Eduardo Pozo

Value of CMR for the Differential Diagnosis of Cardiac Masses

OBJECTIVESnThe goal of this study was to evaluate the diagnostic value of CMR features for the differential diagnosis of cardiac masses.nnnBACKGROUNDnDifferentiation of cardiac tumors and thrombi and differentiation of benign from malignant cardiac neoplasms is often challenging but important in clinical practice. Studies assessing the value of cardiac magnetic resonance (CMR) in this regard are scarce.nnnMETHODSnWe reviewed the CMR scans of patients with a definite cardiac thrombus or tumor. Mass characteristics on cine, T1-weighted turbo spin echo (T1w-TSE) and T2-weighted turbo spin echo (T2w-TSE), contrast first-pass perfusion (FPP), post-contrast inversion time (TI) scout, and late gadolinium enhancement (LGE) sequences were analyzed.nnnRESULTSnThere were 84 thrombi, 17 benign tumors, and 25 malignant tumors in 116 patients. Morphologically, thrombi were smaller (median area 1.6 vs. 8.5 cm(2); p < 0.0001), more homogeneous (99% vs. 46%; p < 0.0001), and less mobile (13% vs. 33%; p = 0.007) than tumors. Hyperintensity compared with normal myocardium on T2w-TSE, FPP, and LGE were more common in tumors than in thrombi (85% vs. 42%, 70% vs. 4%, and 71% vs. 5%, respectively; all p < 0.0001). A pattern of hyperintensity/isointensity (compared with normal myocardium) with short TI and hypointensity with long TI was very frequent in thrombi (94%), rare in tumors (2%), and had the highest accuracy (95%) for the differentiation of both entities. Regarding the characterization of neoplastic masses, malignant tumors were larger (median area 11.9 vs. 6.3 cm(2); p = 0.006) and more frequently exhibited FPP (84% vs. 47%; p = 0.03) and LGE (92% vs. 41%; p = 0.001). The ability of CMR features to distinguish benign from malignant neoplasms was moderate, with LGE showing the highest accuracy (79%).nnnCONCLUSIONSnCMR features demonstrated excellent accuracy for the differentiation of cardiac thrombi from tumors and can be helpful for the distinction of benign versus malignant neoplasms.

Cardiac magnetic resonance evaluation of left ventricular remodelling distribution in cardiac amyloidosis

Background Cardiac amyloidosis (CA) is associated with typical morphological features on echocardiography, including concentric LV hypertrophy (LVH). Cardiac magnetic resonance (CMR) can accurately depict anatomy in different cardiomyopathies. Our aim was to describe the morphological features and remodelling patterns of CA with CMR, and establish their diagnostic accuracy, as well as the value of traditional diagnostic criteria derived from echocardiography and electrocardiography. Methods Consecutive patients referred for CMR for possible CA were retrospectively evaluated. The diagnosis of CA was established in the presence of a positive cardiac biopsy and/or a typical pattern of myocardial late gadolinium enhancement. Morphological parameters were obtained from standard cine sequences. The presence and distribution of LVH, relative wall thickness (RWT) and LV remodelling patterns were determined. Results 130 patients (92 males (70.8%), age 64±13u2005years) were included. CA was diagnosed in 51 (39.2%). Patients with CA had increased LV wall thickness and LV mass index. An LV remodelling pattern different from concentric LVH was found in 42% of patients with CA, and asymmetric LVH was noted in 68.6%. A model including RWT, asymmetric LVH, and LVMI showed diagnostic accuracy of 88%, sensitivity of 67% and specificity of 86% for CA detection. Traditional diagnostic criteria for CA showed high specificity but poor sensitivity. Conclusions Asymmetric LVH and remodelling patterns different from concentric LVH are common in CA. Increased LV mass index, increased RWT, and asymmetric LVH are independently associated with the diagnosis. Traditional diagnostic criteria show poor sensitivity.

Characterization and clinical significance of right ventricular mechanics in pulmonary hypertension evaluated with cardiovascular magnetic resonance feature tracking

BackgroundPrognosis in pulmonary hypertension (PH) is related to right ventricular (RV) function. Quantification of RV mechanics may offer additive value. The objective of our study is to determine the feasibility and clinical and prognostic value of RV strain analysis by cardiovascular magnetic resonance (CMR) based feature tracking (FT) in PH.MethodsWe retrospectively enrolled 116 patients (age 52.2u2009±u200912xa0years, 73.6xa0% women) referred to CMR for PH evaluation who underwent right heart catheterization within 1xa0month. Using dedicated FT software, peak global longitudinal and circumferential RV strain and strain rates (GLS, GCS, GLSR, and GCSR, respectively) were quantified from standard cine images. Using multivariate regression analysis, we evaluated the associations of strain with a composite endpoint of death, lung transplantation, or functional class deterioration.ResultsRV strain analysis was feasible in 110 (95xa0%) patients. Patients were classified into: Group A (no PH, normal right ventricular ejection fraction [RVEF]; nu2009=u200917), Group B (PH, normal RVEF; nu2009=u200926), or Group C (PH, abnormal RVEF; nu2009=u200967). All strain and strain rate values were reduced in Group C. Furthermore, GCSR was significantly reduced in Group B (-0.92 [-1.0/-0.7]; pu2009<u20090.001) compared to Group A (-1.12 [-1.3/-0.9]; pu2009<u20090.001). After adjustment for six clinically meaningful covariates, GLS (hazard ratio 1.06; pu2009=u20090.026), GLSR (hazard ratio 2.52; pu2009=u20090.04), and GCSR (hazard ratio 4.5; pu2009=u20090.01) were independently associated with the composite endpoint. GCSR successfully discriminated patients with and without events (pu2009=u20090.01).ConclusionsQuantification of RV strain with CMR-FT is feasible in the majority of patients, correlates with disease severity, and is independently associated with poor outcomes in PH.

Diagnostic accuracy of coronary ct for the quantification of the syntax score in patients with left main and/or 3-vessel coronary disease. Comparison with invasive angiography

BACKGROUNDnThe SYNTAX score helps in the treatment decision in multivessel coronary disease. Coronary computed tomography angiography (CTA) can measure the SYNTAX score but has been used in few patients with multivessel disease. Our aim was to assess the feasibility, accuracy and reproducibility of SYNTAX score with CCTA compared with invasive coronary angiography (ICA) in de novo left main and/or 3-vessel disease.nnnMETHODSn57 patients with new left main and/or 3-vessel disease on ICA and a CCTA performed within the previous month were included. The SYNTAX score was calculated retrospectively for both modalities. Agreement for the global score, vessel score, different components and inter-readers was evaluated with intraclass correlation coefficient (ICC). The ability to classify SYNTAX score categories (low, intermediate and high) was assessed using weighted kappa (K) coefficient.nnnRESULTSnCCTA-based SYNTAX score showed an acceptable concordance (ICC=0.64) and good correlation (r=0.65, p<0.001) with ICA. ICC per vessel and component ranged from 0 to 0.73. There was good agreement classifying the SYNTAX score categories (K=0.53) and interobserver reproducibility (ICC=0.85). CCTA demonstrated high diagnostic accuracy (0.84) for detecting patients in the high score group. No patient with a high CCTA SYNTAX score had a low risk score by ICA that would suggest benefit from percutaneous revascularization.nnnCONCLUSIONSnCCTA showed good correlation, acceptable concordance, and high reproducibility for the quantification of the SYNTAX score in de novo left main and/or 3-vessel coronary disease. A high CCTA SYNTAX score identified a group of patients less likely to benefit from percutaneous coronary intervention.

Pronóstico hospitalario de la endocarditis protésica tras cirugía urgente

Introduccion y objetivos La endocarditis protesica conlleva una alta morbimortalidad, mas aun si precisa cirugia urgente. Determinar los factores predictores de mal pronostico es el primer paso para disminuirla. Nuestro objetivo es definir el perfil de los pacientes con endocarditis protesica que precisan cirugia urgente e identificar los factores predictores de mortalidad hospitalaria en este grupo de alto riesgo. Metodos De una base de datos que incluye un total de 648 casos de endocarditis infecciosa diagnosticados consecutivamente en cuatro centros terciarios con cirugia cardiaca entre 1996 y 2006, 46 fueron endocarditis protesicas izquierdas y precisaron cirugia urgente. Hemos realizado un estudio retrospectivo de las principales caracteristicas de estos pacientes y un analisis para determinar los factores asociados a una mayor mortalidad hospitalaria. Resultados Las principales indicaciones de cirugia urgente fueron la insuficiencia cardiaca (57%) y la infeccion persistente (33%). La mortalidad hospitalaria fue del 41%. Los factores asociados a un peor pronostico (pxa0 Conclusiones La endocarditis protesica es una enfermedad con una alta mortalidad cuando precisa cirugia urgente. Aunque la insuficiencia cardiaca es la principal causa de cirugia urgente, no empeora el pronostico hospitalario. Las vegetaciones y la falta de control de la infeccion son los factores asociados a mortalidad hospitalaria en los pacientes con endocarditis infecciosa izquierda intervenidos urgentemente.

In-Hospital Prognosis of Prosthetic Valve Endocarditis After Urgent Surgery

INTRODUCTION AND OBJECTIVESnProsthetic valve endocarditis is associated with high morbidity and mortality, particularly when urgent surgery is needed. The identification of factors that predict a poor prognosis is the first step in improving outcomes. The study objectives were to characterize patients with prosthetic valve endocarditis who need urgent surgery and to identify factors that predict in-hospital mortality in this high-risk group.nnnMETHODSnFrom a database of 648 consecutive patients with infective endocarditis diagnosed between 1996 and 2006 at four tertiary-care centers with cardiac surgery facilities, 46 patients with left-sided prosthetic valve endocarditis who needed urgent surgery were identified. A retrospective study was carried out to determine these patients main characteristics and to identify predictors of in-hospital mortality.nnnRESULTSnThe main indications for urgent surgery were heart failure (57%) and persistent infection (33%). In-hospital mortality was 41%. Factors significantly associated with a poor prognosis were fever at admission, persistent infection, positive blood cultures, persistently positive cultures, and echocardiographic evidence of vegetations (P< .05). No specific microorganism was associated with a poor prognosis.nnnCONCLUSIONSnProsthetic valve endocarditis was associated with high mortality when urgent surgery was needed. Although heart failure was the principle reason for urgent surgery, it did not lead to a worse in-hospital prognosis. The presence of vegetations and uncontrolled infection were the main factors associated with higher in-hospital mortality in patients with left-sided infective endocarditis who needed urgent surgery.

Myocardial Amyloid Quantification with Look-Locker Magnetic Resonance Sequence in Cardiac Amyloidosis. Diagnostic Accuracy in Clinical Practice and Histological Validation

BACKGROUNDnCardiac magnetic resonance (CMR) has demonstrated its utility in the noninvasive diagnosis of cardiac amyloidosis (CA). Our aim was to evaluate the ability of standard Look-Locker sequences to quantify amyloid deposition in CA.nnnMETHODS AND RESULTSnConsecutive patients referred for CMR for possible CA were retrospectively evaluated. Positive cardiac biopsy and/or typical pattern of late gadolinium enhancement were required for the diagnosis of CA. Postcontrast T1 values were obtained from Look-Locker sequences and correlated with markers of severity of disease and major events. When cardiac biopsies were available, histological validation was determined. A total of 174 patients were included. A final diagnosis of CA was reached in 37.4%. Myocardial and endocardial T1 times, as well as the respective ratios with blood and skeletal muscle, were lower among patients with CA and demonstrated good diagnostic performance. The best parameters were myocardial/blood (area under the curve u20090.83; Pu2009<u2009.001) and endocardial/blood (area under the curve 0.84; Pu2009<u2009.001) T1 ratios. Among patients with CA, no associations were found between T1 ratios either with markers of amyloid burden or with prognostic variables. However, all T1 indexes showed significant correlations with histological quantification of amyloid deposition.nnnCONCLUSIONSnLook-Looker derived postcontrast T1 shows good diagnostic accuracy to detect CA and correlation with histological amyloid burden.

Myocardial fibrosis with T1 mapping and right ventricular performance in pulmonary hypertension

Pulmonary hypertension (PH) leads to progressive right ventricular (RV) dilatation, hypertrophy, and systolic dysfunction. PH is also associated with the presence of late gadolinium enhancement in the interventricular septum (IVS). Post-contrast T1 mapping is a previously validated non-invasive technique for the quantification of extracellular volume increase as a surrogate of diffuse interstitial fibrosis. The aim of our study was to evaluate the presence of septal fibrosis in PH patients with T1 mapping, and to investigate potential correlations with RV performance and hemodynamic status. Methods

Asymptomatic large aortic root thrombus after left ventricular assist device implantation detected by cardiac computed tomography.

A 65-year old male with past medical history of non-ischemic cardiomyopathy, heart failure with reduced ejection fraction of 5e10% and chronic atrial fibrillation on anticoagulation, was admitted to our hospital due to repeated episodes of flash pulmonary edema. After the patient was medically stabilized, a left ventricular assist device (LVAD) Thoratec HeartMate II was implanted as destination therapy. Anticoagulation was initiated the following day, but subsequently suspended for 24 hours due to lower gastrointestinal bleeding. Heparin-induced thrombocytopenia (HIT) was ruled by negative HIT antibody and serotonin reactive assay. An echocardiogram did not identify any complication in the immediate postoperative period. Per local protocol, gated cardiac computed tomography (CT) was performed, which showed a large thrombus (4.5 2.5 cm) in the aortic root (Panel A, arrowhead) involving the left and non-coronary sinuses, in close proximity to the left main coronary ostium (Panel B, arrow), and extending into the sinotubular junction and tubular aorta (Panel C). Pulmonary embolism was also detected in the distal right main pulmonary artery and proximal right upper lobar artery (Panel D, asterisk). Due to high operative risk, the patient was managed medically and discharged in hemodynamically stable conditions. The patient has been followed as an outpatient for more than a year without any clinical events.

LOW VERSUS STANDARD DOSE CORONARY ARTERY CALCIUM SCANNING

Radiation exposure associated with coronary artery calcium scanning (CACS) may contribute to its delayed acceptance despite inclusion in guidelines. This study was designed to assess the accuracy of CACS acquired at radiation doses lower than mammography (0.7 mSv) and low dose lung scanning (0.65