Rafael Payá-Serrano

Late gadolinium enhancement-cardiovascular magnetic resonance identifies coronary artery disease as the aetiology of left ventricular dysfunction in acute new-onset congestive heart failure

AIMS We evaluated the ability of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance (CMR) to identify acute new-onset heart failure (HF) with left ventricular systolic dysfunction (LVSD), whether or not in relation to underlying coronary artery disease (CAD), in patients with no clinical evidence of associated ischaemic cardiomyopathy. METHODS AND RESULTS Hundred consecutive patients admitted with acute new-onset decompensated HF and EF <40%, with no clinical or electrocardiographic data suggestive of CAD. The patients were classified according to the presence or absence of significant CAD (stenosis > or =70% in at least one major vessel). Twenty-one patients (21%) had significant CAD. Seventy-nine (79%) had no lesions. Eighteen of the 21 patients (85%) with CAD had subendocardial/transmural LGE. In the diagnosis of CAD, LGE has a sensitivity of 85.7% (95% CI, 80-91) and specificity of 92.4% (95% CI, 87-96), respectively, with a negative predictive value of 96% (95% CI, 90-99). It has an area under the receiver operating characteristic curve of 0.906 (95% CI, 0.814-0.998). CONCLUSION In patients with new-onset HF and LVSD for whom there are no clinical and exploratory data suggestive of ischaemic heart disease, CMR with LGE is an excellent means of ruling out significant CAD and is a valid alternative to angiography.

Diagnóstico etiológico de la disfunción ventricular izquierda con tomografía computarizada: comparación con coronariografía y cardiorresonancia

INTRODUCTION AND OBJECTIVES To evaluate the capability of multidetector computed tomography to diagnose the coronary etiology of left ventricular dysfunction compared with using invasive coronary angiography and magnetic resonance. METHODS Forty consecutive patients with left ventricular dysfunction of uncertain etiology underwent invasive coronary angiography and contrast magnetic resonance. All patients were evaluated with multidetector computed tomography including coronary calcium presence and score, noninvasive coronary angiography, and myocardial tissue assessment. RESULTS The sensitivity and specificity of the presence of coronary calcium to identify left ventricular dysfunction was 100% and 31%, respectively. If an Agatston calcium score of >100 is taken, specificity increases to 58% with sensitivity still 100%. Sensitivity and specificity for coronary angiography by multidetector computed tomography was 100% and 96%, respectively; for identifying necrosis in contrast acquisition it was 57% and 100%, respectively; and in late acquisition, 84% and 96%, respectively. To identify coronary ventricular dysfunction with necrosis, the sensitivity and specificity was 92% and 100%, respectively. CONCLUSIONS Of all the diagnostic tools available in multidetector computed tomography, coronary angiography is the most accurate in determining the coronary origin of left ventricular dysfunction. A combination of coronary angiography and myocardial tissue study after contrast allows a single test to obtain similar information compared with the combination of invasive coronary angiography and contrast magnetic resonance.

Prognostic Value of Discharge Hemoglobin Level in Patients Hospitalized for Acute Heart Failure

INTRODUCTION AND OBJECTIVES Recent studies show that the prevalence of anemia in patients with heart failure is high and indicate that its presence leads to increased mortality and morbidity. Our aims were to determine the prevalence of anemia in patients hospitalized for heart failure and to study the long-term prognostic significance of anemia by evaluating its relationship with mortality (total and due to heart failure) and readmission for heart failure. METHODS The study included 242 consecutive patients admitted to our cardiology department and discharged with a diagnosis of congestive heart failure. The Kaplan-Meier technique and Cox regression modeling were used to determine whether anemia is an independent predictor of death or readmission for heart failure. Anemia was defined as a hemoglobin level <12 g/dL. The mean follow-up period was 23.5 (10.9) months. RESULTS Overall, 79 patients (32.6%) were anemic. During follow-up, 77 died (53 due to heart disease) and 117 were readmitted for heart failure. Multivariate analysis showed that anemia was an independent predictor of death (hazard ratio [HR]=1.85, 95% confidence interval [CI], 1.12-3.06), death due to heart disease (HR=1.88, 95% CI, 1.03-3.45), and readmission for heart failure (HR=1.87, 95% CI, 1.28-2.74). CONCLUSIONS The prevalence of anemia was high in patients hospitalized for heart failure. Moreover, a discharge hemoglobin level less than 12 g/dL was a predictor of all-cause death, cardiac death, and readmission for heart failure.

Valoración no invasiva de injertos aortocoronarios y coronarias nativas con tomografía computarizada de 64 detectores: comparación con la coronariografía invasiva

Introduccion y objetivos Aunque la tomografia computarizada (TC) multidetector muestra una elevada exactitud diagnostica en la valoracion no invasiva de las arterias coronarias e injertos, son escasos los trabajos que valoren su fiabilidad en el estudio conjunto de vasos nativos, injertos y vasos distales a las anastomosis. El objetivo de este estudio es valorar la exactitud diagnostica de la TC de 64 detectores en la valoracion de injertos coronarios y arterias coronarias nativas. Metodos Se estudia con TC de 64 detectores a 36 pacientes revascularizados quirurgicamente e indicacion clinica de evaluacion angiografica de sus injertos. Se analizo la exactitud diagnostica de la TC para la deteccion de lesiones significativas en los injertos y coronarias nativas comparando sus resultados con los de la coronariografia invasiva. Resultados De los 103 injertos referidos (49 arteriales y 54 venosos) se visualizaron 96 (93,2%) por coronariografia y 98 (95,1%) por TC. Los valores diagnosticos para los injertos mostraron una sensibilidad del 100% (30/30) y especificidad del 97% (64/66) y valores predictivos positivo (VPP) y negativo (VPN) del 94 y el 100%, respectivamente. Respecto a los vasos nativos no revascularizados (258 segmentos), se obtuvo sensibilidad del 94%, especificidad del 95%, VPP del 80% y VPN del 99%. La sensibilidad y la especificidad de la valoracion de vasos distales fueron del 86 y el 97% respectivamente, con VPP del 67% y VPN del 99%. Conclusiones La TC de 64 detectores presenta una alta exactitud diagnostica en la valoracion de los injertos coronarios y arterias coronarias nativas.

Valor pronóstico de las cifras de hemoglobina en el momento del alta en pacientes hospitalizados por insuficiencia cardiaca

Introduccion y objetivos Estudios recientes muestran una elevada prevalencia de anemia en pacientes con insuficiencia cardiaca y senalan que su presencia condiciona un aumento de la morbimortalidad. El objetivo de nuestro estudio fue determinar la prevalencia de anemia en pacientes dados de alta con diagnostico de insuficiencia cardiaca, estudiar su valor pronostico a largo plazo y evaluar la relacion entre anemia y mortalidad (total y cardiaca) y reingresos por nueva descompensacion. Metodos Analizamos una serie de 242 pacientes ingresados en el servicio de cardiologia y dados de alta con diagnostico de insuficiencia cardiaca. Utilizamos el metodo de Kaplan-Meier y el modelo de regresion de Cox para el estudio de la anemia como predictor independiente de mortalidad y reingresos por insuficiencia cardiaca. Consideramos anemia una cifra de hemoglobina Resultados En total, 79 (32,6%) pacientes tenian anemia. Durante el seguimiento fallecieron 77 pacientes, 53 por causa cardiaca, y reingresaron por insuficiencia cardiaca 117 pacientes. En el analisis multivariable, la anemia resulto predictora de mortalidad total (hazard ratio [HR] = 1,85; intervalo de confianza [IC] del 95%, 1,12-3,06), mortalidad cardiaca (HR = 1,88; IC del 95%, 1,03-3,45) y reingreso por insuficiencia cardiaca (HR = 1,87; IC del 95%, 1,28-2,74). Conclusiones En nuestra serie de pacientes hospitalizados por insuficiencia cardiaca observamos una elevada prevalencia de anemia. Ademas, una cifra de hemoglobina en el momento del alta

Non-Invasive Assessment of Coronary Artery Bypass Grafts and Native Coronary Arteries Using 64-Slice Computed Tomography: Comparison With Invasive Coronary Angiography

INTRODUCTION AND OBJECTIVES Although the diagnostic accuracy of CT in the non-invasive assessment of coronary arteries and grafts is known to be high, only a few studies have investigated the techniques reliability for the combined assessment of native coronary arteries, grafts, and vessels lying distal to anastomoses. The aim of this study was to evaluate the diagnostic accuracy of 64-slice CT for assessing coronary grafts and native coronary arteries. METHODS In the study, 64-slice CT was used to evaluate 36 patients who had undergone coronary artery bypass graft surgery and had a clinical indication for angiographic graft assessment. The diagnostic accuracy of CT for identifying significant lesions in grafts and native coronary arteries was determined and compared with that of invasive coronary angiography. RESULTS Of the 103 grafts studied (49 arterial and 54 venous), 96 (93.2%) could be visualized by angiography and 98 (95.1%) by CT. The sensitivity and specificity of CT for detecting significant lesions in grafts were 100% (30/30) and 97% (64/66), respectively, and the positive predictive value (PPV) and negative predictive value (NPV) were 94% and 100%, respectively. For non-revascularized coronary arteries (258 segments), the sensitivity, specificity, PPV and NPV were 94%, 95%, 80%, and 99%, respectively, and for distal vessels, 86%, 97%, 67%, and 99%, respectively. CONCLUSIONS The diagnostic accuracy of 64-slice CT for evaluating both coronary grafts and native coronary arteries was high.

Gerbode-type left ventricular outflow tract to right atrial fistula complicating prosthetic aortic valve replacement identified by cardiac computed tomographic angiography.

Acquired left ventricular-right atrial communication (Gerbode-type defect) is a rare complication of infective endocarditis. Although transesophageal echocardiography remains the technique of choice for the evaluation of complications of endocarditis this case highlights the usefulness of cardiac computed tomography in this scenario, particularly in cases where assessment of coronary anatomy is required before surgery.

Arteria coronaria izquierda anómala en el seno de Valsalva derecho asociada a ateromatosis coronaria

El origen anomalo de la arteria coronaria izquierda en el seno de Valsalva derecho es una anomalia que suele asociarse con isquemia miocardica y muerte subita. Aunque puede coexistir con aterosclerosis coronaria, esta no suele asentar en el trayecto coronario anomalo. Cuando coexiste esta anomalia coronaria con la enfermedad aterosclerotica coronaria resulta dificil diferenciar el origen de los sintomas isquemicos. Presentamos un caso en el que se emplearon 3 modalidades diagnosticas para dilucidar el origen de los sintomas isquemicos en un paciente con origen anomalo de la coronaria izquierda en el seno de Valsava derecho y trayecto entre la aorta y el tronco pulmonar asociado con lesions ateroscleroticas obstructivas en la coronaria derecha: la angiografia convencional como diagnostico inicial,la tomografia computarizada para identificar con exactitud el trayecto de la coronaria anomala y su relacion con estructuras vasculares y la ecocardiografia de esfuerzo para valorar isquemia en territorio de la coronaria izquierda tras el tratamiento de las lesiones en la coronaria derecha.

Isolated non-compaction of the myocardium as a cause of coronary and cerebral embolic events in the same patient

A 44-year-old woman with a history of smoking and previous cerebral thrombo-embolism presented to the emergency department with prolonged chest pain and ECG changes showing an acute anterior myocardial infarction. She was referred to the cath-lab for primary angioplasty. Coronary angiography showed a thrombotic occlusion at the origin of first diagonal …

Prognostic Value of Pulmonary Vascular Resistance by Magnetic Resonance in Systolic Heart Failure

Background Pulmonary hypertension is associated with poor prognosis in heart failure. However, non-invasive diagnosis is still challenging in clinical practice. Objective We sought to assess the prognostic utility of non-invasive estimation of pulmonary vascular resistances (PVR) by cardiovascular magnetic resonance to predict adverse cardiovascular outcomes in heart failure with reduced ejection fraction (HFrEF). Methods Prospective registry of patients with left ventricular ejection fraction (LVEF) < 40% and recently admitted for decompensated heart failure during three years. PVRwere calculated based on right ventricular ejection fraction and average velocity of the pulmonary artery estimated during cardiac magnetic resonance. Readmission for heart failure and all-cause mortality were considered as adverse events at follow-up. Results 105 patients (average LVEF 26.0 ±7.7%, ischemic etiology 43%) were included. Patients with adverse events at long-term follow-up had higher values of PVR (6.93 ± 1.9 vs. 4.6 ± 1.7estimated Wood Units (eWu), p < 0.001). In multivariate Cox regression analysis, PVR ≥ 5 eWu(cutoff value according to ROC curve) was independently associated with increased risk of adverse events at 9 months follow-up (HR2.98; 95% CI 1.12-7.88; p < 0.03). Conclusions In patients with HFrEF, the presence of PVR ≥ 5.0 Wu is associated with significantly worse clinical outcome at follow-up. Non-invasive estimation of PVR by cardiac magnetic resonance might be useful for risk stratification in HFrEF, irrespective of etiology, presence of late gadolinium enhancement or LVEF.