Wael AlJaroudi

Impact of Progression of Diastolic Dysfunction on Mortality in Patients With Normal Ejection Fraction

Background— Diastolic dysfunction is an independent predictor of mortality in patients with normal left ventricular ejection fraction. There are limited data, however, on whether worsening of diastolic function is associated with worse prognosis. Methods and Results— We reviewed clinical records and echocardiograms of consecutive patients who had baseline echocardiograms between January 1, 2005, and December 31, 2009, that showed left ventricular ejection fraction ≥55% and who subsequently had a follow-up echocardiogram within 6 to 24 months. Diastolic function was labeled as normal, mild, moderate, or severe dysfunction. All-cause mortality was determined by use of the Social Security Death Index. Kaplan-Meier survival analysis and Cox regression analysis with a proportional hazard model were performed to assess outcomes. A total of 1065 outpatients were identified (mean±SD age, 67.9±13.9 years; 58% male). Baseline diastolic dysfunction was present in 770 patients (72.3%), with mild being the most prevalent. On follow-up testing (mean±SD, 1.1±0.4 years), 783 patients (73%) had stable, 168 (16%) had worsening, and 114 (11%) had improved baseline diastolic function. Eighty-eight patients (8.3%) had a decrease in left ventricular ejection fraction to <55% and were more likely to have advanced diastolic dysfunction (P=0.002). After a mean±SD follow-up (from the second study) of 1.6±0.8 years, 142 patients (13%) died. On multivariate analysis, a decrease in left ventricular ejection fraction to <55% and any worsening of diastolic function were independently associated with increased risk of mortality (hazard ratio, 1.78; 95% confidence interval, 1.10–2.85; P=0.02; and hazard ratio, 1.78; 95% confidence interval, 1.21–2.59; P=0.003, respectively). Conclusion— In patients with normal baseline left ventricular ejection fraction, worsening of diastolic function is an independent predictor of mortality.

CMR Imaging With Rapid Visual T1 Assessment Predicts Mortality in Patients Suspected of Cardiac Amyloidosis

OBJECTIVESnThis study tested the diagnostic and prognostic utility of a rapid, visual T1 assessment method for identification of cardiac amyloidosis (CA) in a real-life referral population undergoing cardiac magnetic resonance for suspected CA.nnnBACKGROUNDnIn patients with confirmed CA, delayed-enhancement cardiac magnetic resonance (DE-CMR) frequently shows a diffuse, global hyperenhancement (HE) pattern. However, imaging is often technically challenging, and the prognostic significance of diffuse HE is unclear.nnnMETHODSnNinety consecutive patients referred for suspected CA and 64 hypertensive patients with left ventricular hypertrophy (LVH) were prospectively enrolled and underwent a modified DE-CMR protocol. After gadolinium administration a method for rapid, visual T1 assessment was used to identify the presence of diffuse HE during the scan, allowing immediate optimization of settings for the conventional DE-CMR that followed. The primary endpoint was all-cause mortality.nnnRESULTSnAmong patients with suspected CA, 66% (59 of 90) demonstrated HE, with 81% (48 of 59) of these meeting pre-specified visual T1 assessment criteria for diffuse HE. Among hypertensive LVH patients, 6% (4 of 64) had HE, with none having diffuse HE. During 29 months of follow-up (interquartile range: 12 to 44 months), there were 50 (56%) deaths in patients with suspected CA and 4 (6%) in patients with hypertensive LVH. Multivariable analysis demonstrated that the presence of diffuse HE was the most important predictor of death in the group with suspected CA (hazard ratio: 5.5, 95% confidence interval: 2.7 to 11.0; p < 0.0001) and in the population as a whole (hazard ratio: 6.0, 95% confidence interval 3.0 to 12.1; p < 0.0001). Among 25 patients with myocardial histology obtained during follow-up, the sensitivity, specificity, and accuracy of diffuse HE in the diagnosis of CA were 93%, 70%, and 84%, respectively.nnnCONCLUSIONSnAmong patients suspected of CA, the presence of diffuse HE by visual T1 assessment accurately identifies patients with histologically-proven CA and is a strong predictor of mortality.

Comparison of three commercially available softwares for measuring left ventricular perfusion and function by gated SPECT myocardial perfusion imaging.

BackgroundThe three softwares, Quantitative Perfusion SPECT (QPS), Emory Cardiac Toolbox, and 4 Dimension-Myocardial SPECT (4DM) are widely used with myocardial perfusion imaging (MPI) to determine perfusion defect size (PDS) and left ventricular (LV) function. There are limited data on the degree of agreement between these methods in quantifying the LV perfusion pattern and function.Methods and ResultsIn 120 consecutive patients who had abnormal regadenoson SPECT MPI with a visually derived summed stress score ≥4, the correlation between the softwares for measurements of PDS, reversible, and fixed defects was poor to fair (Spearman’s ρxa0=xa00.18-0.72). Overall, estimation of defect size was smaller by QPS and larger by 4DM. There was discordance among the softwares in 62% of the cases in defining PDS as small/moderate/large. The correlation between the softwares was better for measuring LVEF, volumes and mass (ρxa0=xa00.84-0.97), and discrepant results for defining normal/mild-moderate/severe LV systolic dysfunction were prevalent in 28% of the patients.ConclusionThere are significant differences between the softwares in measuring PDS as well as LV function, and more importantly in defining small, moderate, or large ischemic burden. These results suggest the necessity of using the same software when assessing interval changes by serial imaging.

Exercise stress echocardiography in patients with aortic stenosis: impact of baseline diastolic dysfunction and functional capacity on mortality and aortic valve replacement.

BACKGROUNDnPatients with aortic stenosis (AS) often undergo exercise echocardiography. Diastolic dysfunction (DD) is frequently associated with AS but little is known about its impact on functional capacity (FC). We sought to determine the relationship between DD and FC and their impact on mortality and need for aortic valve replacement (AVR) in patients with AS.nnnMETHODS AND RESULTSnData was analyzed for consecutive patients with any degree of AS undergoing exercise stress echocardiography between 2000 and 2010 at our institution. The primary endpoint was a composite of death or need for AVR. We identified 1,267 patients [mean age 67±11 years, ejection fraction (56±7)%, mean aortic valve gradient 19±12 mmHg, mean maximal metabolic equivalents (METs) achieved 8±2.6]. The proportion with normal, stage 1, and ≥ stage 2 diastology was 195 (15%), 928 (73%), 144 (12%). A total of 475 (37.5%) patients had a primary outcome with 164 deaths (mean follow up 5.6±4.1 years) and 341 AVR (mean follow up 2.4±2.6 years). Predictors of FC were age, gender, body mass index, Bruce protocol, heart rate recovery (HRR), ejection fraction, mean aortic valve gradient, and diabetes but not baseline DD. Baseline DD [HR 1.82, 95% CI (1.17, 2.82), P=0.008] and FC [HR 0.93, 95% CI (0.88, 0.98), P=0.003] were independent predictors of death or AVR.nnnCONCLUSIONSnFor patients with AS undergoing exercise echocardiography, baseline DD was not predictive of FC. However, both baseline DD and FC were independent predictors of death or need for AVR.

Stress-induced worsening of left ventricular diastolic function as a marker of myocardial ischemia

Background: Echocardiography has been the subject of interest in diagnosing diastolic dysfunction and estimating left ventricular filling pressures (LVFPs). The present study is set to estimate the correlation between the worsening of diastolic parameters and the evidence of inducible ischemia during an exercise stress echocardiography (SE) in comparison with the results of coronary computed tomographic angiogram (CCTA). Methods: A total of 191 consecutive patients from the executive screening program who underwent exercise SE followed by CCTA were evaluated. Baseline demographics, heart rate, and blood pressure measurements were extracted for analysis. Standard two-dimensional and tissue Doppler imaging parameters were analyzed. Diastolic function was graded at rest and peak exercise. Results: Patients who had worsening of diastolic function by at least one grade had had 2–3-fold higher odds of having abnormal SE. In addition, patients with worsening of diastolic function had higher stress LVFPs (E/e = 11.7 ± 2.7 vs. E/e 8.0 ± 2.0; P < 0.0001), more E/e change >25% (48% vs. 22%, P = 0.012), and were more likely to have obstructive coronary artery disease (CAD) on CCTA (23.8% vs. 9.2%; P = 0.045). A change in E/e >25% (stress-rest) was highly associated with a positive stress test and abnormal CCTA result. Patients with no change or improvement in diastolic function with stress had a 92% negative predictive value of having normal SE and 91% of normal/nonobstructive CCTA. Conclusion: A worsening of diastolic function and a change in E/e >25% (stress-rest) were associated with abnormal SE, positive stress test, and obstructive CAD when compared to CCTA results.

Review of cardiovascular imaging in the journal of nuclear cardiology in 2015. Part 1 of 2: Plaque imaging, positron emission tomography, computed tomography, and magnetic resonance

In 2015, many original articles pertaining to cardiovascular imaging with impressive quality were published in the Journal of Nuclear Cardiology. In a set of 2 articles, we provide an overview of these contributions to facilitate for the interested reader a quick review of the advancements that occurred in the field over this year. In this first article, we focus on arterial plaque imaging, cardiac positron emission tomography, computed tomography, and magnetic resonance imaging.

Left Ventricular Pseudoaneurysm: “To-and-Fro” Flow

![Figure][1] nn[![Graphic][3] ][3][![Graphic][4] ][4]nnnnAn 81-year-old man with known coronary disease and prior single-vessel coronary artery bypass grafting surgery presented with shortness of breath on moderate exertion. An extensive lateral wall infarct with free wall rupture

Mechanical dyssynchrony with phase analysis of gated SPECT: Nap time is over

Cardiac resynchronization therapy (CRT) improves left ventricular (LV) remodeling, quality of life, and survival among patients with heart failure and reduced ejection fraction (EF 35%) and electrical dyssynchrony (wide QRS duration). However, a significant proportion of patients do not derive the expected benefit from such expensive and invasive procedure. In 2011, Goldengerb et al. identified 7 factors from the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy (MADIT-CRT) trial that improved patient selection and predicted better CRT response; these included female gender, non-ischemic cardiomyopathy, left bundle branch block (LBBB), QRS C 150 ms, prior hospitalization for heart failure, left ventricular end-diastolic volume index C 125 ml/m, and left atrial volume index less than 40 ml/m. Shortly after, the 2012 guidelines for CRT implantation were updated and recommended CRT for patients with EF B 35%, NYHA class C II with LBBB, and QRS C 150 ms (the only class I indication) as compared to a QRS threshold C 120–130 ms with 2008 guidelines. The more stringent QRS threshold for CRT implementation was meant to choose patients with greater electrical dyssynchrony, thus greater mechanical dyssynchrony, and therefore those with higher chance of CRT restoring synchronicity of myocardial contraction. However, electrical and mechanical dyssynchrony are not interchangeable, which explains in part the remaining high rate of non-responders. Because of its non-invasiveness, low cost, and wide availability, significant effort and research were placed on identifying mechanical dyssynchrony parameters with echocardiography that would be best predictive of CRT response. Indeed, an exponential increase in the number of research papers was observed in the field of echocardiography between 2004 and 2008 exploring dozen of parameters with 2D, 3D echocardiography, strain, strain rate, and many others (Fig. 1). Promising single-center data were published, while others had conflicting data, until the negative and conclusive results of PROSPECT trial, a multicenter study that tested many echocardiography parameters (interobserver and intraobserver variability 4%–24% and 7%–72%, respectively) all of which failed to predict CRT response. Shortly thereafter, interest in mechanical dyssynchrony with echocardiography took a significant hit, and despite recent efforts to revive it, the number of publications kept on declining dramatically (Fig. 1). In 2005, Chen et al. published one of the first papers on mechanical dyssynchrony using phase analysis concept from gated single-photon emission computed tomography (SPECT). Briefly, a 3D count distribution is extracted from each of the LV short-axis datasets; a 1D fast Fourier transform is applied to the count variation over time for each voxel, generating a 3D phase distribution that describes the timing of LV onset of mechanical contraction over the entire R–R cycle. Unlike echocardiography, SPECT myocardial perfusion imaging (MPI) provides a single parameter to define mechanical dyssynchrony (phase analysis derived standard deviation SD) which is reproducible, repeatable on serial imaging testing, and easy to derive. Shortly after, Henneman et al. showing that a phase SD[ 43 was an independent predictor of CRT response. In the following years, significant data were published on phase analysis and mechanical dyssynchrony. It was shown to predict ICD shock, and all-cause mortality. In addition, it was tested and validated with PET imaging. However, phase analysis faced several challenges Reprint requests: Wael AlJaroudi, MD, FASNC, Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon; wjaroudi@hotmail.com J Nucl Cardiol 2018;25:2039-43. 1071-3581/

Cardiovascular disease in the literature: A selection of recent original research papers.

34.00 Copyright 2017 American Society of Nuclear Cardiology.

Prognostic value of silent myocardial infarction in patients with chronic kidney disease being evaluated for kidney transplantation

Background: Aspirin is widely used in patients with coronary artery disease for primary and secondary prevention. In patients undergoing coronary artery bypass grafting (CABG), aspirin is usually stopped 5-7 days prior to surgery to avoid the risk of peri-operative bleeding. Myles et al from Alfred Hospital, Australia, conducted amulticenter, double-blind randomized trial to test whether aspirin would reduce the occurrence of death and thrombotic complications in at-risk patientswhowere undergoingCABG (with orwithout other procedures such as cardiac valve placement). The study randomized 2100 patients who were considered at increased risk of complications and were not taking aspirin regularly, or had stopped taking aspirin at least 4 days prior to surgery, to receive 100 mg of aspirin or placebo on the day of surgery. The primary outcome was a composite of death and thrombotic events (nonfatalmyocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) during the first 30 postoperative days. Findings: The 30-day follow-up was complete in more than 99.9% of participants. The primary outcome occurred in 19.3% in the aspirin group vs 20.4% in the placebo group (relative risk 0.94, P = .55). Similarly, myocardial infarction (13.8% vs 15.8%, RR 0.87, P = .20), major hemorrhage leading to reoperation (1.8%, vs 2.1%, P = .75), and cardiac tamponade (1.1% vs 0.4%, P = .08) were not different between the aspirin and placebo groups.