Rodolfo Bonamini

Good Prognosis for Pericarditis With and Without Myocardial Involvement Results From a Multicenter, Prospective Cohort Study

Background— The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study. Methods and Results— A total of 486 patients (median age, 39 years; range, 18–83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P<0.001). Troponin elevation was not associated with an increase in complications. Conclusions— The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting.Background— The natural history of myopericarditis/perimyocarditis is poorly known, and recently published studies have presented contrasting data on their outcomes. The aim of the present article is to assess the prognosis of myopericarditis/perimyocarditis in a multicenter, prospective cohort study. Methods and Results— A total of 486 patients (median age, 39 years; range, 18–83 years; 300 men) with acute pericarditis or a myopericardial inflammatory syndrome (myopericarditis/perimyocarditis; 85% idiopathic, 11% connective tissue disease or inflammatory bowel disease, 5% infective) were prospectively evaluated from January 2007 to December 2011. The diagnosis of acute pericarditis was based on the presence of 2 of 4 clinical criteria (chest pain, pericardial rubs, widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion). Myopericardial inflammatory involvement was suspected with atypical ECG changes for pericarditis, arrhythmias, and cardiac troponin elevation or new or worsening ventricular dysfunction on echocardiography and confirmed by cardiac magnetic resonance. After a median follow-up of 36 months, normalization of left ventricular function was achieved in >90% of patients with myopericarditis/perimyocarditis. No deaths were recorded, as well as evolution to heart failure or symptomatic left ventricular dysfunction. Recurrences (mainly as recurrent pericarditis) were the most common complication during follow-up and were recorded more frequently in patients with acute pericarditis (32%) than in those with myopericarditis (11%) or perimyocarditis (12%; P <0.001). Troponin elevation was not associated with an increase in complications. Conclusions— The outcome of myopericardial inflammatory syndromes is good. Unlike acute coronary syndromes, troponin elevation is not a negative prognostic marker in this setting. # Clinical Perspective {#article-title-31}

Spontaneous beat-to-beat variability of the ventricular repolarization duration

The spontaneous beat-to-beat variability of the ventricular repolarization duration was investigated in 21 healthy subjects (age 25-71 years; mean, 40 years) during the basal state in a recumbent position. For each subject, approximately 1,000 consecutive cycles were analyzed with an automated technique. The time series of the RR, QT, and RT intervals generate histograms that approximate normal distributions and have mean standard deviations of 57.0 ms, 5.4 ms, and 4.3 ms, respectively. Spectral analysis was used to detect rhythmical oscillations in these time series. The power spectra densities of both heart rate and ventricular repolarization during show peaks in the same frequency bands: low frequency (0.05-0.12 Hz) and high frequency (0.2-0.4 Hz). The power distribution between these two bands observed in the ventricular repolarization duration spectra was found to be the reverse of that in heart rate spectra (p less than 0.005).

Magnetic Resonance Cardiac Vein Imaging : Relation to Mitral Valve Annulus and Left Circumflex Coronary Artery

OBJECTIVES To evaluate in vivo anatomical relationships between the coronary sinus-great cardiac vein (CS-GCV), the mitral valve annulus (MVA), and left circumflex coronary artery (LCX) with cardiovascular magnetic resonance. BACKGROUND The CS-GCV has become an anatomical structure of interest because it provides a way of access to the heart for a number of interventional procedures. Previous reports demonstrate that the postulated close anatomical proximity of the CS-GCV to the MVA does not always hold true in patients, both in autopsy specimens and in vivo by computed tomography. METHODS In 31 participants (24 volunteers and 7 patients; 15 men; 42 +/- 19 years), cardiovascular magnetic resonance was performed for noninvasive evaluation of the coronary sinus and of the coronary arteries using whole-heart imaging and intravascular contrast agents. Three-dimensional reconstructions, standard orthogonal planes, and unprocessed raw data were used to assess CS-GCV anatomy and its relation to the MVA and the LCX along their entire course. RESULTS The CS-GCV was located behind the left atrium in all examined participants, at a minimum distance of 8.6 +/- 3.9 mm from the MVA. In 80% of the participants, the LCX crossed the CS-GCV inferiorly, between the CS-GCV and the MVA. The CS-GCV and the LCX had a parallel course for 26.2 +/- 23.0 mm, with great variability of location and length. In several participants, the CS-GCV had a long parallel course, but in other participants, the LCX crossed below the CS-GCV at a discrete point. CONCLUSIONS In all participants, the CS-GCV coursed behind the left atrium rather than behind the MVA. In the majority of the participants, the LCX coursed between the CS-GCV and the MVA. These anatomical relationships should be kept in mind when referring a patient for interventional procedures requiring the access to the CS-GCV, and cardiovascular magnetic resonance might provide important information for the selection of candidates for these procedures.

Bedside evaluation of atrioventricular block with narrow QRS complexes: Usefulness of carotid sinus massage and atropine administration

Second-degree intra-His bundle block is frequently of type I (Wenckebach periods) or 2:1. In this situation, the surface electrocardiogram does not permit distinction between intranodal (atrioventricular [A-V] and subnodal (intra-His) block. This study examined the value of bedside carotid sinus massage and atropine administration in diagnosing the site of block from the standard electrocardiogram in subjects with chronic A-V block and narrow QRS complexes. Fifteen patients had intra-His bundle block and 10 had intranodal block. The combination of two tests correctly located the site of block in 22 subjects, and was noncontributory in 3. Thirteen of the 15 intra-His bundle blocks and 9 of the 10 intranodal blocks were properly identified; in three cases the results were nondiagnostic, but no wrong diagnoses were made. The noninvasive bedside method of carotid sinus massage and the use of atropine permit both the localization and the determination of the type of block in the majority of cases of second degree A-V block and narrow QRS complexes. In a proper clinical context they can obviate the need for invasive electrophysiologic studies.

Coronary artery anomalies overview: The normal and the abnormal

The aim of this review is to give a comprehensive and concise overview of coronary embryology and normal coronary anatomy, describe common variants of normal and summarize typical patterns of anomalous coronary artery anatomy. Extensive iconography supports the text, with particular attention to images obtained in vivo using non-invasive imaging. We have divided this article into three groups, according to their frequency in the general population: Normal, normal variant and anomaly. Although congenital coronary artery anomalies are relatively uncommon, they are the second most common cause of sudden cardiac death among young athletes and therefore warrant detailed review. Based on the functional relevance of each abnormality, coronary artery anomalies can be classified as anomalies with obligatory ischemia, without ischemia or with exceptional ischemia. The clinical symptoms may include chest pain, dyspnea, palpitations, syncope, cardiomyopathy, arrhythmia, myocardial infarction and sudden cardiac death. Moreover, it is important to also identify variants and anomalies without clinical relevance in their own right as complications during surgery or angioplasty can occur.

Rest perfusion abnormalities in hypertrophic cardiomyopathy: correlation with myocardial fibrosis and risk factors for sudden cardiac death

Aim To measure the prevalence of abnormal rest perfusion in a population of consecutive patients with known hypertrophic cardiomyopathy (HCM) referred for cardiovascular MRI (CMR), and to assess any associations between abnormal rest perfusion and the presence, pattern, and severity of myocardial scar and the presence of risk factors for sudden death. Materials and methods Eighty consecutive patients with known HCM referred for CMR underwent functional imaging, rest first-pass perfusion, and late gadolinium enhancement (LGE). Results Thirty percent of the patients had abnormal rest perfusion, all of them corresponding to areas of mid-myocardial LGE and to a higher degree of segmental hypertrophy. Rest perfusion abnormalities correlated with more extensive and confluent LGE. The subgroup of patients with myocardial fibrosis and rest perfusion abnormalities (fibrosis+/perfusion+) had more than twice the incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring in comparison to patients with myocardial fibrosis and normal rest perfusion (fibrosis+/perfusion–) and patients with no fibrosis and normal rest perfusion (fibrosis–/perfusion–). Conclusions First-pass perfusion CMR identifies abnormal rest perfusion in a significant proportion of patients with HCM. These abnormalities are associated with the presence and distribution of myocardial scar and the degree of hypertrophy. Rest perfusion abnormalities identify patients with increased incidence of episodes of non-sustained ventricular tachycardia on Holter monitoring, independently from the presence of myocardial fibrosis.

Late gadolinium enhancement on cardiac magnetic resonance and phenotypic expression in hypertrophic cardiomyopathy

BACKGROUND Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) can identify areas of myocardial fibrosis in vivo in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to examine the association between clinical-morphological variables, risk factor for sudden death, and LGE findings in a consecutive, unselected population of HCM patients. METHODS From January 2005 to August 2009, 124 HCM patients (53 ± 17 years, 86 men) were prospectively evaluated with CMR examination, assessing left ventricular (LV) hypertrophy, function, and LGE. RESULTS In univariate analysis, patients were divided into tertiles according to the number of segments positive for LGE (first tertile, 0.3 ± 0.4; second tertile, 2.2 ± 0.4; third tertile, 5.2 ± 1.9 segments). Male gender (P = .05), maximum LV wall thickness (P = .002), nonsustained ventricular tachycardia (P = .001), ejection fraction <50% (P = .02), LV mass (P = .02), left atrium dilation (P = .04), perfusion defects (P ≤ .001), and telesystolic volume (P = .04) were all positively related with the number of segments of LGE. In multivariable analysis, male gender (P = .007), maximum LV wall thickness (P = .006), LV mass (P = .031), and perfusion alterations (P = .017) were independent predictors of LGE extent. CONCLUSIONS Our study shows an independent association, even at multivariate analysis, between the entity of LGE and maximum LV wall thickness, mass, and perfusion defects in patients with HCM. Whether the presence and the extent of LGE translates into clinical events later on awaits further long-term follow-up studies.

Extensive Myocardial Fibrosis in a Patient With Hypertrophic Cardiomyopathy and Ventricular Tachycardia Without Traditional High-Risk Features

Although patients with hypertrophic cardiomyopathy (HCM) and without conventional risk factors for sudden death are generally considered at low risk, the magnitude of risk in such patients remains unknown, and additional markers of prognosis may permit more accurate risk stratification.1–3 We report a patient with HCM and without conventional risk factors who had a sustained life-threatening ventricular tachyarrhythmia 6 months after identification of extensive myocardial fibrosis at contrast-enhanced cardiovascular magnetic resonance (CMR). A 61-year-old asymptomatic patient with HCM had been followed at our institution for 12 years. The patient had none of the conventional risk factors for sudden …

Left ventricular noncompaction in patients with β-thalassemia: Uncovering a previously unrecognized abnormality†

Left ventricular noncompaction (LVNC) is a rare cardiomyopathy with potentially serious outcomes. It results in multiple and excessive trabeculations, deep intertrabecular recesses, and a thickened ventricular myocardium with two distinct layers, compacted and noncompacted. The condition is most commonly congenital; however, acquired forms have also been described. A recent report of LVNC detected in a β‐thalassemia twin suggested an association with cardiac siderosis. In a cross‐sectional study of 135 transfusion‐dependent patients with β‐thalassemia (130 major and 5 intermedia, mean age 29.6 ± 7.7 years, 49.6% males) presenting for cardiac iron assessment by magnetic resonance imaging (MRI), we evaluated the prevalence and risk factors for LVNC. None of the patients had neuromuscular or congenital heart disease. Eighteen patients (13.3%; 95% confidence interval [CI] = 8.6–20.1) fulfilled the preassigned strict criteria for LVNC on cardiac MRI. There were no statistically significant differences between patients with and without LVNC with respect to demographics; hemoglobin levels; splenectomy status; systemic, hepatic, and cardiac iron overload indices; hepatic disease and infection studies; or iron chelator type. Patients with LVNC were more likely to have heart failure (adjusted odds ratio = 1.77; 95% CI = 0.29–10.89); although with high uncertainty. Patients with β‐thalassemia have a higher prevalence of LVNC than normal individuals. As this finding could not be explained by conventional risk factors in this patient population, further investigation of the underlying mechanisms of LVNC is warranted. This remains crucial for an entity with adverse cardiac outcomes, especially in patients with β‐thalassemia where cardiac disease remains a primary cause of mortality. Am. J. Hematol., 2012.

Cardiovascular magnetic resonance as a reliable alternative to cardiovascular computed tomography and transesophageal echocardiography for aortic annulus valve sizing

To assess the accuracy and reproducibly of cardiovascular magnetic resonance (CMR) in the measurement of the aortic annulus and in process of valve sizing as compared to intra-operative sizing, cardiovascular computed tomography (CCT) and transesophageal echocardiography (TEE). Retrospective study on 42 patients who underwent aortic valve replacement from September 2010 to September 2015, with available records of pre surgery annulus assessment by CMR, CCT and TEE and of peri-operative assessment. In CCT and CMR, the annular plane was considered a virtual ring formed by the lowest hinge points of the valvular attachments to the aorta. In TEE the annulus was measured at the base of leaflet insertion in the mid-esophageal long-axis view using the X-plane technique. Two double-blinded operators performed the assessments for each imaging technique. Intra-operative evaluation was performed using Hegar dilators. Continuous variables were studied with within-subject ANOVA, Bland–Altman (BA) plots, Wilcoxon’s and Friedman’s tests; trends were explored with scatter plots. Categorical variables were studied with Fisher’s exact test. The intra- and inter-operator reliability was satisfying. There were no significant differences between the annulus dimensions measured by CMR and either one of the three references. Valve sizing for CoreValve by CMR had the same good agreement with CCT and TEE, with a 78 % match rate; for SAPIEN XT the agreement was slightly better (82 %) for CCT than for TEE (66 %). MR performs well when compared to the surgical reference of intra-operative sizing and stands up to the level of the most used imaging references (CCT and TEE).