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Gao Y, Liu M, Ju Z, Wang H, Gu H, Wang X. Entropy as a novel predictor of cardiovascular events in patients with left ventricular noncompaction. Int J Cardiol 2023; 392:131279. [PMID: 37598912 DOI: 10.1016/j.ijcard.2023.131279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/31/2023] [Accepted: 08/17/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND The risk stratification of left ventricular noncompaction (LVNC) remains ambiguous. LV entropy derived from late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR) as a novel measurement of myocardial heterogeneity may serve as the substrate of major adverse cardiovascular events (MACEs). This retrospective study aimed to investigate the value of LV entropy for predicting MACEs in LVNC patients. METHODS Consecutive patients who underwent CMR and met the diagnosis criteria of LVNC were included. All patients were follow-up for MACEs (cardiac death, ventricular arrhythmia requiring therapy or heart failure hospitalization), and their LV entropy derived from the distribution of pixel signal intensities in the LGE of the LV myocardium was analyzed. RESULTS One hundred and forty-three patients (mean age 40 years, 64.3% male) were followed for a median of 3.2 years, and forty-two (29.4%) experienced MACEs. Presenting of symptoms, left ventricular end-diastolic diameter (LVEDD), LV end-diastolic volume (LVEDV) index, LV end-systolic volume (LVESV) index, LV ejection fraction (LVEF), LGE extent, and LV entropy showed association with MACEs. LV entropy maintained independent association with MACEs (HR: 4.76, 95%CI 3.68-5.15, p < 0.001) in multivariable analysis. Entropy was also strong independent predictor of MACEs in patients with and without LGE (HR: 5.89, 95% CI4.18-7.73, p < 0.001; HR: 3.06, 95% CI:1.53-4.80, p = 0.013, respectively). CONCLUSIONS LV entropy can predict MACEs in LVNC patients and provide incremental prognostic value on top of LVEF and LGE. Also, LV entropy may help risk stratification in LGE-negative LVNC patients.
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Affiliation(s)
- Yan Gao
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong 250021, China; Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China
| | - Mengxiao Liu
- MR Scientific Marketing, Diagnostic Imaging, Siemens Healthcare Ltd., Shanghai, China
| | - Zhiguo Ju
- College of Medical Imaging, Shanghai University of Medicine & Health Science, Shanghai, China
| | - Haipeng Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China
| | - Hui Gu
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China
| | - Ximing Wang
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong 250021, China; Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China.
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2
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Bazoukis G, Tyrovolas K, Letsas KP, Vlachos K, Radford D, Chung CT, Liu T, Efremidis M, Tse G, Baranchuk A. Predictors of fatal arrhythmic events in patients with non-compaction cardiomyopathy: a systematic review. Heart Fail Rev 2022; 27:2067-2076. [PMID: 35776368 DOI: 10.1007/s10741-022-10257-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 12/01/2022]
Abstract
Left ventricular non-compaction cardiomyopathy (LVNC) is a congenital heart disease with autosomal dominant inheritance. This review aims to summarize the existing data about the predictors of fatal arrhythmias in patients with LVNC. Medline and Cochrane library databases were searched from inception to November 2021 for articles on LVNC. The reference lists of the relevant research studies as well as the relevant review studies and meta-analyses were also searched. Clinical symptoms and electrocardiogram findings such as left bundle branch block are significantly associated with ventricular arrhythmias. Other non-invasive tools such as Holter monitoring, echocardiography, and cardiac magnetic resonance (CMR) can provide additional value for risk stratification. CMR-derived left and right ventricular ejection fraction, left ventricular end-diastolic diameter, late gadolinium enhancement, and non-compacted to compacted myocardium ratio are predictive of ventricular arrhythmias. An electrophysiological study can provide additional prognostic data in patients with LVNC who are at moderate risk of ventricular arrhythmias. Risk stratification of LVNC patients with no prior history of a fatal arrhythmic event remains challenging. Symptoms assessment, electrocardiogram, Holter monitoring, and cardiac imaging should be performed on every patient, while an electrophysiological study should be performed for moderate-risk patients. Large cohort studies are needed for the construction of score models for arrhythmic risk stratification purposes.
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Affiliation(s)
- George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus. .,Department of Basic and Clinical Sciences, University of Nicosia Medical School, 2414, Nicosia, Cyprus.
| | | | | | | | - Danny Radford
- Kent and Medway Medical School, Canterbury, Kent, UK
| | | | - Tong Liu
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, Collaboration, Hong Kong, China-UK, China.,Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Michael Efremidis
- Department of Electrophysiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Gary Tse
- Kent and Medway Medical School, Canterbury, Kent, UK.,Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, Collaboration, Hong Kong, China-UK, China
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, ON, Canada
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3
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Wang W, Chen W, Lin X, Fang L. Influence of Right Ventricular Dysfunction on Outcomes of Left Ventricular Non-compaction Cardiomyopathy. Front Cardiovasc Med 2022; 9:816404. [PMID: 35174234 PMCID: PMC8842670 DOI: 10.3389/fcvm.2022.816404] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/11/2022] [Indexed: 12/12/2022] Open
Abstract
Background Various adverse outcomes such as mortality and rehospitalization are associated with left ventricular non-compaction (LVNC). Due to data limitations, prospective risk assessment for LVNC remains challenging. This study aimed to investigate the influence of right ventricular (RV) dysfunction on the clinical outcomes of patients with LVNC through accurate and comprehensive measurements of RV function. Methods and Results Overall, 117 patients with LVNC (47.6 ± 18.3 years, 34.2% male) were enrolled, including 53 (45.3%) and 64 (54.7%) patients with and without RV dysfunction, respectively. RV dysfunction was defined as meeting any two of the following criteria: (i) tricuspid annular systolic excursions <17 mm, (ii) tricuspid S′ velocity <10 cm/s, and (iii) RV fractional area change (FAC) <35%. The proportion of biventricular involvement was significantly higher in patients with RV dysfunction than in controls (p = 0.0155). After a follow-up period of 69.0 [33.5, 96.0] months, 18 (15.4%) patients reached the primary endpoint (all-cause mortality), with 14 (26.4%) and 4 (6.3%) from the RV dysfunction group and normal RV function group, respectively. The Kaplan–Meier method and log-rank test revealed that patients with RV dysfunction had a higher risk of all-cause mortality than those in the control group (hazard ratio [HR]: 5.132 [2.003, 13.15], p = 0.0013). Similar results were obtained for patients with left ventricular ejection fraction (LVEF) <50% [HR, 6.582; 95% confidence interval (CI), 2.045–21.19; p = 0.0367]. The relationship between RV dysfunction and heart failure rehospitalization and implantation of implantable cardioverter-defibrillator (ICD)/cardiac resynchronization therapy (CRT) was not statistically significant (both p > 0.05). The multivariable Cox proportional hazard modeling analysis showed that RV dysfunction (HR: 4.950 [1.378, 17.783], p = 0.014) and impaired RV global longitudinal strain (RVGLS) (HR: 1.103 [1.004, 1.212], p = 0.041) were independent predictors of mortality rather than increased RV end-diastolic area and decreased LVEF (both p > 0.05). Conclusions RV dysfunction is associated with the prognosis of patients with LVNC.
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Affiliation(s)
- Wuwan Wang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Chen
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xue Lin
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ligang Fang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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4
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Yildirim G, Dursun M, Arslan R. Effect of trabeculated myocardial mass on left ventricle global and regional functions in noncompaction cardiomyopathy. World J Cardiol 2021; 13:211-222. [PMID: 34367505 PMCID: PMC8326155 DOI: 10.4330/wjc.v13.i7.211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/12/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Left ventricular (LV) noncompaction cardiomyopathy is a rare cardiomyopathic subtype that has been recognized in recent years and is being diagnosed at an increased rate. There is no consensus regarding the diagnosis of the disease, and increased trabeculation rates that meet the existing diagnostic criteria may even be present in healthy asymptomatic people. This indicates that differentiating criteria for diagnosis are needed.
AIM To examine the increase in myocardial trabeculation and the change in left ventricular global and regional functions.
METHODS This retrospective study included 65 patients (28 females, 37 males) diagnosed with LV noncompaction cardiomyopathy who underwent cardiac magnetic resonance imaging between January 2011 and August 2016 and had a noncompacted/compacted myocardial thickness ratio of over 2.3 in more than one segment in the left ventricle. The distribution and ratios of trabeculations in apical, midventricular, and basal regions were examined in short-axis images obtained from cardiac magnetic resonance. In addition, by using short-axis cine images, regional ejection fraction (EF) and global EF were calculated using the Simpson method in the left ventricle at apical, basal, and midventricular levels.
RESULTS While the number of trabeculated segments were similar at the apical (3.2 ± 1.0) and midventricular levels, a statistically significant level of involvement was not observed at the basal level (0.4 ± 0.9) (P > 0.05). The highest noncompacted/compacted (trabeculation) ratio was observed at the apical level (3.9 ± 1.4), while this ratio was higher at the anterior (59%-89.4%) and lateral (62%-84.8%) segments (P > 0.05). Global EF was positively correlated with apical, midventricular, and basal regional EF (P < 0.05). However, there was no significant correlation between regional EF and the number of trabeculated segments or trabeculation ratio in all three regions; nor was there a significant correlation between regional EF and the number of trabeculated segments or trabeculation ratio in the entire LV (P > 0.05).
CONCLUSION No global or regional relationship was observed between LV dysfunction and trabeculation rate or the number of trabeculated segments. This limits the usefulness of change in LV functions in the differentiation between normal and pathological trabeculation.
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Affiliation(s)
- Gulsah Yildirim
- Department of Radiology, University of Health Sciences, Istanbul Fatih Sultan Mehmet Training and Research Hospital, İstanbul 34752, Turkey
| | - Memduh Dursun
- Department of Radiology, İstanbul University School of Medicine, İstanbul 34752, Turkey
| | - Rıfat Arslan
- Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, İstanbul 34752, Turkey
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5
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Macaione F, Meloni A, Positano V, Barison A, Todiere G, Pistoia L, Di Lisi D, Novo G, Novo S, Pepe A. The prognostic role of CMR using global planimetric criteria in patients with excessive left ventricular trabeculation. Eur Radiol 2021; 31:7553-7565. [PMID: 33821336 DOI: 10.1007/s00330-021-07875-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Although cardiovascular magnetic resonance (CMR) is widely used in the assessment of left ventricular non-compaction (LVNC), there are no universally accepted diagnostic criteria and limited data regarding their prognostic value. We assessed the long-term prognostic role of the planimetric global Grothoff's criteria and of the CMR findings in predicting adverse cardiovascular events (CE). METHODS We prospectively enrolled 78 patients (46.7 ± 18.7 years, 33.3% females) with documented positive Jenni's echocardiographic criteria for LVNC. Cine images were used to quantify function parameters and to assess for the presence of all four quantitative Grothoff's criteria (global Grothoff's criteria). Late gadolinium enhancement (LGE) images were acquired to detect the presence of replacement myocardial fibrosis. RESULTS Petersen's CMR criterion for LVNC (NC/C ratio > 2.3 in at least one myocardial segment) was fulfilled in the whole population. Twenty-six patients fulfilled the global Grothoff's criteria (four out of four). The mean duration of the follow-up was 44.2 ± 27.4 months and 28 CE were registered: 10 ventricular tachycardias, 12 episodes of heart failure (HF), four strokes, and two cardiac deaths. In the multivariate analysis, the independent predictive factors for CE were positive global Grothoff's criteria (hazard ratio, HR = 3.33, 95% CI = 1.52-7.29; p = 0.003) and myocardial fibrosis (HR = 2.41, 95% CI = 1.08-5.36; p = 0.032). CONCLUSIONS Positive global Grothoff's criteria and myocardial fibrosis were powerful predictors of CE in patients with a diagnosis of LVNC by CMR Petersen's criterion. Thus, we strongly suggest a step approach confirming the diagnosis of LVNC by using the global planimetric Grothoff's criteria, which showed a prognostic impact. KEY POINTS • Positive global Grothoff's criteria and replacement myocardial fibrosis were powerful predictors of cardiovascular events in patients with a diagnosis of LVNC by CMR Petersen's criterion. • Positive global Grothoff's criteria were associated with a higher frequency of ventricular arrhythmias in patients with a diagnosis of LVNC by CMR Petersen's criterion.
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Affiliation(s)
- Francesca Macaione
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi 1, 56124, Pisa, Italy.,Department of Cardiology, Policlinico "P. Giaccone", Palermo, Italy
| | - Antonella Meloni
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi 1, 56124, Pisa, Italy
| | - Vincenzo Positano
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi 1, 56124, Pisa, Italy
| | - Andrea Barison
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi 1, 56124, Pisa, Italy
| | - Giancarlo Todiere
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi 1, 56124, Pisa, Italy
| | - Laura Pistoia
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi 1, 56124, Pisa, Italy
| | | | - Giuseppina Novo
- Department of Cardiology, Policlinico "P. Giaccone", Palermo, Italy
| | - Salvatore Novo
- Department of Cardiology, Policlinico "P. Giaccone", Palermo, Italy
| | - Alessia Pepe
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi 1, 56124, Pisa, Italy.
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6
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Long term clinical outcomes associated with CMR quantified isolated left ventricular non-compaction in adults. Int J Cardiol 2020; 328:235-240. [PMID: 33309759 DOI: 10.1016/j.ijcard.2020.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/19/2020] [Accepted: 12/02/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Left ventricular non-compaction (LVNC) is a complex clinical condition with several diagnostic criteria but no diagnostic gold standard. We aimed to evaluate our thresholding technique in a group of patients with LVNC and assess the risk of major adverse cardiovascular and cerebrovascular events (MACCE). METHODS We retrospectively analyzed cardiac magnetic resonance (CMR) scans of patients with Petersen criteria LVNC and quantified noncompacted myocardial mass. We assessed the association of noncompacted myocardial mass, CMR derived LV volumetric parameters and late gadolinium enhancement (LGE) to MACCE including cardiac death, cardiac transplantation, sustained ventricular tachycardia/ventricular fibrillation (VT/VF) and ischemic stroke. Patients with known genetic mutations and cardiovascular disease were excluded. RESULTS 98 patients with LVNC were included (55 males,56.7%); 17(17.3%) patients had impaired LV function and five (5.1%) had LGE. Patients with impaired LV function had more end-systolic noncompacted mass (61.9 g±22.4 vs. 38.1 g±15.8, p < 0.001) and larger end-systolic noncompacted to total myocardial mass (44%±9 vs. 36%±12, p = 0.003). At 78 months follow-up [interquartile range(IQR) 66-90], MACCE occurred in 11(11.3%) patients; nine(81.8%) had impaired LV function and two(18.2%) had LGE. Impaired LV function and LV LGE were predictors of MACCE (HR = 35.6, 95% CI = 7.65-165.21, p < 0.001 and HR = 16.2, 95% CI = 4.54-57.84, p < 0.001) whereas noncompacted mass were not. CONCLUSION Noncompacted mass was not an independent predictor of major adverse events but in patients with impaired LV function and/or LV LGE, the risk of MACCE was high. These results highlight the importance of including LV volumetrics and scar in the assessment of patients with LV noncompaction.
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7
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Rao K, Bhaskaran A, Choudhary P, Tan TC. The role of multimodality imaging in the diagnosis of left ventricular noncompaction. Eur J Clin Invest 2020; 50:e13254. [PMID: 32329049 DOI: 10.1111/eci.13254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/06/2020] [Accepted: 04/12/2020] [Indexed: 12/15/2022]
Abstract
Left ventricular noncompaction (LVNC) is a heterogeneous entity and, in reality, a likely spectrum of disease which is clinically associated with arrhythmia, thromboembolic complications and sudden cardiac death. With the emergence of cardiac MRI (cMRI), the phenotype is increasingly more prevalent, resulting in clinical uncertainty regarding prognosis and management. The currently accepted hypothesis suggests an early embryonic arrest of the normal, sequential myocardial compaction process. LVNC is observed in isolation or in association with congenital heart disease, neuromuscular disease or a vast array of genetic cardiomyopathies. Definition of the entity varies among international society guidelines with differences both within and between imaging modalities, predominantly echocardiography and cMRI. Long-term prognostic data are emerging but due to the intrinsic variability in reported prevalence, selection bias and lack of pathological to prognostic correlation, there are many uncertainties regarding clinical management. This review seeks to clarify the role of multimodality imaging in diagnosis and management of the disease. We discuss the sensitivity and specificity of the current diagnostic criteria, as well as the nuances in diagnosis using the available imaging modalities.
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Affiliation(s)
- Karan Rao
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.,University of Sydney, NSW, Australia
| | - Ashwin Bhaskaran
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.,University of Sydney, NSW, Australia
| | - Preeti Choudhary
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Timothy C Tan
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.,University of Sydney, NSW, Australia.,University of Western Sydney, NSW, Australia
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Pöyhönen P, Kuusisto J, Järvinen V, Pirinen J, Räty H, Lehmonen L, Paakkanen R, Martinez-Majander N, Putaala J, Sinisalo J. Left ventricular non-compaction as a potential source for cryptogenic ischemic stroke in the young: A case-control study. PLoS One 2020; 15:e0237228. [PMID: 32797064 PMCID: PMC7428175 DOI: 10.1371/journal.pone.0237228] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/21/2020] [Indexed: 12/27/2022] Open
Abstract
Background Up to 50% of ischemic strokes in the young after thorough diagnostic work-up remain cryptogenic or associated with low-risk sources of cardioembolism such as patent foramen ovale (PFO). We studied with cardiac magnetic resonance (CMR) imaging, whether left ventricular (LV) non-compaction—a possible source for embolic stroke due to sluggish blood flow in deep intertrabecular recesses—is associated with cryptogenic strokes in the young. Methods Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO; NCT01934725) is an international prospective multicenter case-control study of young adults (aged 18–49 years) presenting with an imaging-positive first-ever ischemic stroke of undetermined etiology. In this pilot substudy, 30 cases and 30 age- and sex-matched stroke-free controls were examined with CMR. Transcranial Doppler (TCD) bubble test was performed to evaluate the presence and magnitude of right-to-left shunt (RLS). Results There were no significant differences in LV volumes, masses or systolic function between cases and controls; none of the participants had non-compaction cardiomyopathy. Semi-automated assessment of LV non-compaction was highly reproducible. Non-compacted LV mass (median 14.0 [interquartile range 12.6–16.0] g/m2 vs. 12.7 [10.4–16.6] g/m2, p = 0.045), the ratio of non-compacted to compacted LV mass (mean 25.6 ± 4.2% vs. 22.8 ± 6.0%, p = 0.015) and the percentage of non-compacted LV volume (mean 17.6 ± 2.9% vs. 15.7 ± 3.8%, p = 0.004) were higher in cases compared to controls. In a multivariate conditional logistic regression model including non-compacted LV volume, RLS and body mass index, the percentage of non-compacted LV volume (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.10–2.18, p = 0.011) and the presence of RLS (OR 11.94, 95% CI 1.14–124.94, p = 0.038) were independently associated with cryptogenic ischemic stroke. Conclusions LV non-compaction is associated with a heightened risk of cryptogenic ischemic stroke in young adults, independent of concomitant RLS and in the absence of cardiomyopathy. Clinical trial registration SECRETO; NCT01934725. Registered 4th September 2013. https://clinicaltrials.gov/ct2/show/NCT01934725
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Affiliation(s)
- Pauli Pöyhönen
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
- * E-mail:
| | - Jouni Kuusisto
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Vesa Järvinen
- Department of Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, Helsinki, Finland
| | - Jani Pirinen
- Department of Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, Helsinki, Finland
| | - Heli Räty
- Department of Clinical Physiology and Nuclear Medicine, HUS Medical Imaging Center, Helsinki, Finland
| | - Lauri Lehmonen
- Radiology, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riitta Paakkanen
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | - Jukka Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Sinisalo
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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9
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Asmakutlu O, Alis D, Topel C, Sahin A. Late gadolinium enhancement on CMRI in patients with LV noncompaction: An overestimated phenomenon? Clin Imaging 2020; 66:121-126. [PMID: 32480266 DOI: 10.1016/j.clinimag.2020.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Subendocardial fibrosis is recognized finding in left ventricular noncompaction (LVNC); however, the evidence regarding the patterns and the frequency of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMRI) is controversial. The present study sought to assess the frequency and patterns of LGE in LVNC. MATERIALS AND METHODS Patients with a diagnosis of LVNC based on the echocardiographic CMRI criteria were enrolled in this retrospective study. The myocardial noncompacted-to-compacted ratio (NC/C) was perpendicularly measured on short-axis cine images. Two observers jointly assessed the presence of LGE on short-axis LGE images. The long-axis four-chamber and long-axis two-chamber images were used to confirm the presence of LGE if needed. RESULTS A total of 42 patients, 20 females (47.7%) and 22 were males (52.3%), were included in the study. The median age of the patients was 32.4 years (range 18-63). LGE was identified in 2 out of 42 patients (4.7%) with LVNC. LGE was identified in the interventricular septum involving the subendocardial layer and noncompacted lateral myocardial wall involving the trabeculae at mid-ventricular and basal levels. CONCLUSION LGE is uncommon in patients with LVNC. We highlight that the diagnosis of LVNC in patients with atypical LGE patterns, such as epicardial or transmural enhancement, should be reappraised and the other cardiac diseases should be discarded before establishing the final diagnosis.
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Affiliation(s)
- Ozan Asmakutlu
- Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Radiology, Halkali/Istanbul, Turkey.
| | - Deniz Alis
- Istanbul Acibadem Mehmet Ali Aydinlar University, Department of Radiology, Istanbul, Turkey.
| | - Cagdas Topel
- Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Radiology, Halkali/Istanbul, Turkey.
| | - Anil Sahin
- Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiology, Halkali/Istanbul, Turkey.
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10
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Bentatou Z, Finas M, Habert P, Kober F, Guye M, Bricq S, Lalande A, Frandon J, Dacher JN, Dubourg B, Habib G, Caudron J, Normant S, Rapacchi S, Bernard M, Jacquier A. Distribution of left ventricular trabeculation across age and gender in 140 healthy Caucasian subjects on MR imaging. Diagn Interv Imaging 2018; 99:689-698. [PMID: 30262171 DOI: 10.1016/j.diii.2018.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/20/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this study was to quantify the distribution of trabeculated (T) and compact (C) left ventricular (LV) myocardium masses in a healthy Caucasian population against age, gender and LV parameters, and to provide normal values for T, C and T/C. MATERIALS AND METHODS One hundred and forty healthy subjects were prospectively recruited and underwent cardiac MRI at 1.5T with a stack of short-axis cine sequences covering the entire LV. End-diastolic volume (EDV), C and T masses were quantified using a semi-automatic method. Ejection fraction (EF) and T/C ratio were computed. RESULTS We included 70 men and 70 women with a mean age of 44±14 (SD) years (range: 20-69 years). The mean EF was 63.7±6.3 (SD) % (range: 50.7-82.0%), the mean EDV was 75.9±16.2 (SD) mL/m2 (range: 36.4-112.2mL/m2), the mean C mass was 53.9±11.2 (SD) g/m2 (range: 26.5-93.4g/m2) and the mean T mass was 4.9±2.4 (SD) g/m2 (range: 1.1-11.4g/m2). The T/C ratio was 9.2±4.5% (range: 2.0-29.4%). Multivariate ANOVA test showed that the compact mass was influenced by EDV (P<0.0001), EF (P=0.001) and gender (P<0.0001), and the trabeculated mass depended on EDV (P<0.0001), gender (P=0.002) and age (P<0.0001), while the T/C ratio was only influenced by age (P=0.0003). Spearman test showed a correlation between EDV and C (r=0.60; P<0.0001),T (r=0.46; P<0.0001) and T/C ratio (r=0.26; P=0.0023).T and T/C ratio correlated with EF (r=-0.18, P=0.0373; r=-0.18, P=0.0321, respectively). CONCLUSION While the compact and trabeculated myocardium masses appear to relate separately to the cardiac function, age and gender, their ratio T/C appears to only decrease with age. Furthermore, we propose here normal values for T, C and T/C in a cohort of healthy Caucasians subjects.
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Affiliation(s)
- Z Bentatou
- UMR CNRS 7339, Aix-Marseille University, 13385 Marseille cedex 05, France; Centre de Résonance Magnétique Biologique et Médicale, Hôpital de la Timone, AP-HM, 13385 Marseille cedex 05, France.
| | - M Finas
- Department of Radiology, CHU de Grenoble, 38043 Grenoble cedex 9, France
| | - P Habert
- Department of Cardiology, Aix-Marseille Université, Hôpital de la Timone, AP-HM, 13385 Marseille cedex 05, France
| | - F Kober
- UMR CNRS 7339, Aix-Marseille University, 13385 Marseille cedex 05, France
| | - M Guye
- UMR CNRS 7339, Aix-Marseille University, 13385 Marseille cedex 05, France; Centre de Résonance Magnétique Biologique et Médicale, Hôpital de la Timone, AP-HM, 13385 Marseille cedex 05, France
| | - S Bricq
- Le2i, University de Bourgogne-Franche Comté, 21000 Dijon, France
| | - A Lalande
- Le2i, University de Bourgogne-Franche Comté, 21000 Dijon, France; MRI Department, University Hospital of Dijon, 21000 Dijon, France
| | - J Frandon
- Department of Radiology, CHU de Grenoble, 38043 Grenoble cedex 9, France
| | - J N Dacher
- Cardiac Imaging Unit, Department of Radiology, hôpital universitaire de Rouen, 76031 Rouen, France
| | - B Dubourg
- Cardiac Imaging Unit, Department of Radiology, hôpital universitaire de Rouen, 76031 Rouen, France
| | - G Habib
- Department of Cardiology, Aix-Marseille Université, Hôpital de la Timone, AP-HM, 13385 Marseille cedex 05, France; IRD, IHU-Méditerranée Infection, université d'Aix Marseille, MEPHI, AP-HM, 13385 Marseille cedex 05, France
| | - J Caudron
- Cardiac Imaging Unit, Department of Radiology, hôpital universitaire de Rouen, 76031 Rouen, France
| | - S Normant
- Cardiac Imaging Unit, Department of Radiology, hôpital universitaire de Rouen, 76031 Rouen, France
| | - S Rapacchi
- UMR CNRS 7339, Aix-Marseille University, 13385 Marseille cedex 05, France; Centre de Résonance Magnétique Biologique et Médicale, Hôpital de la Timone, AP-HM, 13385 Marseille cedex 05, France
| | - M Bernard
- UMR CNRS 7339, Aix-Marseille University, 13385 Marseille cedex 05, France
| | - A Jacquier
- UMR CNRS 7339, Aix-Marseille University, 13385 Marseille cedex 05, France; Centre de Résonance Magnétique Biologique et Médicale, Hôpital de la Timone, AP-HM, 13385 Marseille cedex 05, France
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Boban M, Pesa V, Beck N, Manola S, Zulj M, Rotim A, Vcev A. Supplementary Diagnostic Landmarks of Left Ventricular Non-Compaction on Magnetic Resonance Imaging. Yonsei Med J 2018; 59:63-71. [PMID: 29214778 PMCID: PMC5725366 DOI: 10.3349/ymj.2018.59.1.63] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/09/2017] [Accepted: 09/12/2017] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Diagnostic criteria for left ventricular non-compaction (LVNC) are still a matter of dispute. The aim of our present study was to test the diagnostic value of two novel diagnostic cardiac magnetic resonance (CMR) parameters: proof of non-compact (NC) myocardium blood flow using T2 sequences and changes in geometry of the left ventricle. MATERIALS AND METHODS The study included cases with LVNC and controls, from a data base formed in a period of 3.5 years (n=1890 exams), in which CMR protocol included T2 sequences. Measurement of perpendicular maximal and minimal end diastolic dimensions in the region with NC myocardium from short axis plane was recorded, and calculated as a ratio (MaxMinEDDR), while flow through trabecula was proven by intracavital T2-weighted hyperintensity (ICT2HI). LVNC diagnosis met the following three criteria: thickening of compact (C) layer, NC:C>2.3:1 and NC>20%LV. RESULTS The study included 200 patients; 71 with LVNC (35.5%; i.e., 3.76% of CMRs) and 129 (64.5%) controls. MaxMinEDDR in patients with LVNC was significantly different from that in controls (1.17±0.08 vs. 1.06±0.04, respectively; p<0.001). MaxMinEDDR >1.10 had sensitivity of 91.6% [95% confidence intervals (CI) 82.5-96.8], specificity of 85.3% (95% CI 78.0-90.0), and area under curve (AUC) 0.919 (95% CI 0.872-0.953; p<0.001) for LVNC. Existence of ICT2HI had sensitivity of 100.0% (95% CI 94.9-100.0), specificity of 91.5% (95% CI 85.3-95.7), and AUC 0.957 (95% CI 0.919-0.981; p<0.001) for LVNC. CONCLUSION Two additional diagnostic parameters for LVNC were identified in this study. ICT2HI and geometric eccentricity of the ventricle both had relatively high sensitivity and specificity for diagnosing LVNC.
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Affiliation(s)
- Marko Boban
- Department of Cardiology, University Hospital "Thalassotherapia Opatija," Medical Faculty University of Rijeka, Opatija, Croatia
- Department of Internal Medicine, Medical Faculty "J.J. Strossmayer" University of Osijek, Osijek, Croatia
- Department of Radiology, University Hospital "Thalassotherapia Opatija," Opatija, Croatia.
| | - Vladimir Pesa
- Department of Cardiology, University Hospital "Thalassotherapia Opatija," Medical Faculty University of Rijeka, Opatija, Croatia
- Department of Radiology, University Hospital "Thalassotherapia Opatija," Opatija, Croatia
| | - Natko Beck
- Department of Cardiology, University Hospital "Thalassotherapia Opatija," Medical Faculty University of Rijeka, Opatija, Croatia
- Department of Radiology, University Hospital "Thalassotherapia Opatija," Opatija, Croatia
| | - Sime Manola
- Department of Cardiology-Arrhythmology and Electrophysiology, University Hospital "Sestre Milosrdnice," Zagreb, Croatia
| | - Marinko Zulj
- Department of Internal Medicine, Medical Faculty "J.J. Strossmayer" University of Osijek, Osijek, Croatia
| | - Ante Rotim
- Department of Cardiology, University Hospital "Thalassotherapia Opatija," Medical Faculty University of Rijeka, Opatija, Croatia
| | - Aleksandar Vcev
- Department of Internal Medicine, Medical Faculty "J.J. Strossmayer" University of Osijek, Osijek, Croatia
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Long-Term Prognostic Value of Cardiac Magnetic Resonance in Left Ventricle Noncompaction: A Prospective Multicenter Study. J Am Coll Cardiol 2017; 68:2166-2181. [PMID: 27855806 DOI: 10.1016/j.jacc.2016.08.053] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 08/23/2016] [Accepted: 08/31/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) is useful for the diagnosis of left ventricular noncompaction (LVNC). However, there are limited data regarding its prognostic value. OBJECTIVES The goal of this study was to evaluate the prognostic relevance of CMR findings in patients with LVNC. METHODS A total of 113 patients with an echocardiographic diagnosis of LVNC underwent CMR at 5 referral centers. CMR diagnostic criterion of LVNC (noncompacted/compacted ratio >2.3 in end-diastole) was confirmed in all patients. We performed left ventricular (LV) and right ventricular quantitative analysis and late gadolinium enhancement (LGE) assessments and analyzed the following LVNC diagnostic criteria: left ventricular noncompacted myocardial mass (LV-ncMM) >20% and >25%, total LV-ncMM index >15 g/m2, noncompacted/compacted ratio ≥3:1 ≥1 of segments 1 to 3 and 7 to 16 or ≥2:1 in at least 1 of segments 4 to 6 of the American Heart Association model. Outcome was a composite of thromboembolic events, heart failure hospitalizations, ventricular arrhythmias, and cardiac death. RESULTS At a mean follow-up of 48 ± 24 months, cardiac events (CEs) occurred in 36 patients (16 heart failure hospitalizations, 10 ventricular arrhythmias, 5 cardiac deaths, and 5 thromboembolic events). LV dilation, impaired LV ejection fraction, and LV-ncMM >20% was significantly more frequent in patients with CEs. LV fibrosis was detected by using LGE in 11 cases. CMR predictors of CEs were LV dilation and LGE. LGE was associated with improved prediction of CEs, compared with clinical data and CMR functional parameters in all 3 models. No CEs occurred in patients without dilated cardiomyopathy and/or LGE. CONCLUSIONS In patients with LVNC evaluated by using CMR, the degree of LV trabeculation seems to have no prognostic impact over and above LV dilation, LV systolic dysfunction, and presence of LGE.
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Key Questions Relating to Left Ventricular Noncompaction Cardiomyopathy: Is the Emperor Still Wearing Any Clothes? Can J Cardiol 2017; 33:747-757. [DOI: 10.1016/j.cjca.2017.01.017] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 11/23/2022] Open
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Chebrolu LH, Mehta AM, Nanda NC. Noncompaction cardiomyopathy: The role of advanced multimodality imaging techniques in diagnosis and assessment. Echocardiography 2017; 34:279-289. [DOI: 10.1111/echo.13435] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Lakshmi H. Chebrolu
- Department of Cardiology; Houston Methodist DeBakey Heart and Vascular Center; Houston TX USA
| | - Anjlee M. Mehta
- Division of Cardiology; University of Texas Health Science Center at San Antonio; San Antonio TX USA
| | - Navin C. Nanda
- Division of Cardiovascular Disease; University of Alabama at Birmingham; Birmingham AL USA
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15
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Left ventricular non-compaction and idiopathic dilated cardiomyopathy: the significant diagnostic value of longitudinal strain. Int J Cardiovasc Imaging 2016; 33:83-95. [DOI: 10.1007/s10554-016-0980-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/16/2016] [Indexed: 11/26/2022]
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16
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Gonzalez JA, Kramer CM. Role of Imaging Techniques for Diagnosis, Prognosis and Management of Heart Failure Patients: Cardiac Magnetic Resonance. Curr Heart Fail Rep 2016; 12:276-83. [PMID: 26041670 DOI: 10.1007/s11897-015-0261-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cardiac magnetic resonance (CMR) has evolved into a major tool for the diagnosis and assessment of prognosis of patients suffering from heart failure. Anatomical and structural imaging, functional assessment, T1 and T2 mapping tissue characterization, and late gadolinium enhancement (LGE) have provided clinicians with tools to distinguish between non-ischemic and ischemic cardiomyopathies and to identify the etiology of non-ischemic cardiomyopathies. LGE is a useful tool to predict the likelihood of functional recovery after revascularization in patients with CAD and to guide the left ventricular (LV) lead placement in those who qualify for cardiac resynchronization (CRT) therapy. In addition, the presence of LGE and its extent in myocardial tissue relate to overall cardiovascular outcomes. Emerging roles for cardiac imaging in heart failure with preserved ejection fraction (HFpEF) are being studied, and CMR continues to be among the most promising noninvasive imaging alternatives in the diagnosis of this disease.
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Affiliation(s)
- Jorge A Gonzalez
- Department of Medicine (Division of Cardiology), and the Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA, USA
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17
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Coris EE, Moran BK, De Cuba R, Farrar T, Curtis AB. Left Ventricular Non-Compaction in Athletes: To Play or Not to Play. Sports Med 2016; 46:1249-59. [DOI: 10.1007/s40279-016-0512-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Semiautomatic detection of myocardial contours in order to investigate normal values of the left ventricular trabeculated mass using MRI. J Magn Reson Imaging 2015; 43:1398-406. [DOI: 10.1002/jmri.25113] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 11/23/2015] [Indexed: 01/12/2023] Open
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19
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Zhu D, Yin S, Cheng W, Luo Y, Yang D, Lin K, An Q, Sun J, Chen Y. Cardiac MRI-based multi-modality imaging in clinical decision-making: Preliminary assessment of a management algorithm for patients with suspected cardiac mass. Int J Cardiol 2015; 203:474-81. [PMID: 26551882 DOI: 10.1016/j.ijcard.2015.09.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 08/20/2015] [Accepted: 09/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiac masses are rare with high morbidity and mortality that challenging the management. The purpose of this study was to evaluate the potential role of cardiac-MRI based multi-modality imaging in the clinical decision-making for patients with cardiac mass. METHODS From November 2011 to May 2014, 59 consecutive patients (33 females; mean age, 48.2 ± 21.1 [range, 0.6-85] years) with suspected cardiac mass were enrolled in this prospective single center study, underwent MRI based multi-modality imaging and were followed up for survival status. Management strategy (surgery, chemotherapy or observation) was based on patient's clinical status and cardiac mass imaging characteristics (location, morphology, hemodynamics, embolization risk, metastasis, and resectability). RESULTS Using cardiac MRI, 39 patients were diagnosed with intra-cardiac neoplasm (28 benign, 11 malignant) and 20 with pseudo-tumors (13 thrombi, 4 cysts and 3 fat infiltration); 34 masses (23 neoplasms, 11 pseudo-tumors) were eligible for surgical removal, and 4 underwent PET-CT scan to further delineate characteristics and metastasis. Pathological examination revealed high accuracy of cardiac MRI in differentiating benign from malignant tumors (96%), and neoplasm from pseudo-tumors (100%). As for the 16 patients with cardiac neoplasm not surgically treated, the 9 with "benign" masses as per MRI-based multimodality imaging survived during follow-up, while all 7 with "malignancy" died; the 9 with pseudo-tumors not surgically treated also survived with good condition. The median follow-up period is 2 years (10 days-3 years). CONCLUSION Cardiac MRI based multimodality imaging appears useful for risk stratification and clinical decision making for patients with suspected cardiac mass.
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Affiliation(s)
- Da Zhu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, PR China
| | - Senlin Yin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, PR China
| | - Wei Cheng
- Department of Radiology, West China Hospital, Sichuan University, PR China
| | - Yong Luo
- Department of Cardiology, West China Hospital, Sichuan University, PR China
| | - Dan Yang
- Department of Cardiology, West China Hospital, Sichuan University, PR China
| | - Ke Lin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, PR China
| | - Qi An
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, PR China
| | - Jiayu Sun
- Department of Radiology, West China Hospital, Sichuan University, PR China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, PR China.
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Ma H, Wen Z, Liu Y, Shi L, Wang Y, Jing Y, Shi Y, Sun C, Liu J, Yang J. Letter regarding Choudhary et al. "Improving the diagnosis of LV non-compaction with cardiac magnetic resonance imaging". Int J Cardiol 2015; 187:237. [PMID: 25838221 DOI: 10.1016/j.ijcard.2015.03.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Heng Ma
- Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Zhaoying Wen
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Xijing Hospital, Fourth Military Medical University, China
| | - Lei Shi
- Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Yong Wang
- Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Yanyan Jing
- Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Yinghong Shi
- Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Chunjuan Sun
- Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Jing Liu
- Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Jun Yang
- Yuhuangding Hospital, Yantai, Shandong Province, China.
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