Darius Palionis

Value of scar imaging and inotropic reserve combination for the prediction of segmental and global left ventricular functional recovery after revascularisation

BackgroundThis study sought to prospectively and directly compare three cardiovascular magnetic resonance (CMR) viability parameters: inotropic reserve (IR) during low-dose dobutamine (LDD) administration, late gadolinium enhancement transmurality (LGE) and thickness of the non-contrast-enhanced myocardial rim surrounding the scar (RIM). These parameters were examined to evaluate their value as predictors of segmental left ventricular (LV) functional recovery in patients with LV systolic dysfunction undergoing surgical or percutaneous revascularisation. The second goal of the study was to determine the optimal LDD-CMR- and LGE-CMR-based predictor of significant (≥ 5%) LVEF improvement 6 months after revascularisation.MethodsIn 46 patients with chronic coronary artery disease (CAD) (63 ± 10 years of age, LVEF 35 ± 8%), wall motion and the above mentioned CMR parameters were evaluated before revascularisation. Wall motion and LGE were repeatedly assessed 6 months after revascularisation. Logistic regression analysis models were created using 333 dysfunctional segments at rest.ResultsAn LGE threshold value of 50% (LGE50) and a RIM threshold value of 4 mm (RIM4) produced the best sensitivities and specificities for predicting segmental recovery. IR was superior to LGE50 for predicting segmental recovery. When the areas under the ROC curves is compared, the combined viability prediction model (LGE50 + IR) was significantly superior to IR alone in all analysed sets of segments, except the segments with an LGE from 26% to 75% (p = 0.08). The RIM4 model was not superior to the LGE50 model. A myocardial segment was considered viable if it had no LGE or had any LGE and produced IR during LDD stimulation. ROC analysis demonstrated that ≥ 50% of viable segments from all dysfunctional and revascularised segments in a patient predict significant improvement in LVEF with a 69% sensitivity and 70% specificity (AUC 0.7, p = 0.05). The cut-off of ≥ 3 viable segments was a less useful predictor of significant global LV recovery.ConclusionsLDD-CMR is superior to LGE-CMR as a predictor of segmental recovery. The advantage is greatest in the segments with an LGE from 26% to 75%. The RIM cut-off value of 4 mm had no superiority over the LGE cut-off value of 50% in predicting the segmental recovery. Patients with ≥ 50% of viable segments from all dysfunctional and revascularised had a tendency to improve LVEF by ≥ 5% after revascularisation.

Prediction of long-term segmental and global functional recovery of hibernating myocardium after revascularisation based on low dose dobutamine and late gadolinium enhancement cardiovascular magnetic resonance

BackgroundThis study sought to evaluate the relation between long-term segmental and global functional outcome after revascularisation in patients with chronic ischaemic left ventricular dysfunction (LVD) and baseline markers of viability: late gadolinium enhancement (LGE) transmurality and contractile reserve (CR).MethodsForty-two patients with chronic ischaemic LVD underwent low-dose dobutamine- (LDD) and late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) before surgical or percutaneous revascularisation. Regional and global left ventricular (LV) functions and LGE were repeatedly assessed 6 ± 1 and 35 ± 6 months after revascularisation. In total, 319 at baseline dysfunctional and successfully revascularised segments were available for statistical analysis.ResultsThe likelihood of long-term functional improvement was directly related to the presence of CR and inversely related to both the LGE and the degree of contractile dysfunction at baseline. The time course of functional improvement was protracted, with significantly more delay in segments with more extensive LGE (p = 0.005) and more severe contractile dysfunction at baseline (p = 0.002). The presence of CR was the predictor of earlier functional improvement (p < 0.0001). Using a definition of viable segment as a segment without any LGE or with any LGE and producing CR during LDD stimulation, ≥55% of viable segments from all dysfunctional and revascularised segments in a patient was the only independent predictor of significant improvement (≥5%) in the left ventricular ejection fraction (LVEF) after revascularisation, with a 72% sensitivity and an 80% specificity (AUC 0.76, p = 0.014). Reverse LV remodelling was observed in patients who had a significant amount of viable myocardium successfully revascularised.ConclusionsIn patients with chronic ischaemic LVD, improvement of dysfunctional but viable myocardium can be considerably delayed. Both the likelihood and the time course of functional improvement are related to the LGE, CR and the degree of contractile dysfunction at baseline. At 35 ± 6 months after revascularisation, patients with ≥55% of viable segments from all dysfunctional and revascularised segments significantly improve LVEF and experience reverse LV remodelling. A combination of LDD-CMR and LGE-CMR is a simple and powerful tool for identifying which patients with impaired LV function will benefit from revascularisation.

Prevalence and clinical significance of extracardiac findings in cardiovascular magnetic resonance.

OBJECTIVE In cardiac magnetic resonance imaging (CMR), incidental pathological findings are frequently found outside the investigated cardiovascular system. Some of these findings might have clinical implications. The aim of this study was to determine the prevalence of incidental extracardiac findings (ECF) in CMR and their clinical significance. METHODS A total of 4165 CMR reports from 2009-2012 were retrospectively reviewed for ECF. Two hundred-twenty reports with ECF were found. For each case, we obtained information on sex, age of the patient, reported ECF and radiologist recommendation. Follow-up data were analyzed by reviewing available electronic medical records. ECF was considered clinically significant if there was an associated diagnosis, additional treatment or further investigations in the clinical follow-up data. RESULTS In total, 356 ECF were recorded in 220 (5.3%) CMR reports. Sixty (23.7%) of the 253 ECF with follow-up data available were clinically significant. The most prevalent ECF were pleural effusions (n=54), kidney cysts (n=54), diffuse lung parenchyma changes (n=33) and liver cysts (n=29). Adrenal pathology (n=3, 100% significant), renal masses (n=3, 100%) and pulmonary masses (n=5, 62.5%) were the most clinically significant ECF. Although prevalence of these ECF was low, they were significant particularly frequently. When radiologist recommendations for further investigation were present in the report, the frequency of clinically significant ECF was higher compared to reports with no further investigation recommended (p<0.001). CONCLUSION In this study, ECF in CMR were reported not very commonly (5.3%). A substantial part of ECF was clinically significant, changing patient diagnosis or management, with an overall prevalence of 1.3%.

Predictors of ischaemic mitral regurgitation recurrence in patients undergoing combined surgery: additional value of cardiovascular magnetic resonance imaging†

OBJECTIVES We aimed to evaluate (i) the effectiveness of combined surgery (coronary artery bypass grafting with restrictive mitral valve annuloplasty) and (ii) the late gadolinium enhancement cardiovascular magnetic resonance-based predictors of ischaemic mitral regurgitation (IMR) recurrence. METHODS The prospective analysis included 40 patients with multivessel coronary artery disease, IMR >II° and left ventricular (LV) dysfunction undergoing combined surgery. The degree of IMR and LV parameters were assessed preoperatively by transthoracic echocardiography, 3D transoesophageal echocardiography and cardiovascular magnetic resonance and postoperatively by transthoracic echocardiography. The effective mitral valve repair group (n = 30) was defined as having recurrent ischaemic mitral regurgitation (RIMR) ≤II° at the end of follow-up (25 ± 11 months). RESULTS The surgery was effective: freedom from RIMR >II° at 1 and 2 years after surgery was 80% and 75%, respectively. Using multivariable logistic regression, 2 independent predictors of RIMR >II° were identified: ≥3 non-viable LV segments (odds ratio 22, P = 0.027) and ≥1 non-viable segment in the LV posterior wall (odds ratio 11, P = 0.026). Using classification trees, the best combinations of cardiovascular magnetic resonance-based and 3D transoesophageal echocardiography-based predictors for RIMR >II° were (i) posterior mitral valve leaflet angle >40° and LV end-systolic volume index >45 ml/m2 (sensitivity 100%, specificity 89%) and (ii) scar transmurality >68% in the inferior LV wall and EuroSCORE II >8 (sensitivity 83%, specificity 78%). CONCLUSIONS There is a clear relationship between the amount of non-viable LV segments, especially in the LV posterior and inferior walls, and the recurrence of IMR after the combined surgery.

Heart involvement in Churg-Strauss syndrome

Address for correspondence: Dr. Sigita Glaveckaite, Department of Cardiovascular Medicine, Vilnius University, Vilnius, Lithuania; Cardiology and Angiology Centre, Vilnius University Hospitals Santariskiu Klinikos, Santariskiu 2, LT 08661, Vilnius, Lithuania, tel: +370 68862835; fax: +370 5 2322251, e-mail: sigita.glaveckaite@santa.lt Conflict of interest: none declared Kardiologia Polska Copyright

Intramyocardial haemorrhage as a rare complication of myocardial infarction — the diagnostic value of cardiovascular magnetic resonance imaging

A 77-year-old man with a one-month history of Q wave inferior-inferolateral ST segment elevation myocardial infraction (STEMI) was referred to our hospital for coronary artery bypass grafting (CABG). STEMI was treated conservatively because of delayed presentation (> 48 h after acute episode). Coronary angiography at this time revealed occlusion of obtuse marginal (OM) II (culprit artery), stenosis in the left anterior descending artery (LAD) of 80%, right coronary artery (RCA) of 90%, and OM I of 50%. On admission to our hospital, electrocardiogram (ECG) showed sinus rhythm with Q waves and ST segment elevation in leads III and AVF. On chest X-ray, cardiac enlargement was noticed. Transthoracic echocardiography revealed hypokinesis in the inferior and inferolateral left ventricular (LV) walls with the separation of pericardial layers up to 25 mm with fluid in-between (Fig. 1A, asterisk) together with bilateral pleural effusion and a markedly reduced LV ejection fraction of 35%. Pericardial and bilateral pleural effusions were considered as signs of congestion due to LV dysfunction. The patient was directed to CABG, but after sternotomy and pericardiotomy thickened pericardium and blood clots in the pericardial sac at the right ventricular (RV) free-wall and LV inferior wall without clear signs of myocardial rupture were found. The decision to perform drainage of the pericardial sac with deferment of the CABG due to the increased bleeding risk was made. 1.5 T cardiac magnetic resonance (CMR) imaging was performed for clarification of the diagnosis. CMR revealed microvascular obstruction with intramyocardial haemorrhage (IMH) in the infarcted LV inferolateral wall without rupture (Fig. 1B–I). After uneventful course, the patient was scheduled to percutaneous coronary intervention. We believe that the haemopericardium was due to myocardial necrosis that transformed into IMH with subsequent micro bleeds into the pericardial space.

Acquired Gerbode defect – a rare complication of myocardial infarction

Received 16 June 2016; accepted for publication 26 July 2016. A 74-year-old man was admitted due to Q wave inferior STEMI. Coronary angiography revealed acute occlusion of a small distal segment (S15) of the left circumflex artery and a conservative treatment strategy was chosen. The course of the STEMI was uncomplicated. Transthoracic echocardiography (TTE) was performed two times and revealed the true aneurysm of the basal part of the left ventricular (LV) inferior and inferoseptal walls. Before STEMI the patient was treated for 13 years with NSAIDs due to rheumatoid arthritis. Three months after STEMI the patient was consulted by a cardiologist on a routine basis. He had no complaints. On heart auscultation a holosystolic murmur of grade IV was heard at the left sternal border. TTE revealed a saccular basal inferoseptal and inferior pseudoaneurysm (pAn) with its rupture into the coronary sinus (CS) near the CS ostium causing an intracardiac shunt between the LV and the right atrium Acquired Gerbode defect – a rare complication of myocardial infarction

Early ischemic brain lesions after carotid angioplasty and stenting on diffusion-weighted magnetic resonance imaging study

Summary Aim: The aim of the paper is to evaluate the appearance of the new early ischemic lesions in the brain after carotid angioplasty and stenting on diffusion-weighted magnetic resonance imaging, and their relationship with clinical and procedural factors. Methods: Carotid artery stenting (CAS) procedures performed by a single interventional cardiologist in years November 2006 to January 2013 were evaluated retrospectively. In total, 227 procedures for 211 patients (mean age 69.8 ± 8.5 years) were performed, from which 171 (75.3%) for male and 56 (24.7%) for female patients. Seventy-two (34.1%) patients had symptomatic stenosis of carotid artery. The following protection systems to avoid the distal microembolism were used during the CAS: (1) Filters: FilterWire EZ (Boston Scientific Corporation); Emboshield NAV (Abbott Vascular); SpideRX (EV3); Defender (Medtronic); FiberNet Filter (Invatec-Medtronic); (2) Occlusion MoMa Baloon System (Invatec-Medtronic). Acute ischemic damages of the brain before and after CAS procedure were diagnosed using magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) sequences. Sixty-five (30.8%) patients underwent MRI test. Exact and asymptomatic χ2 criteria were applied for testing the hypothesis of inter-dependency of the symptoms. Results: Forty-six (70.8%) patients had new ischemic foci in the brain on MRI DWI after CAS procedures. Among those patients, focal damage of the brain was diagnosed in 36 (78.3%) cases; linear damage of the brain - in 9 (19.6%) patients; ipsilateral damage of the brain - in 37 (80.4%) patients; bilateral damage of the brain - in 16 (34.8%) patients, 38 (82.6%) patients were diagnosed with forebrain damage; 4 (8.7%) patients were diagnosed with damage of brainstem; 5 (10.9%) patients were diagnosed with cerebellum damage. Clinical symptoms of brain damage were diagnosed only for 2 (4.3%) patients. Focal damage of the brain was significantly less frequent only for aortic arch type 1, if compared with aortic arch type 2 and 3: 64.3%, 93.3% and 100.0%, respectively (p < 0.05). Focal damage of the brain occurred least in patients (28.6%) with Emboshield NAV protection type, if compared to other types of protection (71.4-100.0%). Linear >10mmbrain damage was less frequent when using FilterWire EZ, Emboshield NAV and SpideRX protection type. Ipsilateral ischemic brain damage also occurred less frequent when using Emboshield NAV protection type; bilateral damage occurred less frequent when using FilterWire EZ, Emboshield NAV and SpideRX protection type. Ischemic forebrain damage was also diagnosed less often in patients for whom protection type FilterWire EZ and Emboshield NAV was applied. Conclusions: Most frequent findings by MRI after CAS procedures were focal, ipsilateral and forebrain damage (about 80%), but less than 5% patients had clinical symptoms. In the case of aorta arch type 1 focal ischemic damage of the brain was significantly less frequent, then in aortic arch type 2 and 3. The localization and extent of brain damage was associated with the type of protection systems that have been used.

Multimodality imaging in a rare case of tuberculous pericarditis

A 26-year-old female presented with a 1-month history of chest pain, low-grade fever, and dyspnoea. The pericardial friction rub was audible. Electrocardiogram and chest X-ray were normal; mild monocytosis, and slightly elevated C-reactive protein were observed. The separation of pericardial layers up to 6 mm due to non-homogeneous fluid ( Panel A, arrows ) was observed on the transthoracic echocardiography (Supplementary data online, Movie S1 ). Interventricular septum (IS) bounce towards …