Laura Iacuzio

Long-Term Follow-Up of Patients With First-Time Chest Pain Having 64-Slice Computed Tomography

A paucity of data on outcome of coronary multislice computed tomography (CT) is available. The aim of this study was to assess the long-term follow-up of 64-slice CT in a homogenous patient group. In total 222 patients (136 men, 61%, 59 ± 11 years of age) with chest pain at intermediate risk of coronary artery disease (CAD) and no previous CAD underwent 64-slice CT. Coronary lesions were considered significant or not based on a threshold of 50% luminal narrowing. Plaques were classified as calcified, noncalcified, and mixed based on type. End point during follow-up was major adverse cardiac events (nonfatal myocardial infarction, unstable angina requiring hospitalization, myocardial revascularization). Coronary plaques were detected in 162 patients (73%). Coronary artery stenosis was significant in 62 patients. Normal arteries were found in 59 patients (27%). During a mean follow-up of 5 ± 0.5 years, 30 cardiac events occurred. Annualized event rates were 0% in patients with normal coronary arteries, 1.2% in patients with nonsignificant stenosis, and 4.2% in patients with significant stenosis (p <0.01). Predictors of cardiac events were presence of significant stenosis, proximal stenosis, and multivessel disease. Noncalcified and mixed plaques had the worse prognosis (p <0.05). In conclusion, 64-CT provides long-term incremental value in patients at intermediate risk of CAD.

Incremental value of normal adenosine perfusion cardiac magnetic resonance: Long-term outcome

BACKGROUND The purpose of the study was to determine the long-term prognostic value of normal adenosine stress cardiac magnetic resonance imaging (CMR) in patients referred for evaluation of myocardial ischemia. METHODS We reviewed 300 consecutive patients (age 65 ± 11 years, 74% male) with suspected or known coronary disease and normal wall motion who had undergone adenosine stress CMR negative for ischemia and scar. Most patients were at intermediate risk of coronary artery disease. The end points studied were all causes of mortality and major adverse cardiac events, including cardiac death, myocardial infarction, revascularization, and hospitalization for unstable angina. RESULTS During a mean follow-up of 5.5 years (mean = 5.4 ± 1.1), 16 patients died because of various causes (cardiac death in 5 patients). Three patients had a nonfatal myocardial infarction, 7 patients were hospitalized for revascularization, and 11 were medically treated for unstable angina. The annual cardiac event rate was 1.3% (0.78% in the first 3 years and 1.9% between the fourth and sixth years). The predictors of major adverse cardiac events in a multivariate analysis model were as follows: advanced age (hazard ratio [HR] 1.15, 95% confidence interval [95% CI] 1.02-1.30), diabetes (HR 17.5, 95% CI 2.2-140), and the habit of smoking (HR 5.9, 95% CI 1.0-35.5). For all causes of mortality, the only predictor was diabetes (HR 11.4, 95% CI 1.76-74.2). Patients with normal stress CMR had an excellent outcome during the 3 years after the study. The cardiac event rate was higher between the fourth and sixth years. CONCLUSION Over a 5.5-year period, a low event rate and excellent prognosis occurred in patients with normal adenosine stress CMR. Low- to intermediate-risk patients with a normal CMR are at low risk for subsequent cardiac events.

Contrast-enhanced magnetic resonance imaging guided decision making after primary percutaneous coronary intervention for acute ST-elevation inferior myocardial infarction

Coronary occlusion of large epicardial branches leads to profound ischemia at the infarct core, resulting in simultaneous necrosis of myocytes and endothelial cells. This process leads to microvascular obstruction in the infarct core, described as the no-reflow region in basic studies and documented in humans by contrast-enhanced magnetic resonance imaging and ultrasound. After coronary occlusion, contrast-enhanced magnetic resonance identifies myocardial infarction as a hyperenhanced region containing a hypoenhanced core. There is growing interest in incorporating its assessment into the evaluation of acute myocardial infarction because it is the key in defining specific therapeutic strategies and in directing the interventional therapy. We report a rare case of right ventricular infarction where contrast-enhanced magnetic resonance produced detailed images of myocardial perfusion pattern and tissue damage and directed the treatment after acute myocardial infarction.

Quantitative assessment of primary mitral regurgitation using left ventricular volumes obtained with new automated three-dimensional transthoracic echocardiographic software: A comparison with 3-Tesla cardiac magnetic resonance

BACKGROUND Quantitative assessment of primary mitral regurgitation (MR) using left ventricular (LV) volumes obtained with three-dimensional transthoracic echocardiography (3D TTE) recently showed encouraging results. Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time consuming. AIMS To investigate the accuracy and reproducibility of new automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for the quantification of LV volumes and MR severity in patients with isolated degenerative primary MR; and to compare regurgitant volume (RV) obtained with 3D TTE with a cardiac magnetic resonance (CMR) reference. METHODS Fifty-three patients (37 men; mean age 64±12 years) with at least mild primary isolated MR, and having comprehensive 3D TTE and CMR studies within 24h, were eligible for inclusion. MR RV was calculated using the proximal isovelocity surface area (PISA) method and the volumetric method (total LV stroke volume minus aortic stroke volume) with either CMR or 3D TTE. RESULTS Inter- and intraobserver reproducibility of 3D TTE was excellent (coefficient of variation≤10%) for LV volumes. MR RV was similar using CMR and 3D TTE (57±23mL vs 56±28mL; P=0.22), but was significantly higher using the PISA method (69±30mL; P<0.05 compared with CMR and 3D TTE). The PISA method consistently overestimated MR RV compared with CMR (bias 12±21mL), while no significant bias was found between 3D TTE and CMR (bias 2±14mL). Concordance between echocardiography and CMR was higher using 3D TTE MR grading (intraclass correlation coefficient [ICC]=0.89) than with PISA MR grading (ICC=0.78). Complete agreement with CMR grading was more frequent with 3D TTE than with the PISA method (76% vs 63%). CONCLUSION 3D TTE RV assessment using the new generation of automated software correlates well with CMR in patients with isolated degenerative primary MR.

Right-Sided Heart Structural and Functional Remodeling in Mitral Regurgitation Secondary to Mitral Valve Prolapse

Preoperative evaluation of the mitral valve but also of tricuspid valve and right ventricular (RV) function is mandatory in primary mitral regurgitation (MR) secondary to mitral valve prolapse (MVP). Tricuspid annulus (TA) diameter plays a pivotal role in the surgical decision to perform preventive combined tricuspid valve annuloplasty. Cardiac magnetic resonance (CMR) is the gold standard for the assessment of RV size and function. Based on 70 consecutive patients (17 women; mean age 64 ± 12) with severe MR secondary to MVP referred for CMR, we sought to assess RV geometry and function and TA dimensions and to study the interaction between TA dilatation and right-sided cardiac chambers. Frequency of RV dilatation, RV systolic dysfunction, and TA dilatation (TA diameter ≥ 40 or 21 mm/m²) were 11%, 51%, and 49%, respectively. Left ventricular (LV) end-diastolic volume index was the only independent predictor of RV dilatation. Presence of symptoms, larger LV end-diastolic volume index, and LV ejection fraction <60% were independently associated with RV dysfunction. Absolute TA diameter was 36 ± 6 mm and TA diameter index was 20 ± 3 mm/m². Reproducibility TA diameter measurement was excellent (coefficient of variation ≤10%). TR velocity >220 cm/s (odds ratio = 20.17; [3.57 to 113.90]; p = 0.001 and right atrial volume index ≥ 38 ml/m² (odds ratio = 13.44; [3.57 to 50.54]; p = 0.0001) were independent predictors of TA diameter ≥40 or 21 mm/m². CMR provides accurate right-sided cardiac chambers assessment and may help surgical planning of concomitant tricuspid valve annuloplasty before mitral valve repair in severe MR secondary to MVP. In conclusion, TA dilatation, RV enlargement, and dysfunction are related to pulmonary pressure and left-sided cardiac chambers enlargement, reflecting the long-standing consequences of severe MR.

TREATMENT OF CONGENITAL CORONARY FISTULA

Background: Congenital coronary artery fistulas (CAF) with significant clinical impact are extremely rare vascular anomalies. Little data are available. Aim: To determine the outcome of percutaneous closure of large hemodynamically significant CAF in young patients. Methods: We retrospectively

Multimodality imaging of a congenital diverticulum of the left ventricular outflow tract

A 40-year-old man with no coronary risk factors and no cardiac history was referred for chest pain and palpitations. Physical examination, electrocardiography, and chest X-ray were normal. Transthoracic echocardiography showed normal left ventricular size and function and a high-velocity jet alongside the left ventricular outflow tract (LVOT) at five-chamber view ( Panel A ; see Supplementary data online, Video S1 ). An outpouching structure next to the …

Usefulness of 3-Tesla cardiac magnetic resonance imaging in the assessment of aortic stenosis severity in routine clinical practice.

BACKGROUND Recently, 1.5-Tesla cardiac magnetic resonance imaging (CMR) was reported to provide a reliable alternative to transthoracic echocardiography (TTE) for the quantification of aortic stenosis (AS) severity. Few data are available using higher magnetic field strength MRI systems in this context. AIMS To evaluate the feasibility and reproducibility of the assessment of aortic valve area (AVA) using 3-Tesla CMR in routine clinical practice, and to assess concordance between TTE and CMR for the estimation of AS severity. METHODS Ninety-one consecutive patients (60 men; mean age 74±10years) with known AS documented by TTE were included prospectively in the study. RESULTS All patients underwent comprehensive TTE and CMR examination, including AVA estimation using the TTE continuity equation (0.81±0.18cm2), direct CMR planimetry (CMRp) (0.90±0.22cm2) and CMR using Hakkis formula (CMRhk), a simplified Gorlin formula (0.70±0.19cm2). Although significant agreement with TTE was found for CMRp (r=0.72) and CMRhk (r=0.66), CMRp slightly overestimated (bias=0.11±0.18cm2) and CMRhk slightly underestimated (bias=-0.11±0.17cm2) AVA compared with TTE. Inter- and intraobserver reproducibilities of CMR measurements were excellent (r=0.72 and r=0.74 for CMRp and r=0.88 and r=0.92 for peak aortic velocity, respectively). CONCLUSION 3-Tesla CMR is a feasible, radiation-free, reproducible imaging modality for the estimation of severity of AS in routine practice, knowing that CMRp tends to overestimate AVA and CMRhk to underestimate AVA compared with TTE.

Initial experience for first pass cardiac perfusion with iterative reconstruction in patients

Background MR stress perfusion is a non-invasive, reliable and safe test for ischemic heart disease [1]. Recent publications reported sensitivity and specificity of 89% and 80% respectively [2]. Image quality improvements seem to be essential for improving the predictive value of the method. This leads to the dilemma of finding a compromise between high spatial resolution and sufficient SNR. Lately iterative reconstruction demonstrated great promise in improving SNR [3]. The aim of the current study was to compare cardiac perfusion in 24 patients reconstructed with product and a novel prototype iterative reconstruction. Methods 24 patients (mean age 62 ±15) were examined on a 1.5T clinical MR scanner (MAGNETOM Aera, Siemens AG, Erlangen, Germany) using a saturation prepared TFL product sequence with the following parameters: TR/TE=331/1.4ms ; Flip angle = 12°; BW = 668Hz/Px; Voxel size=0.8×0.8×10.0 mm (inplane interpolated); FOV=290mm2; Matrix = 170x192; Slice thickness=10mm; Acceleration=2; Inversion time= 180ms; Phase oversampling=60%; Motion correction. Pharmacological stress was applied using Adenosine (Adenoscan, Sanofi-Synthelabo). Gadolinium-based contrast agent (Magnevist, Bayer Schering Pharma) was