrated proximal occlusion of the left anterior descending artery (Figure 2) associated with anterior akinesia on ventriculography. To assess viability in this territory, myocardial perfusion scintigraphy and cardiovascular magnetic resonance (CMR) were requested. The myocardial perfusion scintigraphy images showed extensive full-thickness, anterior myocardial infarction involving the apex and the adjacent septum with evidence of peri-infarct ischemia in the basal anteroseptal segment (Figure 3). Gadolinium contrast-enhanced CMR imaging confirmed the anterior wall and septal akinesia (Movies I and …A 61-year-old man, an ex-smoker with a history of hypercholesterolemia, presented with crushing central chest pain radiating to the left arm, nausea, and cold sweat after consuming up to 2 g of recreational cocaine. ECG revealed Q waves in V1 through V3 with associated marginal ST-segment elevation of <1 mm (Figure 1). His troponin I level was 13.7 μg/L (normal range 0 to 0.04 μg/L). The patient was treated with dual antiplatelet therapy in addition to low-molecular-weight heparin and a calcium antagonist. He was referred for invasive coronary angiography, which demonstrated proximal occlusion of the left anterior descending artery (Figure 2) associated with anterior akinesia on ventriculography. To assess viability in this territory, myocardial perfusion scintigraphy and cardiovascular magnetic resonance (CMR) were requested. The myocardial perfusion scintigraphy images showed extensive full-thickness, anterior myocardial infarction involving the apex and the adjacent septum with evidence of peri-infarct ischemia in the basal anteroseptal segment (Figure 3). Gadolinium contrast-enhanced CMR imaging confirmed the anterior wall and septal akinesia (Movies I and …

Perfusion Cardiovascular Magnetic Resonance in a Child With Ischemic Heart Disease Potential Advantages Over Nuclear Medicine

19-month-old boy presented with acute cardiac failureand was found to have an anomalous origin and courseof the left coronary artery (LCA). It arose from the anterioraortic sinus and was compressed between the aorta and thepulmonary artery. He underwent placement of a left internalmammary artery graft to the left anterior descending coronaryartery and made a good recovery. At 2A 19-month-old boy presented with acute cardiac failure and was found to have an anomalous origin and course of the left coronary artery (LCA). It arose from the anterior aortic sinus and was compressed between the aorta and the pulmonary artery. He underwent placement of a left internal mammary artery graft to the left anterior descending coronary artery and made a good recovery. At 2\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{1}{2}\) \end{document} years of age, he had mild limitation of physical exertion. Cardiac catheterization showed the left internal mammary artery graft to be occluded and the proximal course of the LCA origin to be significantly narrowed (Figure 1). Serial technetium-99m single-photon emission computed tomography (SPECT) myocardial perfusion scans showed ongoing inducible ischemia in the anterior and anterolateral walls (Figure 2). He consequently underwent surgical enlargement of the LCA origin with a good final result. Figure 1. Invasive coronary angiography/aortogram at 2![Formula][1] years of age showing a proximal stenosis of the native left main stem coronary artery (black arrow). Figure 2. Technetium-99m–tetrofosmin perfusion scintigraphy performed at 5 years of age showing significant perfusion abnormalities in the anteroapical and anterolateral regions (white arrowheads). By 7\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{1}{2}\) \end{document} years of age, he had developed significantly reduced exercise tolerance, chest pain on exercise, and shortness of breath. … [1]: F1/embed/tex-math-2.gif

An unusual case of cardiac amyloidosis.

To the Editors:—The authors described an unusual case of cardiac amyloidosis and proposed a diagnostic algorithm that investigates amyloid deposition in other organs and cardiac assessment by echocardiography and endomyocardial biopsy. We note that in the proposed diagnostic work up of patients with suspected cardiac amyloidosis, cardiovascular magnetic resonance (CMR) was not included. We believe that CMR should be considered in the armamentarium of clinical available noninvasive imaging techniques that is worth mentioning. Cardiac amyloidosis can be diagnostically challenging, and our group has pioneered and investigated the role of CMR in detecting noninvasively amyloid deposition in the myocardium.1 Because of its unique capability of tissue characterization after the injection of gadolinium-chelate contrast agent, CMR shows a characteristic pattern of distribution of global subendocardial myocardial enhancement of the left ventricle. This finding corresponds to the transmural histologic distribution of amyloid protein confirmed at autopsy (dominantly subendocardial).1 The role of CMR in cardiac amyloidosis has been confirmed by other groups.2,3 Serum amyloid P component (SAP) scan is considered an effective noninvasive tool for diagnosis systemic AL amyloidosis but is not adequate for evaluating cardiac involvement.4 CMR is not available at all centers and requires experienced personnel, and therefore, biopsy remains the gold standard technique to diagnose amyloidosis in most centers. Ideally, a biopsy guided to the gadolinium-enhanced areas might reduce the potential of false negative biopsy result in these patients. Unfortunately, the patient discussed in the case description had a pacemaker, which represents one of few contraindications for a CMR scan.

Cardiovascular magnetic resonance myocardial perfusion: methods and applications in patients with coronary artery disease

Perfusion CMR is an attractive imaging modality that is becoming comparable with other clinically diagnostic tests. SPECT and PET are well clinically validated and have good accuracy for detection of significant CAD. However, these techniques have a rather low spatial resolution and are not suitable for the detection of subendocardial perfusion defect. In addition, the radiation burden, the potential for attenuation artefacts (SPECT) and the limited availability (PET) are limitations of these imaging techniques. An integrated assessment of myocardial perfusion, function and viability is feasible with CMR. In addition, compared to other clinically available imaging techniques, CMR perfusion has excellent spatial resolution and no ionising radiation exposure. However, it is not widely available and there is a need of protocol and pulse sequence standardization. Most perfusion analysis remains observer-dependent (“eyeball” analysis) or dependent on bolus dispersion (semi-quantitative analysis). Fully quantitative analysis using CMR perfusion is currently time-consuming for clinical application. Perfusion CMR is an evolving field with numerous future directions.

Perfusion Cardiovascular Magnetic Resonance in a Child With Ischemic Heart Disease

19-month-old boy presented with acute cardiac failureand was found to have an anomalous origin and courseof the left coronary artery (LCA). It arose from the anterioraortic sinus and was compressed between the aorta and thepulmonary artery. He underwent placement of a left internalmammary artery graft to the left anterior descending coronaryartery and made a good recovery. At 2A 19-month-old boy presented with acute cardiac failure and was found to have an anomalous origin and course of the left coronary artery (LCA). It arose from the anterior aortic sinus and was compressed between the aorta and the pulmonary artery. He underwent placement of a left internal mammary artery graft to the left anterior descending coronary artery and made a good recovery. At 2\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{1}{2}\) \end{document} years of age, he had mild limitation of physical exertion. Cardiac catheterization showed the left internal mammary artery graft to be occluded and the proximal course of the LCA origin to be significantly narrowed (Figure 1). Serial technetium-99m single-photon emission computed tomography (SPECT) myocardial perfusion scans showed ongoing inducible ischemia in the anterior and anterolateral walls (Figure 2). He consequently underwent surgical enlargement of the LCA origin with a good final result. Figure 1. Invasive coronary angiography/aortogram at 2![Formula][1] years of age showing a proximal stenosis of the native left main stem coronary artery (black arrow). Figure 2. Technetium-99m–tetrofosmin perfusion scintigraphy performed at 5 years of age showing significant perfusion abnormalities in the anteroapical and anterolateral regions (white arrowheads). By 7\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(\frac{1}{2}\) \end{document} years of age, he had developed significantly reduced exercise tolerance, chest pain on exercise, and shortness of breath. … [1]: F1/embed/tex-math-2.gif