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Papanastasiou CA, Bazmpani MA, Kampaktsis PN, Zegkos T, Gossios T, Parcharidou D, Kokkinidis DG, Tziatzios I, Economou FI, Nikolaidou C, Kamperidis V, Tsapas A, Ziakas A, Efthimiadis G, Karamitsos TD. Cardiac magnetic resonance for ventricular arrhythmias: a systematic review and meta-analysis. Heart 2024:heartjnl-2024-324182. [PMID: 39084706 DOI: 10.1136/heartjnl-2024-324182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) allows comprehensive myocardial tissue characterisation, revealing areas of myocardial inflammation or fibrosis that may predispose to ventricular arrhythmias (VAs). With this study, we aimed to estimate the prevalence of structural heart disease (SHD) and decipher the prognostic implications of CMR in selected patients presenting with significant VAs. METHODS Electronic databases were searched for studies enrolling adult patients that underwent CMR for diagnostic or prognostic purposes in the setting of significant VAs. A random effects model meta-analysis of proportions was performed to estimate the prevalence of SHD. HRs were pooled together in order to evaluate the prognostic value of CMR. RESULTS The prevalence of SHD was reported in 18 studies. In all-comers with significant VAs, the pooled rate of SHD post-CMR evaluation was 39% (24% in the subgroup of premature ventricular contractions and/or non-sustained ventricular tachycardia vs 63% in the subgroup of more complex VAs). A change in diagnosis after use of CMR ranged from 21% to 66% with a pooled average of 35% (29%-41%). A non-ischaemic cardiomyopathy was the most frequently identified SHD (56%), followed by ischaemic heart disease (21%) and hypertrophic cardiomyopathy (5%). After pooling together data from six studies, we found that the presence of late gadolinium enhancement was associated with increased risk of major adverse outcomes in patients with significant VAs (pooled HR: 1.79; 95% CI 1.33 to 2.42). CONCLUSION CMR is a valuable tool in the diagnostic and prognostic evaluation of patients with VAs. CMR should be considered early after initial evaluation in the diagnostic algorithm for VAs of unclear aetiology as this strategy may also define prognosis and improve risk stratification.
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Affiliation(s)
- Christos A Papanastasiou
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
- Cardiology Department, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Maria-Anna Bazmpani
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Polydoros N Kampaktsis
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Thomas Zegkos
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Thomas Gossios
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Despoina Parcharidou
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Damianos G Kokkinidis
- Heart and Vascular Institute, L&M, Yale New Haven Health, New Haven, Connecticut, USA
| | - Ioannis Tziatzios
- Cardiology Department, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Fotios I Economou
- Cardiology Department, 424 General Military Training Hospital, Thessaloniki, Greece
| | | | - Vasileios Kamperidis
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Apostolos Tsapas
- Center for Clinical Research and Evidence-Based Medicine, Aristotle University Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
| | - Antonios Ziakas
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Georgios Efthimiadis
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Theodoros D Karamitsos
- 1st Cardiology Department, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
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Haberl C, Crean AM, Zelt JGE, Redpath CJ, deKemp RA. Role of Nuclear Imaging in Cardiac Stereotactic Body Radiotherapy for Ablation of Ventricular Tachycardia. Semin Nucl Med 2024; 54:427-437. [PMID: 38658301 DOI: 10.1053/j.semnuclmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia common in patients with structural heart disease or nonischemic cardiomyopathy. Many VTs originate from regions of fibrotic scar tissue, where delayed electrical signals exit scar and re-enter viable myocardium. Cardiac stereotactic body radiotherapy (SBRT) has emerged as a completely noninvasive alternative to catheter ablation for the treatment of recurrent or refractory ventricular tachycardia. While there is no common consensus on the ideal imaging workflow, therapy planning for cardiac SBRT often combines information from a plurality of imaging modalities including MRI, CT, electroanatomic mapping and nuclear imaging. MRI and CT provide detailed anatomic information, and late enhancement contrast imaging can indicate regions of fibrosis. Electroanatomic maps indicate regions of heterogenous conduction voltage or early activation which are indicative of arrhythmogenic tissue. Some early clinical adopters performing cardiac SBRT report the use of myocardial perfusion and viability nuclear imaging to identify regions of scar. Nuclear imaging of hibernating myocardium, inflammation and sympathetic innervation have been studied for ventricular arrhythmia prognosis and in research relating to catheter ablation of VT but have yet to be studied in their potential applications for cardiac SBRT. The integration of information from these many imaging modalities to identify a target for ablation can be challenging. Multimodality image registration and dedicated therapy planning tools may enable higher target accuracy, accelerate therapy planning workflows and improve patient outcomes. Understanding the pathophysiology of ventricular arrhythmias, and localizing the arrhythmogenic tissues, is vital for successful ablation with cardiac SBRT. Nuclear imaging provides an arsenal of imaging strategies to identify regional scar, hibernation, inflammation, and sympathetic denervation with some advantages over alternative imaging strategies.
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Affiliation(s)
- Connor Haberl
- University of Ottawa Heart Institute, Ottawa, ON; Carleton University, Ottawa, ON
| | - Andrew M Crean
- University of Ottawa Heart Institute, Ottawa, ON; North West Heart Center, University of Manchester Foundation NHS Trust, Manchester, UK
| | - Jason G E Zelt
- The Ottawa Hospital, Ottawa, ON; Department of Medicine, University of Ottawa, Ottawa, ON
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Ge Y, Antiochos P, Seno A, Qamar I, Blankstein R, Steigner M, Aghayev A, Jerosch-Herold M, Tedrow UB, Stevenson WG, Kwong RY. Diagnostic Impact and Prognostic Value of Cardiac Magnetic Resonance in Patients With Ventricular Arrhythmias. JACC Cardiovasc Imaging 2023; 16:1536-1549. [PMID: 37318392 DOI: 10.1016/j.jcmg.2023.04.008] [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: 05/16/2022] [Revised: 03/10/2023] [Accepted: 04/27/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) characterizes myocardial substrate relevant to sudden cardiac death (SCD). However, its clinical value in patients presenting with ventricular arrhythmias is still being defined. OBJECTIVES The authors sought to examine the diagnostic and prognostic value of multiparametric CMR in a cohort of consecutive patients referred for assessment of ventricular arrhythmias. METHODS Consecutive patients undergoing CMR for nonsustained ventricular tachycardia (NSVT) (n = 345) or sustained ventricular tachycardia (VT)/aborted SCD (n = 297) were followed over a median of 4.4 years. Major adverse cardiac events included death, recurrent VT/ventricular fibrillation requiring therapy, and hospitalization for congestive heart failure. RESULTS Of the 642 patients, 256 were women (40%), mean age was 54 ± 15 years, and median left ventricular ejection fraction was 58% (IQR: 49%-63%). A structurally abnormal heart by CMR assessment was detected in 40% of patients with NSVT and 66% in those with VT/SCD (P < 0.001). CMR assessment yielded a diagnostic change in 27% of NSVT patients vs 41% of those with VT/SCD (P < 0.001). During follow-up, 51 patients (15%) with NSVT and 104 patients (35%) with VT/SCD experienced major adverse cardiac events (MACE). An abnormal CMR was associated with a higher annual rate for MACE for both NSVT (0.7% vs 7.7%; P < 0.001) and VT/SCD (3.8% vs 13.3%; P < 0.001) patients. In a multivariate model including left ventricular ejection fraction, an abnormal CMR remained strongly associated with MACE in NSVT (HR: 5.23 [95% CI: 2.28-12.0]; P < 0.001) and VT/SCD (HR: 1.88 [95% CI: 1.07-3.30]; P = 0.03). Adding CMR assessment to the multivariable model for MACE yielded a significant improvement in the integrated discrimination improvement and an improvement in the C-statistic in the NSVT cohort. CONCLUSIONS In patients presenting with ventricular arrhythmias, multiparametric CMR assessment provides diagnostic clarification and effective risk stratification beyond current standard of care.
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Affiliation(s)
- Yin Ge
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Panagiotis Antiochos
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Division, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Ayako Seno
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Iqra Qamar
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Steigner
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ayaz Aghayev
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Jerosch-Herold
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond Y Kwong
- Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Basharat SA, Hsiung I, Garg J, Alsaid A. Arrhythmogenic Cardiomyopathy: Evolving Diagnostic Criteria and Insight from Cardiac Magnetic Resonance Imaging. Heart Fail Clin 2023; 19:429-444. [PMID: 37714585 DOI: 10.1016/j.hfc.2023.03.006] [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] [Indexed: 09/17/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an umbrella term encompassing a wide variety of overlapping hereditary and nonhereditary disorders that can result in malignant ventricular arrhythmias and sudden cardiac death. Cardiac MRI plays a critical role in accurate diagnosis of various ACM entities and is increasingly showing promise in risk stratification that can further guide management particularly in decisions regarding use of implantable cardioverter defibrillator. Genotyping plays an important role in cascade testing but challenges remain due to incomplete penetrance and wide phenotypic variability of ACM as well as the presence of gene-elusive cases.
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Affiliation(s)
- Sohaib Ahmad Basharat
- Division of Cardiology, Loma Linda University Medical Center, 11234 Anderson Street, MC2426, Loma Linda, CA 92354, USA
| | - Ingrid Hsiung
- Department of Cardiology, Baylor Scott & White The Heart Hospital, 1100 Allied Drive, Plano, TX 75093, USA
| | - Jalaj Garg
- Division of Cardiology, Loma Linda University Medical Center, 11234 Anderson Street, MC2426, Loma Linda, CA 92354, USA. https://twitter.com/drjalajgarg
| | - Amro Alsaid
- Department of Cardiology, Baylor Scott & White The Heart Hospital, 1100 Allied Drive, Plano, TX 75093, USA.
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Yuan Y, Yang K, Liu Q, Song W, Jin D, Zhao S. Nonspecific intraventricular conduction delay predicts the prognosis of dilated cardiomyopathy. BMC Cardiovasc Disord 2023; 23:409. [PMID: 37596522 PMCID: PMC10439585 DOI: 10.1186/s12872-023-03437-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023] Open
Abstract
PURPOSE Left bundle branch block (LBBB) has been confirmed to be independently associated with adverse outcomes in dilated cardiomyopathy (DCM). However, prognostic data on nonspecific intraventricular conduction delay (NSIVCD) are still limited and conflicting. We aimed to evaluate the prognosis of DCM with NSIVCD. METHODS A total of 548 DCM patients who underwent cardiovascular magnetic resonance imaging (CMR) from January 2016 to December 2017 were consecutively enrolled. The cohort was divided into four groups: 87 with LBBB, 27 with RBBB, 61 with NSIVCD, and 373 without intraventricular conduction delay (IVCD). After a median follow-up of 58 months (interquartile range: 47-65), 123 patients reached the composite endpoints, which included cardiovascular death, heart transplantation, and malignant arrhythmias. The associations between different patterns of IVCD and the outcomes of DCM were analysed by Kaplan‒Meier analysis and Cox proportional hazards regression analysis. RESULTS Of 548 DCM patients, there were 398 males (72.6%), and the average age was 46 ± 15 years, ranging from 18 to 76 years. In Kaplan‒Meier analysis, patients with NSIVCD and LBBB showed higher event rates than patients without IVCD, while RBBB patients did not. By multivariate Cox regression analysis, LBBB, NSIVCD, NYHA class, left ventricular ejection fraction (LVEF), indexed left ventricular end-diastolic diameter (LVEDDI), percentage of late gadolinium enhancement mass (LGE%), and global longitudinal strain (GLS) were found to be independently associated with the outcomes of DCM. CONCLUSIONS In addition to LBBB, NSIVCD was an unfavourable prognostic marker in patients with DCM, independent of LVEDDI, NYHA class, LVEF, LGE%, and GLS.
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Affiliation(s)
- Yong Yuan
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Diagnostic Imaging, Geriatric Hospital of Nanjing Medical University, Nanjing, 210024, China
| | - Kai Yang
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Qianjun Liu
- Department of Cardiology, Huadong Hospital Affiliated to Fudan University, Shanghai, 200040, China
| | - Weixiang Song
- Department of Radiology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Dongsheng Jin
- Department of Diagnostic Imaging, Geriatric Hospital of Nanjing Medical University, Nanjing, 210024, China.
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Cardiovascular Imaging and Intervention Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
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Vázquez-Calvo S, Roca-Luque I, Althoff TF. Management of Ventricular Arrhythmias in Heart Failure. Curr Heart Fail Rep 2023; 20:237-253. [PMID: 37227669 DOI: 10.1007/s11897-023-00608-y] [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] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE OF REVIEW Despite substantial progress in medical and device-based heart failure (HF) therapy, ventricular arrhythmias (VA) and sudden cardiac death (SCD) remain a major challenge. Here we review contemporary management of VA in the context of HF with one particular focus on recent advances in imaging and catheter ablation. RECENT FINDINGS Besides limited efficacy of antiarrhythmic drugs (AADs), their potentially life-threatening side effects are increasingly acknowledged. On the other hand, with tremendous advances in catheter technology, electroanatomical mapping, imaging, and understanding of arrhythmia mechanisms, catheter ablation has evolved into a safe, efficacious therapy. In fact, recent randomized trials support early catheter ablation, demonstrating superiority over AAD. Importantly, CMR imaging with gadolinium contrast has emerged as a central tool for the management of VA complicating HF: CMR is not only essential for an accurate diagnosis of the underlying entity and subsequent treatment decisions, but also improves risk stratification for SCD prevention and patient selection for ICD therapy. Finally, 3-dimensional characterization of arrhythmogenic substrate by CMR and imaging-guided ablation approaches substantially enhance procedural safety and efficacy. VA management in HF patients is highly complex and should be addressed in a multidisciplinary approach, preferably at specialized centers. While recent evidence supports early catheter ablation of VA, an impact on mortality remains to be demonstrated. Moreover, risk stratification for ICD therapy may have to be reconsidered, taking into account imaging, genetic testing, and other parameters beyond left ventricular function.
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Affiliation(s)
- Sara Vázquez-Calvo
- Arrhythmia Section, Cardiovascular Institute (ICCV), CLÍNIC Barcelona University Hospital, C/Villarroel N° 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Arrhythmia Section, Cardiovascular Institute (ICCV), CLÍNIC Barcelona University Hospital, C/Villarroel N° 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Till F Althoff
- Arrhythmia Section, Cardiovascular Institute (ICCV), CLÍNIC Barcelona University Hospital, C/Villarroel N° 170, 08036, Barcelona, Catalonia, Spain.
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
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Shalmon T, Hamad FMD, Jimenez-Juan L, Kirpalani A, Urzua Fresno CM, Folador L, Tan NS, Singh SM, Ge Y, Dorian P, Lima JAC, Wong KCK, Deva DP, Yan AT. Prognostic Value of Different Thresholds for Myocardial Scar Quantification on Cardiac MRI Late Gadolinium Enhancement Images in Patients Receiving Implantable Cardioverter Defibrillators. Radiol Cardiothorac Imaging 2023; 5:e210247. [PMID: 37404790 PMCID: PMC10316291 DOI: 10.1148/ryct.210247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 03/20/2023] [Accepted: 04/14/2023] [Indexed: 07/06/2023]
Abstract
Purpose To compare the predictive value of different myocardial scar quantification thresholds using cardiac MRI for appropriate implantable cardioverter defibrillator (ICD) shock and mortality. Materials and Methods In this retrospective, two-center observational cohort study, patients with ischemic or nonischemic cardiomyopathy underwent cardiac MRI prior to ICD implantation. Late gadolinium enhancement (LGE) was first determined visually and then quantified by blinded cardiac MRI readers using different SDs above the mean signal of normal myocardium, full-width half-maximum, and manual thresholding. The intermediate signal "gray zone" was calculated as the differences between different SDs. Results Among 374 consecutive eligible patients (mean age, 61 years ± 13 [SD]; mean left ventricular ejection fraction, 32% ± 14; secondary prevention, 62.7%), those with LGE had a higher rate of appropriate ICD shock or death than those without (37.5% vs 26.6%, log-rank P = .04) over a median follow-up of 61 months. In multivariable analysis, none of the thresholds for quantifying scar was a significant predictor of mortality or appropriate ICD shock, while the extent of gray zone was an independent predictor (adjusted hazard ratio per 1 g = 1.025; 95% CI: 1.008, 1.043; P = .005) regardless of the presence or absence of ischemic heart disease (P interaction = .57). Model discrimination was highest for the model incorporating the gray zone (between 2 SD and 4 SD). Conclusion Presence of LGE was associated with a higher rate of appropriate ICD shock or death. Although none of the scar quantification techniques predicted outcomes, the gray zone both in infarct and nonischemic scar was an independent predictor and may refine risk stratification.Keywords: MRI, Scar Quantification, Implantable Cardioverter Defibrillator, Sudden Cardiac Death Supplemental material is available for this article. © RSNA, 2023.
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Hawson J, Joshi S, Al-Kaisey A, Das SK, Anderson RD, Morton J, Kumar S, Kistler P, Kalman J, Lee G. Utility of cardiac imaging in patients with ventricular tachycardia. Indian Pacing Electrophysiol J 2023; 23:63-76. [PMID: 36958589 PMCID: PMC10160788 DOI: 10.1016/j.ipej.2023.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/09/2023] [Accepted: 03/13/2023] [Indexed: 03/25/2023] Open
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia that may be idiopathic or result from structural heart disease. Cardiac imaging is critical in the diagnostic workup and risk stratification of patients with VT. Data gained from cardiac imaging provides information on likely mechanisms and sites of origin, as well as risk of intervention. Pre-procedural imaging can be used to plan access route(s) and identify patients where post-procedural intensive care may be required. Integration of cardiac imaging into electroanatomical mapping systems during catheter ablation procedures can facilitate the optimal approach, reduce radiation dose, and may improve clinical outcomes. Intraprocedural imaging helps guide catheter position, target substrate, and identify complications early. This review summarises the contemporary imaging modalities used in patients with VT, and their uses both pre-procedurally and intra-procedurally.
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Affiliation(s)
- Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Subodh Joshi
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ahmed Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Souvik K Das
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Joseph Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital and Westmead Applied Research Centre, Westmead, New South Wales, Australia; Western Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter Kistler
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia.
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Power Modulation Echocardiography to Detect and Quantify Myocardial Scar. J Am Soc Echocardiogr 2022; 35:1146-1155. [PMID: 35798123 DOI: 10.1016/j.echo.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/28/2022] [Accepted: 06/05/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Myocardial scar correlates with clinical outcomes. Traditionally, late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is used to detect and quantify scar. In this prospective study using LGE CMR as reference, the authors hypothesized that nonlinear ultrasound imaging, namely, power modulation, can detect and quantify myocardial scar in selected patients with previous myocardial infarction. In addition, given the different histopathology between ischemic and nonischemic scar, a further aim was to test the diagnostic performance of this echocardiographic technique in unselected consecutive individuals with ischemic and nonischemic LGE or no LGE on CMR. METHODS Seventy-one patients with previous myocardial infarction underwent power modulation echocardiography following CMR imaging (group A). Subsequently, 101 consecutive patients with or without LGE on CMR, including individuals with nonischemic LGE, were scanned using power modulation echocardiography (group B). RESULTS In group A, echocardiography detected myocardial scar in all 71 patients, with good scar volume agreement with CMR (bias = -1.9 cm3; limits of agreement [LOA], -8.0 to 4.2 cm3). On a per-segment basis, sensitivity was 82%, specificity 97%, and accuracy 92%. Sensitivity was higher in the inferior and posterior segments and lower in the anterior and lateral walls. In group B, on a per-subject basis, the sensitivity of echocardiography was 62% (91% for ischemic and 30% for nonischemic LGE), with specificity and accuracy of 89% and 72%, respectively. The bias for scar volume between modalities was 5.9 cm3, with LOA of 34.6 to 22.9 cm3 (bias = -1.9 cm3 [LOA, -11.4 to 7.6 cm3] for ischemic LGE, and bias = 18.9 cm3 [LOA, -67.4 to 29.7.6 cm3] for nonischemic LGE). CONCLUSIONS Power modulation echocardiography can detect myocardial scar in both selected and unselected individuals with previous myocardial infarction and has good agreement for scar volume quantification with CMR. In an unselected cohort with nonischemic LGE, sensitivity is low.
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Antiochos P, Ge Y, van der Geest RJ, Madamanchi C, Qamar I, Seno A, Jerosch-Herold M, Tedrow UB, Stevenson WG, Kwong RY. Entropy as a Measure of Myocardial Tissue Heterogeneity in Patients With Ventricular Arrhythmias. JACC Cardiovasc Imaging 2022; 15:783-792. [PMID: 35512951 DOI: 10.1016/j.jcmg.2021.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The authors investigated the incremental prognostic value of entropy, a novel measure of myocardial tissue heterogeneity by cardiac magnetic resonance (CMR) imaging in patients presenting with ventricular arrhythmias (VAs). BACKGROUND CMR can characterize myocardial areas serving as arrhythmogenic substrate. METHODS Consecutive patients undergoing CMR imaging for VAs were followed for major adverse cardiac events (MACEs) defined by all-cause death, incident VAs requiring therapy, or heart failure hospitalization. Entropy was derived from the probability distribution of pixel signal intensities of the left ventricular (LV) myocardium. RESULTS A total of 583 patients (age 54 ± 15 years, female 39%, left ventricular ejection fraction [LVEF] 54 ± 13%) were followed for a median of 4.4 years and experienced 141 MACEs. Entropy showed strong unadjusted association with MACE (HR: 1.88; 95% CI: 1.63-2.17; P < 0.001). In a multivariable model including LVEF, QRS duration, late gadolinium enhancement, and presenting arrhythmia, entropy maintained independent association with MACE (HR: 1.61; 95% CI: 1.32-1.96; P < 0.001). Entropy was further significantly associated with MACE in patients without myocardial scar (HR: 2.43; 95% CI: 1.55-3.82; P < 0.001) and in those presenting with nonsustained VAs (HR: 2.16; 95% CI: 1.43-3.25; P < 0.001). Addition of LV entropy to the baseline multivariable model significantly improved model performance (C-statistic improvement: 0.725 to 0.754; P = 0.003) and risk reclassification. CONCLUSIONS In patients with VAs, CMR-assessed LV entropy was independently associated with MACE and provided incremental prognostic value, on top of LVEF and late gadolinium enhancement. LV entropy assessment may help risk stratification in patients with absence of myocardial scar or with nonsustained VAs.
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Affiliation(s)
- Panagiotis Antiochos
- Noninvasive Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Division, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Yin Ge
- Noninvasive Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rob J van der Geest
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Chaitanya Madamanchi
- Noninvasive Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Iqra Qamar
- Noninvasive Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ayako Seno
- Noninvasive Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Jerosch-Herold
- Noninvasive Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Cardiovascular Division of Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Program, Cardiovascular Division of Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiovascular Division of Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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11
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Harapoz M, Zada M, Matthews J, Kumar S, Thomas L. Echocardiographic predictors of ventricular arrhythmias in patients with non-ischemic cardiomyopathy. IJC HEART & VASCULATURE 2022; 39:100962. [PMID: 35169613 PMCID: PMC8829059 DOI: 10.1016/j.ijcha.2022.100962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/19/2022] [Indexed: 11/03/2022]
Abstract
Objective Methods Results Conclusion
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12
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Salinas-Arce J, Alca-Clares R, Gonzales-Luna AC, Cabrera-Saldaña M, Mendoza-Novoa P, Solórzano-Altamirano P, Guevara-Valdivia M. [Cardiac arrhythmias and amyloidosis]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2022; 3:82-97. [PMID: 37351307 PMCID: PMC10284580 DOI: 10.47487/apcyccv.v3i2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/27/2022] [Indexed: 06/24/2023]
Abstract
Cardiac amyloidosis (CA) is a form of cardiomyopathy characterized by the extracellular deposit of protein fibers in the myocardium, leading to the development of heart failure, arrhythmias, and electrical conduction system alterations. It is known that most cardiomyopathies have a close relationship with heart rhythm abnormalities, however, CA is specially related to different kinds of arrhythmias even in pre-diagnosis stages. Arrhythmias like atrial fibrillation are present in up to 70% of patients with CA associated with a high risk of cardioembolic complications independent of the risk stratification. Ventricular arrhythmias are frequent, but the use of implantable cardioverter defibrillator has not been demonstrated to improve survival. The Atrial-Ventricular node disease is also common, and is frequently associated with the implantation of a pacemaker, even in asymptomatic patients. In this review, we clarify the recommendations of the most current guidelines, summarize historical and contemporaneous data and describe evidence-based strategies for the management of arrhythmias and their complications in CA.
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Affiliation(s)
- Jorge Salinas-Arce
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
| | - Raúl Alca-Clares
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Servicio de Cardiología, Hospital Cayetano Heredia. Lima, Perú.Servicio de CardiologíaHospital Cayetano HerediaLimaPerú
| | - Ana Cecilia Gonzales-Luna
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital Edgardo Rebagliati. Lima, Perú.Unidad de ArritmiasHospital Edgardo RebagliatiLimaPerú
| | - Mario Cabrera-Saldaña
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Servicio de Cardiología Invasiva, Instituto Nacional Cardiovascular - INCOR EsSalud. Lima, Perú.Unidad de ArritmiasServicio de Cardiología InvasivaInstituto Nacional Cardiovascular - INCOR EsSaludLimaPerú
| | - Pablo Mendoza-Novoa
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital del Niño. Lima, Perú.Unidad de ArritmiasHospital del NiñoLimaPerú
| | - Paula Solórzano-Altamirano
- . Unidad de Docencia en Arritmias, APSA-QRS VITAL. Lima, Perú.Unidad de Docencia en ArritmiasAPSA-QRS VITALLimaPerú
| | - Milton Guevara-Valdivia
- . Departamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social. Ciudad de México, México.Instituto Mexicano del Seguro SocialDepartamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga MouretCentro Médico Nacional La RazaInstituto Mexicano del Seguro SocialCiudad de MéxicoMexico
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13
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Oebel S, Jahnke C, Hindricks G, Paetsch I. Nutzen der kardialen Magnetresonanzdiagnostik für Patienten mit Herzrhythmusstörungen. Herz 2022; 47:110-117. [DOI: 10.1007/s00059-022-05105-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/28/2022]
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14
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Extracellular volume is an independent predictor of arrhythmic burden in dilated cardiomyopathy. Sci Rep 2021; 11:24000. [PMID: 34907272 PMCID: PMC8671445 DOI: 10.1038/s41598-021-03452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/25/2021] [Indexed: 11/08/2022] Open
Abstract
The current stratification of arrhythmic risk in dilated cardiomyopathy (DCM) is sub-optimal. Cardiac fibrosis is involved in the pathology of arrhythmias; however, the relationship between cardiovascular magnetic resonance (CMR) derived extracellular volume (ECV) and arrhythmic burden (AB) in DCM is unknown. This study sought to evaluate the presence and extent of replacement and interstitial fibrosis in DCM and to compare the degree of fibrosis between DCM patients with and without AB. This is a prospective, single-center, observational study. Between May 2019 and September 2020, 102 DCM patients underwent CMR T1 mapping. 99 DCM patients (88 male, mean age 45.2 ± 11.8 years, mean EF 29.7 ± 10%) composed study population. AB was defined as the presence of VT or a high burden of PVCs. There were 41 (41.4%) patients with AB and 58 (58.6%) without AB. Replacement fibrosis was assessed with late gadolinium enhancement (LGE), whereas interstitial fibrosis with ECV. Overall, LGE was identified in 41% of patients. There was a similar distribution of LGE (without AB 50% vs. with AB 53.7%; p = 0.8) and LGE extent (without AB 4.36 ± 5.77% vs. with AB 4.68 ± 3.98%; p = 0.27) in both groups. ECV at nearly all myocardial segments and a global ECV were higher in patients with AB (global ECV: 27.9 ± 4.9 vs. 30.3 ± 4.2; p < 0.02). Only indexed left ventricular end-diastolic diameter (HR 1.1, 95%CI 1.0-1.2; p < 0.02) and global ECV (HR 1.12, 95%CI 1.0-1.25; p < 0.02) were independently associated with AB. The global ECV cut-off value of 31.05% differentiated both groups (AUC 0.713; 95%CI 0.598-0.827; p < 0.001). Neither qualitative nor quantitative LGE-based assessment of replacement fibrosis allowed for the stratification of DCM patients into low or high AB. Interstitial fibrosis, expressed as ECV, was an independent predictor of AB in DCM. Incorporation of CMR parametric indices into decision-making processes may improve arrhythmic risk stratification in DCM.
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15
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Ye Y, Ji Z, Zhou W, Pu C, Li Y, Zhou C, Hu X, Chen C, Sun Y, Huang Q, Zhang W, Qian Y, Ren H, Yu F, Jiang C, Mao Y, Wang B, Augusto JB, Lai D, Hu H, Fu GS. Mean Scar Entropy by Late Gadolinium Enhancement Cardiac Magnetic Resonance Is Associated With Ventricular Arrhythmias Events in Hypertrophic Cardiomyopathy. Front Cardiovasc Med 2021; 8:758635. [PMID: 34869672 PMCID: PMC8635716 DOI: 10.3389/fcvm.2021.758635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Ventricular arrhythmias are associated with sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). Previous studies have found the late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) was independently associated with ventricular arrhythmia (VA) in HCM. The risk stratification of VA remains complex and LGE is present in the majority of HCM patients. This study was conducted to determine whether the scar heterogeneity from LGE-derived entropy is associated with the VAs in HCM patients. Materials and Methods: Sixty-eight HCM patients with scarring were retrospectively enrolled and divided into VA (31 patients) and non-VA (37 patients) groups. The left ventricular ejection fraction (LVEF) and percentage of the LGE (% LGE) were evaluated. The scar heterogeneity was quantified by the entropy within the scar and left ventricular (LV) myocardium. Results: Multivariate analyses showed that a higher scar [hazard ratio (HR) 2.682; 95% CI: 1.022–7.037; p = 0.039] was independently associated with VA, after the adjustment for the LVEF, %LGE, LV maximal wall thickness (MWT), and left atrium (LA) diameter. Conclusion: Scar entropy and %LGE are both independent risk indicators of VA. A high scar entropy may indicate an arrhythmogenic scar, an identification of which may have value for the clinical status assessment of VAs in HCM patients.
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Affiliation(s)
- Yang Ye
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - ZhongPing Ji
- Institute of Graphics and Image, School of Computer Science and Technology, Hangzhou Dianzi University, Hangzhou, China
| | - Wenli Zhou
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Cailing Pu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ya Li
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Chengqin Zhou
- Institute of Graphics and Image, School of Computer Science and Technology, Hangzhou Dianzi University, Hangzhou, China
| | - Xiuhua Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Chen
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaxun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Qi Huang
- Department of Cardiovascular, Zhejiang Integrated Traditional and Western Medicine Hospital (HangZhou Red Cross Hospital), Hangzhou, China
| | - Wenjuan Zhang
- Department of Information Technology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu'e Qian
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong Ren
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Feidan Yu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Yankai Mao
- Department of Cardiac Echocardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bei Wang
- Department of Cardiac Echocardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - João B Augusto
- Department of Cardiology, Hospital Professor Doutor Fernando Fonseca, Lisbon, Portugal.,Institute of Cardiovascular Science, University College London, London, United Kingdom.,Cardiac Imaging Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Dongwu Lai
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
| | - Hongjie Hu
- Institute of Graphics and Image, School of Computer Science and Technology, Hangzhou Dianzi University, Hangzhou, China
| | - Guo-Sheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Hangzhou, China
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16
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Vergara P, Scarfò I, Esposito A, Colantoni C, Palmisano A, Altizio S, Falasconi G, Pannone L, Lapenna E, Gulletta S, Alfieri O, Castiglioni A, Maisano F, De Bonis M, Della Bella P, La Canna G. Characterization of the electrophysiological substrate in patients with Barlow's disease. J Cardiovasc Electrophysiol 2021; 32:3179-3186. [PMID: 34664762 DOI: 10.1111/jce.15270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/27/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Myxomatous mitral valve prolapse (MVP) and mitral-annular disjunction (Barlow disease) are at-risk for ventricular arrhythmias (VA). Fibrosis involving the papillary muscles and/or the infero-basal left ventricular (LV) wall was reported at autopsy in sudden cardiac death (SCD) patients with MVP. OBJECTIVES We investigated the electrophysiological substrate subtending VA in MVP patients with Barlow disease phenotype. METHODS Twenty-three patients with VA were enrolled, including five with syncope and four with a history of SCD. Unipolar (Uni < 8.3 mV) and bipolar (Bi < 1.5 mV) low-voltage areas were analyzed with electro-anatomical mapping (EAM), and VA inducibility was evaluated with programmed ventricular stimulation (PES). Electrophysiological parameters were correlated with VA patterns, electrocardiogram (ECG) inferior negative T wave (nTW), and late gadolinium enhancement (LGE) assessed by cardiac magnetic resonance. RESULTS Premature ventricular complex (PVC) burden was 12 061.9 ± 12 994.6/24 h with a papillary-muscle type (PM-PVC) in 18 patients (68%). Twelve-lead ECG showed nTW in 12 patients (43.5%). A large Uni less than 8.3 mV area (62.4 ± 45.5 cm2 ) was detected in the basal infero-lateral LV region in 12 (73%) patients, and in the papillary muscles (2.2 ± 2.9 cm2 ) in 5 (30%) of 15 patients undergoing EAM. A concomitant Bi less than 1.5 mV area (5.0 ± 1.0 cm2 ) was identified in two patients. A history of SCD, and the presence of nTW, and LGE were associated with a greater Uni less than 8.3 mV extension: (32.8 ± 3.1 cm2 vs. 9.2 ± 8.7 cm2 ), nTW (20.1 ± 11.0 vs. 4.1 ± 3.8 cm2 ), and LGE (19.2 ± 11.7 cm2 vs. 1.0 ± 2.0 cm2 , p = .013), respectively. All patients with PM-PVC had a Uni less than 8.3 mV area. Sustained VA (ventricular tachycardia 2 and VF 2) were induced by PES only in four patients (one with resuscitated SCD). CONCLUSIONS Low unipolar low voltage areas can be identified with EAM in the basal inferolateral LV region and in the papillary muscles as a potential electrophysiological substrate for VA and SCD in patients with MVP and Barlow disease phenotype.
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Affiliation(s)
- Pasquale Vergara
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Iside Scarfò
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Clinical and Research Center, Milan, Italy
| | - Antonio Esposito
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milano, Italy.,IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milano, Italy
| | - Caterina Colantoni
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Anna Palmisano
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Savino Altizio
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giulio Falasconi
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Luigi Pannone
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Simone Gulletta
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | | | - Francesco Maisano
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giovanni La Canna
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Clinical and Research Center, Milan, Italy
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17
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Baritussio A, Biglino G, Scatteia A, De Garate E, Dastidar AG, Palazzuoli A, Harries I, Strange JW, Diab I, Bucciarelli-Ducci C. Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors. Eur Heart J Cardiovasc Imaging 2021; 22:1149-1156. [PMID: 33247898 DOI: 10.1093/ehjci/jeaa293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation. METHODS AND RESULTS We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P < 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass >4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005). CONCLUSIONS We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable outcome.
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Affiliation(s)
- Anna Baritussio
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Giovanni Biglino
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Alessandra Scatteia
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Estefania De Garate
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Amardeep Ghosh Dastidar
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, University of Siena, Siena 53100, Italy
| | - Iwan Harries
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Julian W Strange
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Ihab Diab
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre University Hospitals Bristol NHS Foundation Trust and University of Bristol, Upper Maudlin Street, Bristol BS2 8HW, UK
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18
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CMR-Based Risk Stratification of Sudden Cardiac Death and Use of Implantable Cardioverter-Defibrillator in Non-Ischemic Cardiomyopathy. Int J Mol Sci 2021; 22:ijms22137115. [PMID: 34281168 PMCID: PMC8268120 DOI: 10.3390/ijms22137115] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 01/04/2023] Open
Abstract
Non-ischemic cardiomyopathy (NICM) is one of the most important entities for arrhythmias and sudden cardiac death (SCD). Previous studies suggest a lower benefit of implantable cardioverter–defibrillator (ICD) therapy in patients with NICM as compared to ischemic cardiomyopathy (ICM). Nevertheless, current guidelines do not differentiate between the two subgroups in recommending ICD implantation. Hence, risk stratification is required to determine the subgroup of patients with NICM who will likely benefit from ICD therapy. Various predictors have been proposed, among others genetic mutations, left-ventricular ejection fraction (LVEF), left-ventricular end-diastolic volume (LVEDD), and T-wave alternans (TWA). In addition to these parameters, cardiovascular magnetic resonance imaging (CMR) has the potential to further improve risk stratification. CMR allows the comprehensive analysis of cardiac function and myocardial tissue composition. A range of CMR parameters have been associated with SCD. Applicable examples include late gadolinium enhancement (LGE), T1 relaxation times, and myocardial strain. This review evaluates the epidemiological aspects of SCD in NICM, the role of CMR for risk stratification, and resulting indications for ICD implantation.
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19
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Papachristidis A, Queirós S, Theodoropoulos KC, D'hooge J, Rafter P, Masoero G, Zidros S, Pagnano G, Huang M, Dancy L, Sado D, Shah AM, Murgatroyd FD, Monaghan MJ. The Impact of Vendor-Specific Ultrasound Beam-Forming and Processing Techniques on the Visualization of In Vitro Experimental "Scar": Implications for Myocardial Scar Imaging Using Two-Dimensional and Three-Dimensional Echocardiography. J Am Soc Echocardiogr 2021; 34:1095-1105.e6. [PMID: 34082020 DOI: 10.1016/j.echo.2021.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Myocardial scar appears brighter compared with normal myocardium on echocardiography because of differences in tissue characteristics. The aim of this study was to test how different ultrasound pulse characteristics affect the brightness contrast (i.e., contrast ratio [CR]) between tissues of different acoustic properties, as well as the accuracy of assessing tissue volume. METHODS An experimental in vitro "scar" model was created using overheated and raw pieces of commercially available bovine muscle. Two-dimensional and three-dimensional ultrasound scanning of the model was performed using combinations of ultrasound pulse characteristics: ultrasound frequency, harmonics, pulse amplitude, steady pulse (SP) emission, power modulation (PM), and pulse inversion modalities. RESULTS On both two-dimensional and three-dimensional imaging, the CR between the "scar" and its adjacent tissue was higher when PM was used. PM, as well as SP ultrasound imaging, provided good "scar" volume quantification. When tested on 10 "scars" of different size and shape, PM resulted in lower bias (-9.7 vs 54.2 mm3) and narrower limits of agreement (-168.6 to 149.2 mm3 vs -296.0 to 404.4 mm3, P = .03). The interobserver variability for "scar" volume was better with PM (intraclass correlation coefficient = 0.901 vs 0.815). Two-dimensional and three-dimensional echocardiography with PM and SP was performed on 15 individuals with myocardial scar secondary to infarction. The CR was higher on PM imaging. Using cardiac magnetic resonance as a reference, quantification of myocardial scar volume showed better agreement when PM was used (bias, -645 mm3; limits of agreement, -3,158 to 1,868 mm3) as opposed to SP (bias, -1,138 mm3; limits of agreement, -5,510 to 3,233 mm3). CONCLUSIONS The PM modality increased the CR between tissues with different acoustic properties in an experimental in vitro "scar" model while allowing accurate quantification of "scar" volume. By applying the in vitro findings to humans, PM resulted in higher CR between scarred and healthy myocardium, providing better scar volume quantification than SP compared with cardiac magnetic resonance.
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Affiliation(s)
- Alexandros Papachristidis
- Cardiology Department, King's College Hospital, London, United Kingdom; King's College London, British Heart Foundation Centre, London, United Kingdom.
| | - Sandro Queirós
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; Lab on Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Jan D'hooge
- Lab on Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Giovanni Masoero
- Cardiology Department, King's College Hospital, London, United Kingdom
| | - Spyridon Zidros
- Cardiology Department, King's College Hospital, London, United Kingdom
| | - Gianpiero Pagnano
- Cardiology Department, King's College Hospital, London, United Kingdom
| | - Marilou Huang
- Cardiology Department, King's College Hospital, London, United Kingdom
| | - Luke Dancy
- Cardiology Department, King's College Hospital, London, United Kingdom; King's College London, British Heart Foundation Centre, London, United Kingdom
| | - Daniel Sado
- Cardiology Department, King's College Hospital, London, United Kingdom; King's College London, British Heart Foundation Centre, London, United Kingdom
| | - Ajay M Shah
- Cardiology Department, King's College Hospital, London, United Kingdom; King's College London, British Heart Foundation Centre, London, United Kingdom
| | - Francis D Murgatroyd
- Cardiology Department, King's College Hospital, London, United Kingdom; King's College London, British Heart Foundation Centre, London, United Kingdom
| | - Mark J Monaghan
- Cardiology Department, King's College Hospital, London, United Kingdom; King's College London, British Heart Foundation Centre, London, United Kingdom
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20
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Sasko B, Patschan D, Nordbeck P, Seidlmayer L, Andresen H, Jänsch M, Bramlage P, Ritter O, Pagonas N. Secondary Prevention of Potentially Life-Threatening Arrhythmia Using Implantable Cardioverter Defibrillators in Patients with Biopsy-Proven Viral Myocarditis and Preserved Ejection Fraction. Cardiology 2021; 146:213-221. [PMID: 33550300 DOI: 10.1159/000511120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 08/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arrhythmia and sudden cardiac death (SCD) are known complications of acute viral myocarditis, regardless of ejection fraction (EF) at presentation. Whether such complications confer long-term risk is unknown, especially in those who present with preserved left ventricular (LV) function. No guidelines exist to the long-term reduction of arrhythmic death in such patients. METHOD In this retrospective study, we analyzed the long-term results of implantable cardioverter defibrillator (ICD) treatment in patients after an acute phase of myocarditis with life-threatening arrhythmia. RESULTS We identified 51 patients who had ICDs implanted following life-threatening arrhythmia presentation of confirmed acute viral myocarditis, despite preserved LVEF. Overall, 72.5% of patients had a clinical history of chest pain and viral infection with fever. Viral myocarditis was confirmed by cardiac magnetic resonance imaging (all had late enhancement) plus endomyocardial biopsies (most frequent were Epstein-Barr virus 29.4%, adenovirus 17.6%, and Coxsackie 17.6%), and 88.2% were discharged on anti-arrhythmic drugs. Overall, 12 patients (23.5%) required ICD intervention within the first 3 months, a further 7 patients (37.3% overall) between 3 and 12 months, and a further 12 patients (60.8% overall) until 58 months. During the follow-up, 3 of 51 patients (5.9%) died-deaths were due to cardiac events (n = 1), fatal infection (n = 1), and car accidents (n = 1). Of the 31 patients who had ventricular tachycardias after the acute phase of myocarditis, 11 needed radiofrequency ablation due to a high number of events or electrical storm. No baseline variables were identified that would serve as a basis for risk stratification. CONCLUSION Malignant arrhythmic events due to viral myocarditis are potential predictors of future SCD in patients not only with a reduced but also with a preserved EF.
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Affiliation(s)
- Benjamin Sasko
- Department of Internal Medicine I - Cardiology, Brandenburg Medical School, Brandenburg an der Havel, Germany,
| | - Daniel Patschan
- Department of Internal Medicine I - Cardiology, Brandenburg Medical School, Brandenburg an der Havel, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital of Würzburg, Würzburg, Germany
| | - Lea Seidlmayer
- Department of Cardiology, University Hospital, Oldenburg, Germany
| | - Henrike Andresen
- Department of Internal Medicine I - Cardiology, Brandenburg Medical School, Brandenburg an der Havel, Germany
| | - Monique Jänsch
- Department of Internal Medicine I - Cardiology, Brandenburg Medical School, Brandenburg an der Havel, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Oliver Ritter
- Department of Internal Medicine I - Cardiology, Brandenburg Medical School, Brandenburg an der Havel, Germany
| | - Nikolaos Pagonas
- Department of Internal Medicine I - Cardiology, Brandenburg Medical School, Brandenburg an der Havel, Germany.,Department of Internal Medicine I, Marien Hospital Herne, Ruhr-University of Bochum, Bochum, Germany
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21
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Antonopoulos AS, Azzu A, Androulakis E, Tanking C, Papagkikas P, Mohiaddin RH. Eosinophilic heart disease: diagnostic and prognostic assessment by cardiac magnetic resonance. Eur Heart J Cardiovasc Imaging 2021; 22:1273-1284. [PMID: 33432319 DOI: 10.1093/ehjci/jeaa346] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/01/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Eosinophilic heart disease (EHD) is a rare cardiac condition with a wide spectrum of phenotypes. The diagnostic and prognostic value of cardiac magnetic resonance (CMR) in EHD remains unknown. METHODS AND RESULTS This was a retrospective analysis of 250 patients with eosinophilia referred for a CMR scan (period 2000-2020). CMR data sets and clinical/laboratory data were collected. Patients were followed up for a mean of 24 months (range 1-224) for the composite endpoint of death, acute coronary syndrome, hospitalization for acute heart failure, malignant ventricular arrhythmias, or the need for implantable cardiac defibrillator/pacemaker. The main objectives were to explore the diagnostic value of CMR in EHD; relationships between cardiac function, late gadolinium enhancement (LGE), and EHD phenotypes; and the prognostic value of fibrosis and oedema by CMR. The prevalence of findings compatible with EHD was 39% (patients with cardiac symptoms: 57% vs. screening: 20%, P < 0.001). EHD phenotypes included subendocardial LGE (n = 58), mid-wall/subepicardial LGE (n = 26), pericarditis (n = 5) or dilated cardiomyopathy (n = 8). Myocardial oedema was present in 10% of patients. Intracardiac thrombi (7%) were associated with EHD phenotype (χ2=47.3, P = 1.3×10-8). LGE extent correlated with LVEDVi (rho = 0.268, P = 5.3×10-5) and LVEF (rho=-0.415, P = 8.6×10-11). A CMR scan positive for EHD [hazard ratio (HR) = 5.61, 95% confidence interval (CI): 1.82-17.89, P = 0.0026] or a subendocardial LGE pattern (HR = 5.13, 95% CI: 1.29-20.38, P = 0.020) were independently associated with the composite clinical endpoint. CONCLUSION The diagnostic yield of CMR screening in patients with persistent eosinophilia, even if asymptomatic, is high. The extent of subendocardial fibrosis correlates with LV remodelling and independently predicts clinical outcomes in patients with eosinophilia.
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Affiliation(s)
- Alexios S Antonopoulos
- CMR Unit, Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Alessia Azzu
- CMR Unit, Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, SW3 6NP London, UK.,Faculty of Medicine, National Heart and Lung Institute, Imperial College London, UK
| | - Emmanuel Androulakis
- CMR Unit, Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Chonthicha Tanking
- CMR Unit, Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Panagiotis Papagkikas
- CMR Unit, Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Raad H Mohiaddin
- CMR Unit, Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, SW3 6NP London, UK.,Faculty of Medicine, National Heart and Lung Institute, Imperial College London, UK
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22
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Muser D, Nucifora G, Muser D, Nucifora G, Pieroni M, Castro SA, Casado Arroyo R, Maeda S, Benhayon DA, Liuba I, Sadek M, Magnani S, Enriquez A, Liang JJ, Sassone B, Desjardins B, Dixit S, Deo R, Garcia FC, Callans DJ, Frankel DS, Selvanayagam JB, Marchlinski FE, Santangeli P. Prognostic Value of Nonischemic Ringlike Left Ventricular Scar in Patients With Apparently Idiopathic Nonsustained Ventricular Arrhythmias. Circulation 2021; 143:1359-1373. [PMID: 33401956 DOI: 10.1161/circulationaha.120.047640] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Left ventricular (LV) scar on late gadolinium enhancement (LGE) cardiac magnetic resonance has been correlated with life-threatening arrhythmic events in patients with apparently idiopathic ventricular arrhythmias (VAs). We investigated the prognostic significance of a specific LV-LGE phenotype characterized by a ringlike pattern of fibrosis. METHODS A total of 686 patients with apparently idiopathic nonsustained VA underwent contrast-enhanced cardiac magnetic resonance. A ringlike pattern of LV scar was defined as LV subepicardial/midmyocardial LGE involving at least 3 contiguous segments in the same short-axis slice. The end point of the study was time to the composite outcome of all-cause death, resuscitated cardiac arrest because of ventricular fibrillation or hemodynamically unstable ventricular tachycardia and appropriate implantable cardioverter defibrillator therapy. RESULTS A total of 28 patients (4%) had a ringlike pattern of scar (group A), 78 (11%) had a non-ringlike pattern (group B), and 580 (85%) had normal cardiac magnetic resonance with no LGE (group C). Group A patients were younger compared with groups B and C (median age, 40 vs 52 vs 45 years; P<0.01), more frequently men (96% vs 82% vs 55%; P<0.01), with a higher prevalence of family history of sudden cardiac death or cardiomyopathy (39% vs 14% vs 6%; P<0.01) and more frequent history of unexplained syncope (18% vs 9% vs 3%; P<0.01). All patients in group A showed VA with a right bundle-branch block morphology versus 69% in group B and 21% in group C (P<0.01). Multifocal VAs were observed in 46% of group A patients compared with 26% of group B and 4% of group C (P<0.01). After a median follow-up of 61 months (range, 34-84 months), the composite outcome occurred in 14 patients (50.0%) in group A versus 15 (19.0%) in group B and 2 (0.3%) in group C (P<0.01). After multivariable adjustment, the presence of LGE with ringlike pattern remained independently associated with increased risk of the composite end point (hazard ratio, 68.98 [95% CI, 14.67-324.39], P<0.01). CONCLUSIONS In patients with apparently idiopathic nonsustained VA, nonischemic LV scar with a ringlike pattern is associated with malignant arrhythmic events.
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Affiliation(s)
- Daniele Muser
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | | | - Daniele Muser
- Cardiothoracic Department, Udine Civil Hospital, Italy (D.M.)
| | - Gaetano Nucifora
- Cardiac Imaging Unit, Wythenshawe Hospital, Manchester University National Health Service Foundation Trust, United Kingdom (G.N.)
| | - Maurizio Pieroni
- Cardiovascular Department, San Donato Hospital, Arezzo, Italy (M.P.)
| | - Simon A Castro
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | | | - Shingo Maeda
- Arrhythmia Advanced Therapy Center, AOI Universal Hospital, Kanagawa, Japan (S.M.)
| | - Daniel A Benhayon
- Cardiac Electrophysiology, Memorial Healthcare System, Hollywood, FL (D.A.B.)
| | - Ioan Liuba
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia.,Division of Electrophysiology, Department of Cardiology, University Hospital Linköping, Sweden (I.L.)
| | - Mouhannad Sadek
- Cardiac Electrophysiology, University of Ottawa Heart Institute, Ontario, Canada (M.S.)
| | - Silvia Magnani
- Cardiac Electrophysiology/Heart Rhythm Center, New York University (S.M.).,Cardiovascular Medicine Division, San Paolo Hospital, Milan, Italy (S.M.)
| | - Andres Enriquez
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - Jackson J Liang
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - Biagio Sassone
- Division of Cardiology, SS.ma Annunziata Hospital, Department of Translational Medicine, University of Ferrara, Italy (B.S.)
| | - Benoit Desjardins
- Radiology Department (B.D.), Hospital of the University of Pennsylvania, Philadelphia
| | - Sanjay Dixit
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - Rajat Deo
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - Fermin C Garcia
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - David J Callans
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - David S Frankel
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - Joseph B Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre, Flinders University, Bedford Park, Adelaide, South Australia (J.B.S.)
| | - Francis E Marchlinski
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia
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Kolluru L, Srikala J, Rao HN, Maheen S, Rao BH. Incremental value of Late Gadolinium Enhancement by Cardiac MRI in risk stratification of heart failure patients with moderate and severe LV dysfunction. Indian Heart J 2020; 73:49-55. [PMID: 33714409 PMCID: PMC7961248 DOI: 10.1016/j.ihj.2020.11.150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 11/28/2022] Open
Abstract
Objective This is a prospective study of patients with LVEF ≤40%, with the objective of correlating CV events to LGE detected and quantified by CMRI. Methods Heart Failure (HF) patients with LVEF <40% who underwent CMRI were included. LGE volume of ≥6% of the myocardial volume was considered significant. Data of appropriate ICD shocks, CV hospitalizations and mortality were recorded. Results There were 133 HF (72 ICM & 62 NIDCM) patients with a mean age of 54 ± 12 years, mean LVEF of 34 ± 6% and a follow up of 24 ± 3 months. Totally 46 CV events were recorded in 30 patients, 44 in LGE +ve & 2 in LGE -ve groups (HR 17.8, 95% CI-8.03-39.3, P = 0.000095). All the 7 deaths were in LGE +ve group. CV events were 22 (30.5%) in ICM group and 8 (13.1%) in NIDCM group (p = 0.03). All the 22 ICM patients and 6 of the 8 NIDCM with CV events were LGE +ve. The distribution of CV events amongst LGE +ve and LGE -ve were 35 vs 0 (ICM) and 9 vs 2 (NIDCM); p < 0.005.CV events in LVEF ≤ 30% group, were seen in 19 (47.5%) vs 1 (5.8%) in LGE +ve vs LGE -ve and no of events were 29 vs 1 (p = 0.003). In those with LVEF >30% the corresponding figures were 9 (22.5%) vs 1 (2.8%) and 15 vs 1 respectively (p = 0.02). Conclusion Demonstration of significant LGE by CMRI indicates high risk occurrence of CV events (CV hospitalization, appropriate shocks and total mortality) in NIDCM & ICM patients with LVEF < 40%.
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Affiliation(s)
- Laxman Kolluru
- Department of Cardiology, KIMS Hospitals, Hyderabad, India
| | - Jwala Srikala
- Department of Radiology, KIMS Hospitals, Hyderabad, India
| | - H Nagaraj Rao
- Department of Cardiology, KIMS Hospitals, Nellore, India
| | - Sania Maheen
- Department of Radiology, KIMS Hospitals, Hyderabad, India
| | - B Hygriv Rao
- Department of Cardiology, KIMS Hospitals, Hyderabad, India; Arrhythmia Research & Training Society(ARTS), Hyderabad, India.
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24
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Role of Imaging in Improving Outcomes with Ablation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00835-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Khanna S, Lo P, Cho K, Subbiah R. Ventricular Arrhythmias in Cardiac Amyloidosis: A Review of Current Literature. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820963055. [PMID: 33088185 PMCID: PMC7545745 DOI: 10.1177/1179546820963055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/06/2020] [Indexed: 01/29/2023]
Abstract
Cardiac Amyloidosis is an infiltrative cardiomyopathy which occurs secondary to deposition of mis-folded protein in the myocardium, with the two most common subtypes being AL amyloidosis and TTR amyloidosis. The pathogenesis of the disease is multifaceted and involves a variety of mechanisms including an inflammatory response cascade, oxidative stress and subsequent separation of myocyte fibrils. Cardiac Amyloidosis frequently results in congestive cardiac failure and arrhythmias, from a disruption in cardiac substrate with subsequent electro-mechanical remodelling. Disease progression is usually demonstrated by development of progressive pump failure, which may be seen with a high arrhythmic burden, usually portending a poor prognosis. There is a paucity of literature on the clinical implications of ventricular arrhythmias in the context of cardiac amyloidosis. The important diagnostic investigations for these patients include transthoracic echocardiography, cardiac magnetic resonance imaging and an electrophysiology study. Whilst there are no robust management guidelines, studies have indicated benefits from contemporary pharmacological therapy and case-by-case catheter ablation. There are novel directed therapies available for TTR amyloidosis that have shown to improve overall survival. The role of ICD therapy in cardiac amyloidosis is controversial, with benefits seen predominantly in early phases of the disease process. The only definitive surgical therapy includes heart transplantation, but is largely indicated for progressive decompensated heart failure (Figure 1). Further large-scale studies are required to better outline management paradigms for treating ventricular arrhythmias in cardiac amyloidosis.
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Affiliation(s)
- Shaun Khanna
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Phillip Lo
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Kenneth Cho
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Rajesh Subbiah
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Kensington, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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26
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Updating the Risk Stratification for Sudden Cardiac Death in Cardiomyopathies: The Evolving Role of Cardiac Magnetic Resonance Imaging. An Approach for the Electrophysiologist. Diagnostics (Basel) 2020; 10:diagnostics10080541. [PMID: 32751773 PMCID: PMC7460122 DOI: 10.3390/diagnostics10080541] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
The prevention of sudden cardiac death (SCD) in cardiomyopathies (CM) remains a challenge. The current guidelines still favor the implantation of devices for the primary prevention of SCD only in patients with severely reduced left ventricular ejection fraction (LVEF) and heart failure (HF) symptoms. The implantation of an implantable cardioverter-defibrillator (ICD) is a protective barrier against arrhythmic events in CMs, but the benefit does not outweigh the cost in low risk patients. The identification of high risk patients is the key to an individualized prevention strategy. Cardiac magnetic resonance (CMR) provides reliable and reproducible information about biventricular function and tissue characterization. Furthermore, late gadolinium enhancement (LGE) quantification and pattern of distribution, as well as abnormal T1 mapping and extracellular volume (ECV), representing indices of diffuse fibrosis, can enhance our ability to detect high risk patients. CMR can also complement electro-anatomical mapping (EAM), a technique already applied in the risk evaluation and in the ventricular arrhythmias ablation therapy of CM patients, providing a more accurate assessment of fibrosis and arrhythmic corridors. As a result, CMR provides a new insight into the pathological substrate of CM. CMR may help identify high risk CM patients and, combined with EAM, can provide an integrated evaluation of scar and arrhythmic corridors in the ablative therapy of ventricular arrhythmias.
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27
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Prognostic value of cardiovascular magnetic resonance in patients with biopsy-proven systemic sarcoidosis. Eur Radiol 2020; 30:3702-3710. [PMID: 32166494 DOI: 10.1007/s00330-020-06765-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES As prognosis in sarcoidosis is determined by cardiac involvement, the objective was to study the added value of cardiovascular magnetic resonance (CMR) in risk stratification. METHODS In 114 patients (48 ± 12 years/52% male) with biopsy-proven sarcoidosis, we studied the value of clinical and CMR-derived parameters to predict future events, using sustained ventricular tachycardia, ventricular fibrillation, aborted cardiac death, implantable cardioverter-defibrillator (ICD) placement with appropriate shocks, hospitalization for heart failure, and death as composite endpoint. Median follow-up after CMR was 3.1 years (1.1-5.7 years). RESULTS The ejection fraction (EF) was 58.2 ± 9.1% and 54.7 ± 10.8% for left ventricle (LV) and right ventricle (RV), respectively. LV late gadolinium enhancement (LGE) was present in 40 patients (35%) involving 5.1% of the LV mass (IQR, 3.0-12.0%), with concomitant RV involvement in 12 patients (11%). T2-weighting imaging and/or T2 mapping showed active disease in 14 patients. The composite endpoint was reached in 34 patients, with 7 deaths in the LGE-positive group (17.5%), versus two deaths in the LGE-negative group (2.7%) (p = 0.015). At univariate analysis, RVEF (p = 0.009), pulmonary arterial pressure (p = 0.002), and presence of LGE (p < 0.001) and LGE (% of LV) (p < 0.001) were significant. At multivariate analysis, only presence of LGE and LGE (% of LV) was significant (both p = 0.03). At Kaplan-Meier, presence of LGE and an LGE of 3% predicted event-free survival and patient survival. We found no difference in active versus inactive disease with regard to patient survival. CONCLUSION Myocardial enhancement at LGE-CMR adds independent prognostic value in risk stratification sarcoidosis patients. In contrast, clinical as well as functional cardiac parameters lack discriminative power. KEY POINTS • Sarcoidosis often affects the heart. • Comprehensive CMR, including T2 imaging and LGE enhancement CMR, allows to depict both active and inactive myocardial damage. • Patient prognosis in sarcoidosis is determined by the presence and severity of myocardial involvement at LGE CMR.
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28
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Pelliccia A, Caselli S, Sharma S, Basso C, Bax JJ, Corrado D, D'Andrea A, D'Ascenzi F, Di Paolo FM, Edvardsen T, Gati S, Galderisi M, Heidbuchel H, Nchimi A, Nieman K, Papadakis M, Pisicchio C, Schmied C, Popescu BA, Habib G, Grobbee D, Lancellotti P. European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete's heart. Eur Heart J 2019; 39:1949-1969. [PMID: 29029207 DOI: 10.1093/eurheartj/ehx532] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/23/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Antonio Pelliccia
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | - Stefano Caselli
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | | | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Jeroen J Bax
- Departmentt of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Fernando M Di Paolo
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | - Thor Edvardsen
- Department of Cardiology, Center of Cardiologic Innovation, Oslo University Hospital, University of Oslo, Oslo, Norway
| | | | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Hein Heidbuchel
- Jessa Hospital, Hasselt University and Heart Center Hasselt, Hasselt, Belgium
| | | | - Koen Nieman
- Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Cataldo Pisicchio
- Institute of Sports Medicine and Science, Largo Piero Gabrielli, 1, 00197 Rome, Italy
| | | | - Bogdan A Popescu
- Institute of Cardiovascular Diseases, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
| | - Gilbert Habib
- Department of Cardiology, Hôpital La Timone, Marseille, France
| | - Diederick Grobbee
- Department of Epidemiology, University Medical Center, Utrecht, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Valvular Disease Clinic, Belgium
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29
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Sassone B, Muser D, Casella M, Luzi M, Virzì S, Balla C, Nucifora G. Detection of concealed structural heart disease by imaging in patients with apparently idiopathic premature ventricular complexes: A review of current literature. Clin Cardiol 2019; 42:1162-1169. [PMID: 31571249 PMCID: PMC6906994 DOI: 10.1002/clc.23271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 01/02/2023] Open
Abstract
Background Premature ventricular complexes (PVCs) are the most common form of ventricular arrhythmia in the general population. While in most cases PVCs represent a primitive phenomenon with benign behavior, in a non‐negligible proportion of subjects frequent PVCs may be epiphenomenon of underlying occult heart diseases, requiring special medical attention since they have been resulted linked to increased total and cardiac mortality. Nevertheless, PVCs themselves, when incessantly frequent, may be responsible for left ventricular dysfunction in otherwise normal heart. Aim of this narrative review is to update current knowledge on the general approach to patients with frequent PVCs on the basis of available data, with a special focus on the value of imaging. Hypothesis Routine diagnostic work‐up not infrequently miss subtle concealed arrhythmic substrate, leading to erroneously refer to such arrhythmias as to “idiopathic”. Methods Literature search of PVCs articles was conducted in PubMed and Scopus electronic database. Results Conflicting data arise from literature about the true clinical significance of idiopathic PVCs. There is growing body of data providing evidence that more advanced non‐invasive imaging modalities, such as cardiac magnetic resonance, have an incremental diagnostic and prognostic value. On the other hand, in some cases the prognostic significance of isolated subtle myocardial structural abnormalities in patients with PVCs, still remains area of uncertainty. Conclusion In selected subjects with PVCs and high‐risk features for concealed arrhythmic substrate, traditional assessment to rule out the presence of heart disease, including surface ECG and transthoracic echocardiography, should be implemented with more advanced cardiovascular imaging modalities.
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Affiliation(s)
- Biagio Sassone
- Cardiology Division, SS.ma Annunziata Hospital, Department of Emergency, Azienda Unità Sanitaria Locale di Ferrara, Ferrara, Italy.,Cardiology Division, Delta Hospital, Department of Emergency, Azienda Unità Sanitaria Locale di Ferrara, Ferrara, Italy
| | - Daniele Muser
- Cardiothoracic Department, University Hospital, Piazzale Santa Maria della Misericordia 15, Udine, Italy
| | - Michela Casella
- Heart Rhythm Center, Centro Cardiologico Monzino, Milan, Italy
| | - Mario Luzi
- Cardiology Division, Ospedale Provinciale AREA VASTA 3, Macerata MC, Italy
| | - Santo Virzì
- Cardiology Division, SS.ma Annunziata Hospital, Department of Emergency, Azienda Unità Sanitaria Locale di Ferrara, Ferrara, Italy
| | - Cristina Balla
- Cardiology Department, S. Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Gaetano Nucifora
- Cardiology Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Wythenshawe, UK
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30
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Levine RA, Jerosch-Herold M, Hajjar RJ. Mitral Valve Prolapse: A Disease of Valve and Ventricle. J Am Coll Cardiol 2019; 72:835-837. [PMID: 30115221 DOI: 10.1016/j.jacc.2018.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/02/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Robert A Levine
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.
| | | | - Roger J Hajjar
- Cardiovascular Research Center, Mount Sinai Medical School, New York, New York
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31
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Mukherjee RK, Costa CM, Neji R, Harrison JL, Sim I, Williams SE, Whitaker J, Chubb H, O'Neill L, Schneider R, Lloyd T, Pohl T, Roujol S, Niederer SA, Razavi R, O'Neill MD. Evaluation of a real-time magnetic resonance imaging-guided electrophysiology system for structural and electrophysiological ventricular tachycardia substrate assessment. Europace 2019; 21:1432-1441. [PMID: 31219547 PMCID: PMC6735875 DOI: 10.1093/europace/euz165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/22/2019] [Indexed: 11/21/2022] Open
Abstract
Aims Potential advantages of real-time magnetic resonance imaging (MRI)-guided electrophysiology (MR-EP) include contemporaneous three-dimensional substrate assessment at the time of intervention, improved procedural guidance, and ablation lesion assessment. We evaluated a novel real-time MR-EP system to perform endocardial voltage mapping and assessment of delayed conduction in a porcine ischaemia–reperfusion model. Methods and results Sites of low voltage and slow conduction identified using the system were registered and compared to regions of late gadolinium enhancement (LGE) on MRI. The Sorensen–Dice similarity coefficient (DSC) between LGE scar maps and voltage maps was computed on a nodal basis. A total of 445 electrograms were recorded in sinus rhythm (range: 30–186) using the MR-EP system including 138 electrograms from LGE regions. Pacing captured at 103 sites; 47 (45.6%) sites had a stimulus-to-QRS (S-QRS) delay of ≥40 ms. Using conventional (0.5–1.5 mV) bipolar voltage thresholds, the sensitivity and specificity of voltage mapping using the MR-EP system to identify MR-derived LGE was 57% and 96%, respectively. Voltage mapping had a better predictive ability in detecting LGE compared to S-QRS measurements using this system (area under curve: 0.907 vs. 0.840). Using an electrical threshold of 1.5 mV to define abnormal myocardium, the total DSC, scar DSC, and normal myocardium DSC between voltage maps and LGE scar maps was 79.0 ± 6.0%, 35.0 ± 10.1%, and 90.4 ± 8.6%, respectively. Conclusion Low-voltage zones and regions of delayed conduction determined using a real-time MR-EP system are moderately associated with LGE areas identified on MRI.
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Affiliation(s)
- Rahul K Mukherjee
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Caroline Mendonca Costa
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Radhouene Neji
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK.,Siemens Healthcare, Sir William Siemens Square, Frimley, Camberley, UK
| | - James L Harrison
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK.,Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Iain Sim
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Henry Chubb
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Louisa O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | | | - Tom Lloyd
- Imricor Medical Systems, 400 Gateway Blvd, MN, USA
| | | | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Steven A Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK
| | - Mark D O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, North Wing, St Thomas' Hospital, London, UK.,Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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van der Velden J, Tocchetti CG, Varricchi G, Bianco A, Sequeira V, Hilfiker-Kleiner D, Hamdani N, Leite-Moreira AF, Mayr M, Falcão-Pires I, Thum T, Dawson DK, Balligand JL, Heymans S. Metabolic changes in hypertrophic cardiomyopathies: scientific update from the Working Group of Myocardial Function of the European Society of Cardiology. Cardiovasc Res 2019; 114:1273-1280. [PMID: 29912308 PMCID: PMC6054261 DOI: 10.1093/cvr/cvy147] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 06/13/2018] [Indexed: 12/20/2022] Open
Abstract
Disturbed metabolism as a consequence of obesity and diabetes may cause cardiac diseases (recently highlighted in the cardiovascular research spotlight issue on metabolic cardiomyopathies).1 In turn, the metabolism of the heart may also be disturbed in genetic and acquired forms of hypertrophic cardiac disease. Herein, we provide an overview of recent insights on metabolic changes in genetic hypertrophic cardiomyopathy and discuss several therapies, which may be explored to target disturbed metabolism and prevent onset of cardiac hypertrophy. This article is part of the Mini Review Series from the Varenna 2017 meeting of the Working Group of Myocardial Function of the European Society of Cardiology.
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Affiliation(s)
- Jolanda van der Velden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Physiology, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, NA, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University, Naples, NA, Italy
| | - Anna Bianco
- Department of Translational Medical Sciences, Federico II University, Naples, NA, Italy.,Department of Cardiology, Maastricht University Medical Center & CARIM, Maastricht University, Maastricht, The Netherlands
| | - Vasco Sequeira
- Amsterdam UMC, Vrije Universiteit Amsterdam, Physiology, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Denise Hilfiker-Kleiner
- Molecular Cardiology, Department of Cardiology and Angiology, Medical School Hannover, Germany
| | - Nazha Hamdani
- Department of Systems Physiology, Ruhr University Bochum, Bochum, Germany
| | - Adelino F Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research Centre, University of Porto, Porto, Portugal
| | - Manuel Mayr
- The James Black Centre & King's British Heart Foundation Centre, King's College, University of London, London, UK
| | - Ines Falcão-Pires
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research Centre, University of Porto, Porto, Portugal
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany.,National Heart and Lung Institute, Imperial College London, London, UK.,REBIRTH Excellence Cluster, Hannover Medical School, Hannover, Germany
| | - Dana K Dawson
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Jean-Luc Balligand
- Pole of Pharmacology and Therapeutics, Institut de Recherche Experimentale et Clinique (IREC), and Clinique Universitaire Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Stephane Heymans
- Netherlands Heart Institute, Utrecht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center & CARIM, Maastricht University, Maastricht, The Netherlands.,Department of Cardiovascular Sciences, Leuven University, Leuven, Belgium
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Nelson T, Garg P, Clayton RH, Lee J. The Role of Cardiac MRI in the Management of Ventricular Arrhythmias in Ischaemic and Non-ischaemic Dilated Cardiomyopathy. Arrhythm Electrophysiol Rev 2019; 8:191-201. [PMID: 31463057 PMCID: PMC6702467 DOI: 10.15420/aer.2019.5.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023] Open
Abstract
Ventricular tachycardia (VT) and VF account for the majority of sudden cardiac deaths worldwide. Treatments for VT/VF include anti-arrhythmic drugs, ICDs and catheter ablation, but these treatments vary in effectiveness and carry substantial risks and/or expense. Current methods of selecting patients for ICD implantation are imprecise and fail to identify some at-risk patients, while leading to others being overtreated. In this article, the authors discuss the current role and future direction of cardiac MRI (CMRI) in refining diagnosis and personalising ventricular arrhythmia management. The capability of CMRI with gadolinium contrast delayed-enhancement patterns and, more recently, T1 mapping to determine the aetiology of patients presenting with heart failure is well established. Although CMRI imaging in patients with ICDs can be challenging, recent technical developments have started to overcome this. CMRI can contribute to risk stratification, with precise and reproducible assessment of ejection fraction, quantification of scar and 'border zone' volumes, and other indices. Detailed tissue characterisation has begun to enable creation of personalised computer models to predict an individual patient's arrhythmia risk. When patients require VT ablation, a substrate-based approach is frequently employed as haemodynamic instability may limit electrophysiological activation mapping. Beyond accurate localisation of substrate, CMRI could be used to predict the location of re-entrant circuits within the scar to guide ablation.
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Affiliation(s)
- Tom Nelson
- Sheffield Teaching Hospitals NHS Foundation TrustSheffield, UK
- Department of Immunity, Infection and Cardiovascular Disease, University of SheffieldSheffield, UK
| | - Pankaj Garg
- Sheffield Teaching Hospitals NHS Foundation TrustSheffield, UK
- Department of Immunity, Infection and Cardiovascular Disease, University of SheffieldSheffield, UK
| | - Richard H Clayton
- INSIGNEO Institute for In-Silico Medicine, University of SheffieldSheffield, UK
- Department of Computer Science, University of SheffieldSheffield, UK
| | - Justin Lee
- Sheffield Teaching Hospitals NHS Foundation TrustSheffield, UK
- Department of Immunity, Infection and Cardiovascular Disease, University of SheffieldSheffield, UK
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34
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Mukherjee RK, Whitaker J, Williams SE, Razavi R, O'Neill MD. Magnetic resonance imaging guidance for the optimization of ventricular tachycardia ablation. Europace 2019; 20:1721-1732. [PMID: 29584897 PMCID: PMC6212773 DOI: 10.1093/europace/euy040] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/19/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation has an important role in the management of patients with ventricular tachycardia (VT) but is limited by modest long-term success rates. Magnetic resonance imaging (MRI) can provide valuable anatomic and functional information as well as potentially improve identification of target sites for ablation. A major limitation of current MRI protocols is the spatial resolution required to identify the areas of tissue responsible for VT but recent developments have led to new strategies which may improve substrate assessment. Potential ways in which detailed information gained from MRI may be utilized during electrophysiology procedures include image integration or performing a procedure under real-time MRI guidance. Image integration allows pre-procedural magnetic resonance (MR) images to be registered with electroanatomical maps to help guide VT ablation and has shown promise in preliminary studies. However, multiple errors can arise during this process due to the registration technique used, changes in ventricular geometry between the time of MRI and the ablation procedure, respiratory and cardiac motion. As isthmus sites may only be a few millimetres wide, reducing these errors may be critical to improve outcomes in VT ablation. Real-time MR-guided intervention has emerged as an alternative solution to address the limitations of pre-acquired imaging to guide ablation. There is now a growing body of literature describing the feasibility, techniques, and potential applications of real-time MR-guided electrophysiology. We review whether real-time MR-guided intervention could be applied in the setting of VT ablation and the potential challenges that need to be overcome.
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Affiliation(s)
- Rahul K Mukherjee
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Mark D O'Neill
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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35
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Muser D, Santangeli P, Selvanayagam JB, Nucifora G. Role of Cardiac Magnetic Resonance Imaging in Patients with Idiopathic Ventricular Arrhythmias. Curr Cardiol Rev 2019; 15:12-23. [PMID: 30251607 PMCID: PMC6367696 DOI: 10.2174/1573403x14666180925095923] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 01/14/2023] Open
Abstract
Ventricular Arrhythmias (VAs) may present with a wide spectrum of clinical manifestations ranging from mildly symptomatic frequent premature ventricular contractions to lifethreatening events such as sustained ventricular tachycardia, ventricular fibrillation and sudden cardiac death. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias which are commonly associated with Structural Heart Diseases (SHD) such as ischemic heart disease, healed myocarditis and non-ischemic cardiomyopathies. However, the arrhythmogenic substrate may remain unclear in up to 50% of the cases after a routine diagnostic workup, comprehensive of 12-lead surface ECG, transthoracic echocardiography and coronary angiography/ computed tomography. Whenever any abnormality cannot be identified, VAs are referred as to "idiopathic". In the last decade, Cardiac Magnetic Resonance (CMR) imaging has acquired a growing role in the identification and characterization of myocardial arrhythmogenic substrate, not only being able to accurately and reproducibly quantify biventricular function, but, more importantly, providing information about the presence of myocardial structural abnormalities such as myocardial fatty replacement, myocardial oedema, and necrosis/ fibrosis, which may otherwise remain unrecognized. Moreover, CMR has recently demonstrated to be of great value in guiding interventional treatments, such as radiofrequency ablation, by reliably identifying VA sites of origin and improving long-term outcomes. In the present manuscript, we review the available data regarding the utility of CMR in the workup of apparently "idiopathic" VAs with a special focus on its prognostic relevance and its application in planning and guiding interventional treatments.
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Affiliation(s)
| | | | | | - Gaetano Nucifora
- Address correspondence to this author author at the Cardiac Imaging Unit, Manchester University NHS Foundation Trust, Manchester, UK; E-mail:
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36
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Relationship between Extension or Texture Features of Late Gadolinium Enhancement and Ventricular Tachyarrhythmias in Hypertrophic Cardiomyopathy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4092469. [PMID: 30271782 PMCID: PMC6151210 DOI: 10.1155/2018/4092469] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/06/2018] [Indexed: 01/21/2023]
Abstract
Purpose To evaluate the relationship between extension or texture features of late gadolinium enhancement (LGE) and ventricular tachyarrhythmias in hypertrophic cardiomyopathy (HCM). Materials and Methods Twenty-three patients with HCM were enrolled in this IRB-approved study. The extension of LGE was determined based on the American Heart Association segments model. Texture analysis was performed for 43 myocardial LGE using an open-access software (MaZda, Technical University of Lodz, Institute of Electronics, Poland). The relationship between the extension or texture features of LGE and ventricular tachyarrhythmias was evaluated using unpaired test and receiver-operating characteristic (ROC) analysis. Results Six of 23 patients had a history of ventricular tachyarrhythmias, and 16 patients had LGE. All of the 6 patients with the arrhythmias had more than 4 LGE segments and more LGE segments than those without (p < 0.01). Among 4 texture features, entropy LL was the only discriminator between the 2 patient groups (p < 0.01; threshold, 19624; area under the curve [AUC], 0.72). An ROC analysis gave the number of segments showing LGE a better result (AUC, 0.96) for identification of HCM patients with ventricular tachyarrhythmias than the entropy LL of LGE. Conclusion Patients with HCM and a history of ventricular tachyarrhythmias had a wider extension of LGE, and their entropy LL of LGE was significantly lower than those without. The extension of LGE and texture analysis may provide information about LGE related to ventricular tachyarrhythmias in HCM.
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37
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Myocardial Fibrosis in Patients With Primary Mitral Regurgitation With and Without Prolapse. J Am Coll Cardiol 2018; 72:823-834. [DOI: 10.1016/j.jacc.2018.06.048] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/28/2018] [Accepted: 06/15/2018] [Indexed: 11/20/2022]
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38
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Bondue A, Arbustini E, Bianco A, Ciccarelli M, Dawson D, De Rosa M, Hamdani N, Hilfiker-Kleiner D, Meder B, Leite-Moreira AF, Thum T, Tocchetti CG, Varricchi G, Van der Velden J, Walsh R, Heymans S. Complex roads from genotype to phenotype in dilated cardiomyopathy: scientific update from the Working Group of Myocardial Function of the European Society of Cardiology. Cardiovasc Res 2018; 114:1287-1303. [PMID: 29800419 PMCID: PMC6054212 DOI: 10.1093/cvr/cvy122] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/05/2018] [Accepted: 05/16/2018] [Indexed: 12/14/2022] Open
Abstract
Dilated cardiomyopathy (DCM) frequently affects relatively young, economically, and socially active adults, and is an important cause of heart failure and transplantation. DCM is a complex disease and its pathological architecture encounters many genetic determinants interacting with environmental factors. The old perspective that every pathogenic gene mutation would lead to a diseased heart, is now being replaced by the novel observation that the phenotype depends not only on the penetrance-malignancy of the mutated gene-but also on epigenetics, age, toxic factors, pregnancy, and a diversity of acquired diseases. This review discusses how gene mutations will result in mutation-specific molecular alterations in the heart including increased mitochondrial oxidation (sarcomeric gene e.g. TTN), decreased calcium sensitivity (sarcomeric genes), fibrosis (e.g. LMNA and TTN), or inflammation. Therefore, getting a complete picture of the DCM patient will include genomic data, molecular assessment by preference from cardiac samples, stratification according to co-morbidities, and phenotypic description. Those data will help to better guide the heart failure and anti-arrhythmic treatment, predict response to therapy, develop novel siRNA-based gene silencing for malignant gene mutations, or intervene with mutation-specific altered gene pathways in the heart.This article is part of the Mini Review Series from the Varenna 2017 meeting of the Working Group of Myocardial Function of the European Society of Cardiology.
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Affiliation(s)
- Antoine Bondue
- Department of Cardiology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, IRCCS Foundation, University Hospital Policlinico San Matteo, Pavia, Italy
| | - Anna Bianco
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Department of Cardiology, Maastricht University Medical Center & CARIM, Maastricht University, Maastricht, The Netherlands
| | - Michele Ciccarelli
- School of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Dana Dawson
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Matteo De Rosa
- School of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Nazha Hamdani
- Department of Systems Physiology, Ruhr University Bochum, Bochum, Germany
| | - Denise Hilfiker-Kleiner
- Molecular Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Benjamin Meder
- Department of Cardiology, Heidelberg University, Heidelberg, Germany
- Department of Genetics, Stanford University School of Medicine, Genome Technology Center, Palo Alto, CA, USA
| | - Adelino F Leite-Moreira
- Cardiovascular R&D Unit, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Cardiothoracic Surgery, Hospital of S. João, Porto, Portugal
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Jolanda Van der Velden
- Department of Physiology, VU University Medical Centre, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Roddy Walsh
- Cardiovascular Research Center, Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Stephane Heymans
- Department of Cardiology, Maastricht University Medical Center & CARIM, Maastricht University, Maastricht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiovascular Sciences, Leuven University, Leuven, Belgium
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39
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Becker MAJ, Cornel JH, van de Ven PM, van Rossum AC, Allaart CP, Germans T. The Prognostic Value of Late Gadolinium-Enhanced Cardiac Magnetic Resonance Imaging in Nonischemic Dilated Cardiomyopathy: A Review and Meta-Analysis. JACC Cardiovasc Imaging 2018; 11:1274-1284. [PMID: 29680351 DOI: 10.1016/j.jcmg.2018.03.006] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/23/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This review and meta-analysis reviews the prognostic value of cardiac magnetic resonance (CMR) in nonischemic dilated cardiomyopathy (DCM). BACKGROUND Late gadolinium-enhanced (LGE) CMR is a noninvasive method to determine the underlying cause of DCM and previous studies reported the prognostic value of the presence of LGE to identify patients at risk of major adverse cardiovascular events. METHODS PubMed was searched for studies describing the prognostic implication of LGE in patients with DCM for the specified endpoints cardiovascular mortality, major ventricular arrhythmic events including appropriate implantable cardioverter-defibrillator therapy, rehospitalization for heart failure, and left ventricular reverse remodeling. RESULTS Data from 34 studies were included, with a total of 4,554 patients. Contrast enhancement was present in 44.8% of DCM patients. Patients with LGE had increased cardiovascular mortality (odds ratio [OR]: 3.40; 95% confidence interval [CI]: 2.04 to 5.67), ventricular arrhythmic events (OR: 4.52; 95% CI: 3.41 to 5.99), and rehospitalization for heart failure (OR: 2.66; 95% CI: 1.67 to 4.24) compared with those without LGE. Moreover, the absence of LGE predicted left ventricular reverse remodeling (OR: 0.15; 95% CI: 0.06 to 0.36). CONCLUSIONS The presence of LGE on CMR substantially worsens prognosis for adverse cardiovascular events in DCM patients, and the absence indicates left ventricular reverse remodeling.
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Affiliation(s)
- Marthe A J Becker
- Department of Cardiology, Northwest Clinics, Alkmaar, the Netherlands; Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands.
| | - Jan H Cornel
- Department of Cardiology, Northwest Clinics, Alkmaar, the Netherlands
| | - Peter M van de Ven
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Albert C van Rossum
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Tjeerd Germans
- Department of Cardiology, Northwest Clinics, Alkmaar, the Netherlands; Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
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Nakamori S, Bui AH, Jang J, El-Rewaidy HA, Kato S, Ngo LH, Josephson ME, Manning WJ, Nezafat R. Increased myocardial native T 1 relaxation time in patients with nonischemic dilated cardiomyopathy with complex ventricular arrhythmia. J Magn Reson Imaging 2018; 47:779-786. [PMID: 28737018 PMCID: PMC5967630 DOI: 10.1002/jmri.25811] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 06/21/2017] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To study the relationship between diffuse myocardial fibrosis and complex ventricular arrhythmias (ComVA) in patients with nonischemic dilated cardiomyopathy (NICM). We hypothesized that NICM patients with ComVA would have a higher native myocardial T1 time, suggesting more extensive myocardial diffuse fibrosis. MATERIALS AND METHODS We prospectively enrolled NICM patients with a history of ComVA (n = 50) and age-matched NICM patients without ComVA (n = 57). Imaging was performed at 1.5T with a protocol that included cine magnetic resonance imaging (MRI) for left ventricular (LV) function, late gadolinium enhancement (LGE) for focal scar, and native T1 mapping for diffuse fibrosis assessment. RESULTS Global native T1 time was significantly higher in patients with NICM with ComVA when compared to patients with NICM without ComVA (1131 ± 42 vs. 1107 ± 45 msec, P = 0.006), and this finding remained after excluding segments with scar on LGE (1124 ± 36 vs. 1102 ± 44 msec, P = 0.006). Native T1 was similar in NICM patients with and without the presence of LGE (1121 ± 39 vs. 1117 ± 48 msec, P = 0.68) and mildly correlated with LV end-diastolic volume index (r = 0.27, P = 0.005), LV end-systolic volume index (r = 0.24, P = 0.01), and LV ejection fraction (r = -0.28, P = 0.003). Native T1 value for each 10-msec increment was an independent predictor of ComVA (odds ratio 1.14, 95% confidence interval 1.03-1.25; P = 0.008) beyond LV function and LGE. CONCLUSION NICM patients with ComVA have higher native T1 compared to NICM without any documented ComVA. Native myocardial T1 is independently associated with ComVA, after adjusting for LV function and LGE. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:779-786. In memoriam: The authors are grateful for Dr. Josephson's inspiring guidance and contributions to this study.
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Affiliation(s)
- Shiro Nakamori
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - An H. Bui
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jihye Jang
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Hossam A. El-Rewaidy
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shingo Kato
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Long H. Ngo
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mark E. Josephson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Warren J. Manning
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Reza Nezafat
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Comparison of Magnetic Resonance Analysis of Myocardial Scarring With Biomarker Release Following S-T Elevation Myocardial Infarction. Heart Lung Circ 2018. [PMID: 29526416 DOI: 10.1016/j.hlc.2018.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Late gadolinium enhancement (LGE) with cardiac magnetic resonance (CMR) is commonly assumed to represent myocardial fibrosis; however, comparative human histological data are limited, and there is no consensus on the most accurate method for LGE quantitation. We evaluated the relationship between CMR assessment of regional fibrosis and infarct size assessment using serial biomarkers after ST elevation acute myocardial infarction (STEMI). METHODS Ninety-three patients treated for STEMI (59±10 years, 86% male) underwent CMR 6 months after infarction. Infarct size was quantified by CMR-LGE using manual and range of semi-automated thresholds (range: 2-10 standard deviations [SD]) above reference myocardium and the full width-half maximum (FWHM) technique, and compared with the rise in serum biomarkers. The agreement between CMR and biomarker in the identification of large infarcts based on peak troponin (TnI) levels was also analysed. RESULTS Quantification methods had a strong influence on the infarct size assessment with CMR-LGE. Significant correlations were observed between LGE and biomarkers across all of the signal intensity thresholds. Whilst there was a wide variation with respect to the estimation of total LGE size (from 6.8±7.7 to 32.1±11.3 grams), the variation in the correlation with peak troponin level was much smaller (r-values ranging from 0.670 to 0.876). There was good agreement between CMR-LGE and biomarker assessment of infarct size; the best agreement between CMR-LGE and large infarction using a threshold of 8SD for peak TnI>50ng/mL (Cohen's kappa (κ)=0.722), and a threshold of 4SD for peak TnI >95ng/mL (κ=0.761). CONCLUSIONS The correlation between CMR-LGE quantification of infarct size and biomarker release following STEMI at a range of semi-automated thresholds was consistently strong, with good agreement between measures across a range of thresholds.
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Li KHC, Bazoukis G, Liu T, Li G, Wu WKK, Wong SH, Wong WT, Chan YS, Wong MCS, Wassilew K, Vassiliou VS, Tse G. Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) in clinical practice. J Arrhythm 2018; 34:11-22. [PMID: 29721109 PMCID: PMC5828272 DOI: 10.1002/joa3.12021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/14/2017] [Indexed: 01/01/2023] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited myocardial disease characterized by fibro-fatty replacement of the right ventricular myocardium, and associated with paroxysmal ventricular arrhythmias and sudden cardiac death (SCD). It is currently the second most common cause of SCD after hypertrophic cardiomyopathy in young people <35 years of age, causing up to 20% of deaths in this patient population. This condition has a male preponderance and is more commonly found in individuals of Italian and Greek descent. To date, there is no single diagnostic test for ARVC/D and the diagnosis is made based on clinical, electrocardiographic, and radiological findings according to the Revised 2010 Task Force Criteria. In this review, we will discuss the mainstay treatment which includes pharmacotherapy, implantable cardioverter-defibrillator insertion for abortion of sudden cardiac death, and in the advanced stages of the disease cardiac transplantation.
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Affiliation(s)
| | - George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensAthensGreece
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Guangping Li
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular diseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - William K. K. Wu
- Department of Anaesthesia and Intensive CareFaculty of MedicineChinese University of Hong KongHong KongChina
- Li Ka Shing Institute of Health SciencesFaculty of MedicineChinese University of Hong KongHong KongChina
| | - Sunny Hei Wong
- Li Ka Shing Institute of Health SciencesFaculty of MedicineChinese University of Hong KongHong KongChina
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong KongChina
| | - Wing Tak Wong
- School of Life SciencesChinese University of Hong KongHong KongChina
| | - Yat Sun Chan
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong KongChina
| | - Martin C. S. Wong
- The Jockey Club School of Public Health and Primary CareFaculty of MedicineThe Chinese University of Hong KongHong KongChina
| | - Katharina Wassilew
- Department of PathologyRigshospitaletUniversity Hospital of CopenhagenCopenhagenDenmark
| | - Vassilios S. Vassiliou
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
- Royal Brompton Hospital and Imperial College LondonLondonUK
| | - Gary Tse
- Li Ka Shing Institute of Health SciencesFaculty of MedicineChinese University of Hong KongHong KongChina
- Department of Medicine and TherapeuticsFaculty of MedicineChinese University of Hong KongHong KongChina
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Mahida S, Sacher F, Dubois R, Sermesant M, Bogun F, Haïssaguerre M, Jaïs P, Cochet H. Cardiac Imaging in Patients With Ventricular Tachycardia. Circulation 2017; 136:2491-2507. [DOI: 10.1161/circulationaha.117.029349] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ventricular tachycardia (VT) is a major cause of sudden cardiac death. The majority of malignant VTs occur in patients with structural heart disease. Multimodality imaging techniques play an integral role in determining the underlying etiology and prognostic significance of VT. In recent years, advances in imaging technology have enabled characterization of the structural arrhythmogenic substrate in patients with VT with increasing precision. In parallel with these advances, the role of cardiac imaging has expanded from a largely diagnostic tool to an adjunctive tool to guide interventional approaches for treatment of VT. Invasive and noninvasive imaging techniques, often used in combination, have made it possible to integrate structural and electrophysiological information during VT ablation procedures. An important area of current development is the use of noninvasive imaging techniques based on body surface electrocardiographic mapping to elucidate the mechanisms of VT. In the future, these techniques may provide a priori information on mechanisms of VT in patients undergoing interventional procedures. This review provides an overview of the role of cardiac imaging in patients with VT.
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Affiliation(s)
- Saagar Mahida
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, UK (S.M.)
| | - Frédéric Sacher
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Rémi Dubois
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Maxime Sermesant
- Inria Sophia Antipolis, Sophia Antipolis-Méditerranée, France (M.S.)
| | - Frank Bogun
- Division of Cardiology, University of Michigan, Ann Arbor (F.B.)
| | - Michel Haïssaguerre
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Pierre Jaïs
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Hubert Cochet
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
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Jablonowski R, Chaudhry U, van der Pals J, Engblom H, Arheden H, Heiberg E, Wu KC, Borgquist R, Carlsson M. Cardiovascular Magnetic Resonance to Predict Appropriate Implantable Cardioverter Defibrillator Therapy in Ischemic and Nonischemic Cardiomyopathy Patients Using Late Gadolinium Enhancement Border Zone: Comparison of Four Analysis Methods. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.006105. [PMID: 28838961 DOI: 10.1161/circimaging.116.006105] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 07/07/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Late gadolinium enhancement (LGE) border zone on cardiac magnetic resonance imaging has been proposed as an independent predictor of ventricular arrhythmias. The purpose was to determine whether size and heterogeneity of LGE predict appropriate implantable cardioverter defibrillator (ICD) therapy in ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM) patients and to evaluate 4 LGE border-zone algorithms. METHODS AND RESULTS ICM and NICM patients who underwent LGE cardiac magnetic resonance imaging prior to ICD implantation were retrospectively included. Two semiautomatic algorithms, expectation maximization, weighted intensity, a priori information and a weighted border zone algorithm, were compared with a modified full-width half-maximum and a 2-3SD threshold-based algorithm (2-3SD). Hazard ratios were calculated per 1% increase in LGE. A total of 74 ICM and 34 NICM were followed for 63 months (1-140) and 52 months (0-133), respectively. ICM patients had 27 appropriate ICD events, and NICM patients had 7 ICD events. In ICM patients with primary prophylactic ICD, LGE border zone predicted ICD therapy in univariable and multivariable analysis measured by the expectation maximization, weighted intensity, a priori information, weighted border zone, and modified full-width half-maximum algorithms (hazard ratios 1.23, 1.22, and 1.05, respectively; P<0.05; negative predictive value 92%). For NICM, total LGE by all 4 methods was the strongest predictor (hazard ratios, 1.03-1.04; P<0.05), though the number of events was small. CONCLUSIONS Appropriate ICD therapy can be predicted in ICM patients with primary prevention ICD by quantifying the LGE border zone. In NICM patients, total LGE but not LGE border zone had predictive value for ICD therapy. However, the algorithms used affects the predictive value of these measures.
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Affiliation(s)
- Robert Jablonowski
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Uzma Chaudhry
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Jesper van der Pals
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Henrik Engblom
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Håkan Arheden
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Einar Heiberg
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Katherine C Wu
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Rasmus Borgquist
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.)
| | - Marcus Carlsson
- From the Clinical Physiology (R.J., H.E., H.A., E.H., M.C.) and Cardiology (U.C., J.v.d.P., R.B.), Department of Clinical Sciences, Lund University, Lund University Hospital, Sweden; Department of Biomedical Engineering and Centre for Mathematical Sciences, Faculty of Engineering, Lund University, Sweden (E.H.); and Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD (K.C.W.).
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Out of hospital cardiac arrest survivors with inconclusive coronary angiogram: Impact of cardiovascular magnetic resonance on clinical management and decision-making. Resuscitation 2017; 116:91-97. [DOI: 10.1016/j.resuscitation.2017.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/14/2017] [Accepted: 03/30/2017] [Indexed: 01/15/2023]
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Abstract
Myocardial injury, mechanical stress, neurohormonal activation, inflammation, and/or aging all lead to cardiac remodeling, which is responsible for cardiac dysfunction and arrhythmogenesis. Of the key histological components of cardiac remodeling, fibrosis either in the form of interstitial, patchy, or dense scars, constitutes a key histological substrate of arrhythmias. Here we discuss current research findings focusing on the role of fibrosis, in arrhythmogenesis. Numerous studies have convincingly shown that patchy or interstitial fibrosis interferes with myocardial electrophysiology by slowing down action potential propagation, initiating reentry, promoting after-depolarizations, and increasing ectopic automaticity. Meanwhile, there has been increasing appreciation of direct involvement of myofibroblasts, the activated form of fibroblasts, in arrhythmogenesis. Myofibroblasts undergo phenotypic changes with expression of gap-junctions and ion channels thereby forming direct electrical coupling with cardiomyocytes, which potentially results in profound disturbances of electrophysiology. There is strong evidence that systemic and regional inflammatory processes contribute to fibrogenesis (i.e., structural remodeling) and dysfunction of ion channels and Ca2+ homeostasis (i.e., electrical remodeling). Recognizing the pivotal role of fibrosis in the arrhythmogenesis has promoted clinical research on characterizing fibrosis by means of cardiac imaging or fibrosis biomarkers for clinical stratification of patients at higher risk of lethal arrhythmia, as well as preclinical research on the development of antifibrotic therapies. At the end of this review, we discuss remaining key questions in this area and propose new research approaches. © 2017 American Physiological Society. Compr Physiol 7:1009-1049, 2017.
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Affiliation(s)
- My-Nhan Nguyen
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Helen Kiriazis
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Xiao-Ming Gao
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Xiao-Jun Du
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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Current Concepts on Diagnosis and Prognosis of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia. J Thorac Imaging 2016; 31:324-335. [DOI: 10.1097/rti.0000000000000171] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Yasuda M, Iwanaga Y, Kato T, Izumi T, Inuzuka Y, Nakamura T, Miyaji Y, Kawamura T, Ikeguchi S, Inoko M, Kurita T, Miyazaki S. Risk stratification for major adverse cardiac events and ventricular tachyarrhythmias by cardiac MRI in patients with cardiac sarcoidosis. Open Heart 2016; 3:e000437. [PMID: 27547432 PMCID: PMC4975863 DOI: 10.1136/openhrt-2016-000437] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/28/2016] [Accepted: 06/30/2016] [Indexed: 01/07/2023] Open
Abstract
Background The presence of myocardial fibrosis by cardiac MRI has prognostic value in cardiac sarcoidosis, and localisation may be equally relevant to clinical outcomes. Objective We aimed to analyse cardiac damage and function in detail and explore the relationship with clinical outcomes in patients with cardiac sarcoidosis using cardiac MRI. Methods We included 81 consecutive patients with cardiac sarcoidosis undergoing cardiac MR. Left ventricular mass and fibrosis mass were calculated, and localisation was analysed using a 17-segment model. Participants underwent follow-up through 2015, and the development of major adverse cardiac events including ventricular tachyarrhythmias was recorded. Results Increased left ventricular fibrosis mass was associated with increased prevalence of ventricular tachyarrhythmias (p<0.001). When localisation was defined as the sum of late gadolinium enhancement in the left ventricular basal anterior and basal anteroseptal areas, or the right ventricular area, it was associated with ventricular tachyarrhythmias (p<0.001). Kaplan-Meier analysis during a median follow-up of 22.1 months showed that both the mass and localisation groupings for fibrosis were significantly associated with major adverse cardiac events or ventricular tachyarrhythmias and that when combined, the risk stratification was better than for each variable alone (p<0.001, respectively). By Cox-proportional hazard risk analysis, the localisation grouping was an independent predictor for the both. Conclusions In patients with cardiac sarcoidosis, both fibrosis mass and its localisation to the basal anterior/anteroseptal left ventricle, or right ventricle was associated with the development of major adverse cardiac events or ventricular tachyarrhythmias. Cardiac MR with late gadolinium enhancement may be useful for improving risk stratification in patients with cardiac sarcoidosis.
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Affiliation(s)
- Masakazu Yasuda
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama , Japan
| | - Yoshitaka Iwanaga
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama , Japan
| | | | | | | | - Takashi Nakamura
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama , Japan
| | - Yuki Miyaji
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama , Japan
| | - Takayuki Kawamura
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama , Japan
| | | | | | - Takashi Kurita
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama , Japan
| | - Shunichi Miyazaki
- Division of Cardiology, Kindai University Faculty of Medicine, Osakasayama , Japan
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Mewton N, Strauss DG, Rizzi P, Verrier RL, Liu CY, Tereshchenko LG, Nearing B, Volpe GJ, Marchlinski FE, Moxley J, Killian T, Wu KC, Spooner P, Lima JAC. Screening for Cardiac Magnetic Resonance Scar Features by 12-Lead ECG, in Patients with Preserved Ejection Fraction. Ann Noninvasive Electrocardiol 2016; 21:49-59. [PMID: 26806840 DOI: 10.1111/anec.12264] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Increased QRS score and wide spatial QRS-T angle are independent predictors of cardiovascular mortality in the general population. Our main objective was to assess whether a QRS score ≥ 5 and/or QRS-T angle ≥ 105° enable screening of patients for myocardial scar features. METHODS Seventy-seven patients of age ≤ 70 years with QRS score ≥ 5 and/or spatial QRS-T angle ≥ 105° as well as left ventricular ejection fraction (LVEF) >35% were enrolled in the study. All participants underwent complete clinical examination, signal-averaged ECG (SAECG), 30-minute ambulatory ECG recording for T-wave alternans (TWA), and late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Relationship between QRS score, QRS-T angle with scar presence and pattern, as well as gray zone, core, and total scar size by LGE-CMR were assessed. RESULTS Myocardial scar was present in 41 (53%) patients, of whom 19 (46%) exhibited a typical ischemic pattern. QRS score but not QRS-T angle was related to total scar size and gray zone size (R(2) = 0.12, P = 0.002; R(2) = 0.17; P ≤ 0.0001, respectively). Patients with QRS scores ≥ 6 had significantly greater myocardial scar and gray zone size, increased QRS duration and QRS-T angle, a higher prevalence of late potentials (LPs) presence, increased LV end-diastolic volume and decreased LVEF. There was a significant independent and positive association between TWA value and total scar (P = 0.001) and gray zone size (P = 0.01). CONCLUSION Patients with preserved LVEF and myocardial scar by CMR also have electrocardiographic features that could be involved in ventricular arrhythmogenesis.
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Affiliation(s)
- Nathan Mewton
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD.,Hôpital Cardiovasculaire Louis Pradel, Centre d'Investigation Clinique, Hospices Civils de Lyon, Bron, France
| | - David G Strauss
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
| | - Patricia Rizzi
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Chia Ying Liu
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Larisa G Tereshchenko
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Bruce Nearing
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gustavo J Volpe
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Francis E Marchlinski
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John Moxley
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Tony Killian
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Katherine C Wu
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Peter Spooner
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - João A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
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MEMON SARFARAZ, GANGA HARSHAV, KLUGER JEFFREY. Late Gadolinium Enhancement in Patients with Nonischemic Dilated Cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:731-47. [DOI: 10.1111/pace.12873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 03/22/2016] [Accepted: 04/06/2016] [Indexed: 01/23/2023]
Affiliation(s)
- SARFARAZ MEMON
- Division of Cardiology; Hartford Hospital; Hartford Connecticut
| | - HARSHA V. GANGA
- Division of Cardiology; Brown University; Providence Rhode Island
| | - JEFFREY KLUGER
- Division of Cardiology; Hartford Hospital; Hartford Connecticut
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