Manuel Barreiro-Pérez

Dynamic Edematous Response of the Human Heart to Myocardial Infarction: Implications for Assessing Myocardial Area at Risk and Salvage

Background: Clinical protocols aimed to characterize the post–myocardial infarction (MI) heart by cardiac magnetic resonance (CMR) need to be standardized to take account of dynamic biological phenomena evolving early after the index ischemic event. Here, we evaluated the time course of edema reaction in patients with ST-segment–elevation MI by CMR and assessed its implications for myocardium-at-risk (MaR) quantification both in patients and in a large-animal model. Methods: A total of 16 patients with anterior ST-segment–elevation MI successfully treated by primary angioplasty and 16 matched controls were prospectively recruited. In total, 94 clinical CMR examinations were performed: patients with ST-segment–elevation MI were serially scanned (within the first 3 hours after reperfusion and at 1, 4, 7, and 40 days), and controls were scanned only once. T2 relaxation time in the myocardium (T2 mapping) and the extent of edema on T2-weighted short-tau triple inversion-recovery (ie, CMR-MaR) were evaluated at all time points. In the experimental study, 20 pigs underwent 40-minute ischemia/reperfusion followed by serial CMR examinations at 120 minutes and 1, 4, and 7 days after reperfusion. Reference MaR was assessed by contrast-multidetector computed tomography during the index coronary occlusion. Generalized linear mixed models were used to take account of repeated measurements. Results: In humans, T2 relaxation time in the ischemic myocardium declines significantly from early after reperfusion to 24 hours, and then increases up to day 4, reaching a plateau from which it decreases from day 7. Consequently, edema extent measured by T2-weighted short-tau triple inversion-recovery (CMR-MaR) varied with the timing of the CMR examination. These findings were confirmed in the experimental model by showing that only CMR-MaR values for day 4 and day 7 postreperfusion, coinciding with the deferred edema wave, were similar to values measured by reference contrast-multidetector computed tomography. Conclusions: Post-MI edema in patients follows a bimodal pattern that affects CMR estimates of MaR. Dynamic changes in post–ST-segment–elevation MI edema highlight the need for standardization of CMR timing to retrospectively delineate MaR and quantify myocardial salvage. According to the present clinical and experimental data, a time window between days 4 and 7 post-MI seems a good compromise solution for standardization. Further studies are needed to study the effect of other factors on these variables.

Effect of Ischemia Duration and Protective Interventions on the Temporal Dynamics of Tissue Composition After Myocardial Infarction

Rationale: The impact of cardioprotective strategies and ischemia duration on postischemia/reperfusion (I/R) myocardial tissue composition (edema, myocardium at risk, infarct size, salvage, intramyocardial hemorrhage, and microvascular obstruction) is not well understood. Objective: To study the effect of ischemia duration and protective interventions on the temporal dynamics of myocardial tissue composition in a translational animal model of I/R by the use of state-of-the-art imaging technology. Methods and Results: Four 5-pig groups underwent different I/R protocols: 40-minute I/R (prolonged ischemia, controls), 20-minute I/R (short-duration ischemia), prolonged ischemia preceded by preconditioning, or prolonged ischemia followed by postconditioning. Serial cardiac magnetic resonance (CMR)-based tissue characterization was done in all pigs at baseline and at 120 minutes, day 1, day 4, and day 7 after I/R. Reference myocardium at risk was assessed by multidetector computed tomography during the index coronary occlusion. After the final CMR, hearts were excised and processed for water content quantification and histology. Five additional healthy pigs were euthanized after baseline CMR as reference. Edema formation followed a bimodal pattern in all 40-minute I/R pigs, regardless of cardioprotective strategy and the degree of intramyocardial hemorrhage or microvascular obstruction. The hyperacute edematous wave was ameliorated only in pigs showing cardioprotection (ie, those undergoing short-duration ischemia or preconditioning). In all groups, CMR-measured edema was barely detectable at 24 hours postreperfusion. The deferred healing-related edematous wave was blunted or absent in pigs undergoing preconditioning or short-duration ischemia, respectively. CMR-measured infarct size declined progressively after reperfusion in all groups. CMR-measured myocardial salvage, and the extent of intramyocardial hemorrhage and microvascular obstruction varied dramatically according to CMR timing, ischemia duration, and cardioprotective strategy. Conclusions: Cardioprotective therapies, duration of index ischemia, and the interplay between these greatly influence temporal dynamics and extent of tissue composition changes after I/R. Consequently, imaging techniques and protocols for assessing edema, myocardium at risk, infarct size, salvage, intramyocardial hemorrhage, and microvascular obstruction should be standardized accordingly.

Cardio-Onco-Hematology in Clinical Practice. Position Paper and Recommendations

Improvements in early detection and treatment have markedly reduced cancer-related mortality. However survival not only depends on effectively cure cancer, but prevention, diagnosis and treatment of cancer-related complications is also needed. Cardiovascular toxicity is a widespread problem across many classes of therapeutic schemes, however scientific evidence in the management of cardiovascular complications of onco-hematological patients is scarce, as these patients have been systematically excluded from clinical trials and current recommendations are based on expert consensus. Multidisciplinary teams are mandatory to decrease morbidity and mortality from both cardiotoxicity and cancer itself. An excessive concern for the occurrence of cardiovascular toxicity, can avoid potentially curative therapies, while underestimating this risk, increases long-term mortality of cancer survivors. The objective of this consensus document, developed in collaboration of the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology and the Spanish Society of Hematology, is to update the necessary concepts and expertise on cardio-onco-hematology that enable its application in daily clinical practice and to promote the development of local multidisciplinary teams, to improve the cardiovascular health of patients with cancer.

Percutaneous Closure of Paravalvular Leaks: A Systematic Review.

Paravalvular leak (PVL) is an uncommon yet serious complication associated with the implantation of mechanical or bioprosthetic surgical valves and more recently recognized with transcatheter aortic valves implantation (TAVI). A significant number of patients will present with symptoms of congestive heart failure or haemolytic anaemia due to PVL and need further surgical or percutaneous treatment. Until recently, surgery has been the only available therapy for the treatment of clinically significant PVLs despite the significant morbidity and mortality associated with re-operation. Percutaneous treatment of PVLs has emerged as a safe and less invasive alternative, with low complication rates and high technical and clinical success rates. However, it is a complex procedure, which needs to be performed by an experienced team of interventional cardiologists and echocardiographers. This review discusses the current understanding of PVLs, including the utility of imaging techniques in PVL diagnosis and treatment, and the principles, outcomes and complications of transcatheter therapy of PVLs.

Measuring the aorta in the era of multimodality imaging: still to be agreed

Thoracic aortic dilatation is associated with major vascular complications with fatal consequences, such as dissection and aortic rupture. We can predict the risk of rupture or dissection based on aortic size (1,2). Broad spectrum of aortic complications benefits from different cardiac imaging techniques: transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, aortic dilatation is one of the most frequent clinical entities for request in cardiac imaging laboratories, both for the initial diagnosis and the monitoring and establishment of the optimal timing for surgery.

Left Atrial Appendage Occlusion in the Presence of Thrombus With a LAmbre Device

A 76-year-old man with nonvalvular atrial fibrillation under oral anticoagulant treatment with direct inhibitor of factor Xa was admitted because of systemic embolism. Transesophageal echocardiogram showed a thrombus in a “chicken wing” left atrial appendage (LAA). The patient was discharged on

First-in-Man Percutaneous Transseptal Closure of Paravalvular Regurgitation After Percutaneous Valve-in-Ring Implantation

A 73-year-old man with permanent atrial fibrillation, coronary artery disease revascularized with coronary artery bypass grafting, mitral valve repair with a 30-mm Carpentier Physio ring (Edwards Lifesciences, Irvine, California), tricuspid valve repair with a 34-mm Edwards MC3 ring (Edwards

Individual chamber segmentation in congenital heart disease

Monitoring complex congenital heart disease patients in specialized centers using magnetic resonance (MR) imaging is recommended to prevent late complications. 3D imaging techniques provide better spatial comprehension; however, fully automatic recognition in these patients is difficult. To improve this, the authors propose semi-automatic individual chamber segmentation created from a contrast-enhanced MR angiography. As examples, a heart with no structural pathology and two common surgical procedures are shown in Figure 1. Each cardiac chamber has been independently processed as individual volume with commercial software (CT Viewer, Philips Healthcare). The whole heart imaging is the sum of each volume, so the user could remove or include any volume individually. This approach may be especially

Severely complicated emergency blind pericardiocentesis: Evidence from multimodality imaging

Figure 1 Multimodality imaging of the path of the pericardiocentesis catheter crossing the aortic valve to the ascending aorta. (A) Two-dimensional transesophageal echocardiogram, left ventricular outflow tract projection; (B) computed tomography curved format reconstruction along the catheter; (C) three-dimensional volume-rendered computed tomography reconstruction of the catheter insertion point and its relationship with the anterior descending artery.

3D-printing in Preprocedural Planning of Paravalvular Leak Closure: Feasibility/Proof-of-concept

Ignacio Cruz-González, Manuel Barreiro-Pérez,* and Israel Valverde Departamento de Cardiologı́a, Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBER-CV), Salamanca, Spain Cardiologı́a Pediátrica, Grupo de Innovación Tecnológica, Unidad de Patologı́a Cardiovascular, Hospital Virgen del Rocı́o, Instituto de Biomedicina de Sevilla (IBIS), Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBER-CV), Sevilla, Spain Division of Imaging Sciences and Biomedical Engineering, King’s College London, The Rayne Institute, St Thomas’ Hospital, London, United Kingdom