Visualization of discrete microinfarction after percutaneous coronary intervention associated with mild creatine kinase-MB elevation

Current Challenges in Coronary Bifurcation Interventions

Coronary bifurcation lesions account for a significant proportion of all percutaneous coronary interventions (PCIs). Interventional treatment of coronary bifurcations is related to significant technical challenges, high complication rates, and worse angiographic and long-term clinical outcomes. This review covers the specific features and structure of coronary bifurcation and explores the main challenges in the interventional treatment of these lesions. This review evaluates various methodologies designed to address these lesions, considering factors such as plaque distribution and bifurcation geometry. It also emphasizes the limitations associated with current techniques. A novel combined optimization approach applied in the interventional treatment of coronary bifurcation may offer superior procedural and long-term outcomes. This combined technique could potentially address the drawbacks of each method, providing a more effective solution for optimizing stent placement in bifurcation lesions. Refining and evaluating these combined techniques is essential for improving clinical outcomes in patients with bifurcation lesions.

Stronger positive correlation of the left ventricular mass index and extracellular volume fraction with diastolic function in diabetic patients without myocardial infarction

BACKGROUND

The structural and functional characteristics of the heart in patients with diabetes mellitus (DM) and without myocardial infarction (MI) are not fully understood.

METHODS

We retrospectively analysed the data of patients with left ventricular ejection fraction (LVEF) ≥ 40% who underwent contrast-enhanced cardiac magnetic resonance imaging (CMR), which was also used to exclude MI, at two hospitals. Volumetric data and extracellular volume fraction (ECVf) of the myocardium evaluated using CMR were compared between patients with and without DM, and their association with diastolic function was evaluated.

RESULTS

Among 322 analysed patients, 53 had DM. CMR revealed that the left ventricular mass index (LVMi) and ECVf were increased while LVEF was decreased in patients with DM after adjusting for patient characteristics (all P < 0.05). A stronger positive correlation was observed between LVMi and the early diastolic transmitral flow velocity to early diastolic mitral annular velocity ratio (E/e') in patients with DM than in those without DM (correlation coefficient [R] = 0.46, p = 0.001; R = 0.15, p = 0.021, respectively; p for interaction = 0.011). ECVf correlated with E/e' only in patients with DM (R = 0.61, p = 0.004).

CONCLUSIONS

Patients with DM have increased LVMi and ECVf. Importantly, there was a difference between patients with and without DM in the relationship between these structural changes and E/e', with a stronger relationship in patients with DM. Furthermore, DM is associated with mildly reduced LVEF even in the absence of MI.

Detection of unrecognized myocardial infarction by preprocedural transthoracic echocardiography in patients undergoing elective percutaneous coronary intervention

BACKGROUND

Previous studies showed that unrecognized myocardial infarction (UMI) identified on cardiac magnetic resonance (CMR) was related to worse prognosis. We aimed to investigate the efficacy of preprocedural transthoracic echocardiography (TTE) to detect the presence of UMI in patients undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 138 patients with chronic coronary syndrome (CCS) and preserved left ventricular ejection fraction (LVEF) without history of myocardial infarction or revascularization were retrospectively studied. UMI was evaluated with pre-PCI late gadolinium enhancement (LGE)-CMR. TTE and two-dimensional speckle-tracking echocardiography (2D-STE) were performed before PCI. All patients were divided into two groups according to the presence or absence of UMI, and clinical and echocardiographic findings were compared between these two groups.

RESULTS

UMI was detected in 43 patients (31.2%). Multivariable logistic regression analysis revealed that higher SYNTAX score, the presence of wall motion abnormalities (WMAs) and lower global longitudinal strain (GLS) were independent predictors of the presence of UMI. Furthermore, GLS provided incremental efficacy for the detection of UMI over abnormal Q waves, SYNTAX score and WMAs.

CONCLUSIONS

Preprocedural TTE in combination with 2D-STE could help identify patients with UMI regardless of the presence or absence of ECG findings and WMAs.

Alirocumab effect on preventing periprocedural ischaemic events in coronary heart disease patients undergoing coronary stenting (APPEASE trial): study protocol of a multicentre, open-label, randomised controlled trial

INTRODUCTION

Percutaneous coronary intervention (PCI)-related myocardial infarction (type 4a MI) and major periprocedural myocardial injury have been demonstrated leading to poor prognosis of patients with coronary heart disease (CHD) undergoing elective PCI and still remain high occurrence even after the therapy of dual antiplatelet agents and statins. Proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab has been shown to be effectively in reducing the risk of acute MI (AMI). However, the effect of alirocumab on preventing PCI-related MI or major periprocedural myocardial injury in patients with CHD undergoing elective PCI remains uncertain.

METHODS AND ANALYSIS

Alirocumab effect on Preventing Periprocedural ischaemic Events in coronary heart diseAse patients undergoing coronary StEnting trial is a multicentre, open-label, randomised controlled trial aiming to determine whether alirocumab could reduce the incidence of type 4a MI or major periprocedural myocardial injury in patients with CHD undergoing elective PCI. In total, 422 non-AMI CHD patients planned to undergo elective PCI will be randomly assigned to receive standard pharmacotherapy of CHD (control group) or additional use of subcutaneous alirocumab 75 mg 1 day before procedure (alirocumab group). The primary outcome is type 4a MI or major periprocedural myocardial injury defined as high-sensitivity cardiac troponin elevating above 5×99 th percentile upper reference limit in 48 hours after PCI. Patients will continue receiving standard pharmacotherapy or additional biweekly subcutaneous alirocumab 75 mg for 3 months according to the initial randomisation group. We will follow up for 3 months and record all the major adverse cardiovascular events (MACEs). Incidence of PCI-related MI or major periprocedural myocardial injury, and MACE in 3 months after PCI will be compared between control group and alirocumab group.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Medical Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University with approval number: (2022)02-140-01. The results of this study will be reported through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2200063191.

Periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention

Percutaneous coronary intervention (PCI) in addition to guideline-directed medical therapy reduces the risk of spontaneous myocardial infarction (MI), urgent revascularization, and improves angina status; however, PCI is associated with an increased risk of periprocedural myocardial injury and MI. Numerous studies have investigated the mechanisms, predictors, and therapeutic strategies for periprocedural MI. Various definitions of periprocedural MI have been proposed by academic groups and professional societies requiring different cardiac biomarker thresholds and ancillary criteria for myocardial ischemia. The frequency and clinical significance of periprocedural MI substantially varies according to the definitions applied. In daily practice, accurate diagnosis of clinically-relevant periprocedural MI is essential because it may have a substantial impact on subsequent patient management. In the clinical trial setting, only clinically relevant periprocedural MI definitions should be applied as a clinical endpoint in order to avoid obscuring meaningful outcomes. In this review, we aim to summarize the mechanisms, predictors, frequency, and prognostic impact of periprocedural MI in patients undergoing PCI and to provide the current perspective on this issue.

A case report of a myocardial ischaemic attack: a novel hyperenhancement pattern on cardiac magnetic resonance in focal ischaemic injury

Background

Delayed enhancement cardiac magnetic resonance (DE-CMR) is the reference standard for the non-invasive assessment of myocardial fibrosis. DE-CMR is able to distinguish ischaemic from non-ischaemic aetiologies based on differences in hyperenhancement distribution patterns. Hyperenhancement caused by ischaemic injury typically involves the endocardium, while hyperenhancement confined to the mid- and epicardial layers of the myocardium suggests a non-ischaemic aetiology.

Case summary

This is a case of a 20-year-old male with an unremarkable medical history with an acute ST-elevation myocardial infarction. DE-CMR revealed two distinct patterns of hyperenhancement: (i) a 'normal' wavefront-ischaemic pattern, and (ii) multiple atypical mid-wall and epicardial areas of focal hyperenhancement. Invasive coronary angiography (ICA) and coronary computed tomographic angiography (CCTA) showed multiple intracoronary thrombi and distal emboli in the left anterior descending, ramus circumflexus, and in smaller branches of the LCA. All hyperenhancement patterns observed on DE-CMR perfectly matched the distribution territories of the affected coronary arteries.

Discussion

This case with an acute myocardial infarction showed intracoronary thrombi and emboli on ICA and CCTA. Interestingly, DE-CMR showed two different patterns of hyperenhancement in the same territories of the coronary thrombi. This observation may challenge the concept that these non-endocardial areas of hyperenhancement on DE-CMR are always of non-ischaemic aetiology. It is hypothesized that occlusion of smaller distal branches of the coronary arteries may result in mid-wall or epicardial fibrosis as opposed to subendocardial fibrosis commonly found in patients with a large epicardial coronary occlusion. Clinicians should be aware of these atypical patterns to be able to initiate adequate medical therapy.

[The role of Cardiovascular Magnetic Resonance in Interventional Cardiology]

Cardiovascular magnetic resonance has emerged as a very helpful tool for the interventional cardiologists not only in the assessment and treatment of coronary artery disease, but also in the evaluation of various structural cardiac diseases. The main pulse sequences are standardised, acquired during short breath-holds, and include steady-state free precession cines, dynamic myocardial first-pass perfusion imaging during contrast injection, and late enhancement imaging for the identification of myocardial substrates. Less than 30-minute CMR studies are now available for the most common clinical indications. More recently, T1 and T2 parametric myocardial maps are promising for detailed myocardial tissue characterisation (edema, replacement fibrosis, diffuse interstitial fibrosis). Technical aspects will not be addressed with particular emphasis on clinical applications.

Non-contrast Cine Cardiac Magnetic Resonance image radiomics features and machine learning algorithms for myocardial infarction detection

OBJECTIVE

Robust differentiation between infarcted and normal tissue is important for clinical diagnosis and precision medicine. The aim of this work is to investigate the radiomic features and to develop a machine learning algorithm for the differentiation of myocardial infarction (MI) and viable tissues/normal cases in the left ventricular myocardium on non-contrast Cine Cardiac Magnetic Resonance (Cine-CMR) images.

METHODS

Seventy-two patients (52 with MI and 20 healthy control patients) were enrolled in this study. MR imaging was performed on a 1.5 T MRI using the following parameters: TR = 43.35 ms, TE = 1.22 ms, flip angle = 65°, temporal resolution of 30-40 ms. N4 bias field correction algorithm was applied to correct the inhomogeneity of images. All images were segmented and verified simultaneously by two cardiac imaging experts in consensus. Subsequently, features extraction was performed within the whole left ventricular myocardium (3D volume) in end-diastolic volume phase. Re-sampling to 1 × 1 × 1 mm³ voxels was performed for MR images. All intensities within the VOI of MR images were discretized to 64 bins. Radiomic features were normalized to obtain Z-scores, followed by Student's t-test statistical analysis for comparison. A p-value < 0.05 was used as a threshold for statistically significant differences and false discovery rate (FDR) correction performed to report q-value (FDR adjusted p-value). The extracted features were ranked using the MSVM-RFE algorithm, then Spearman correlation between features was performed to eliminate highly correlated features (R2 > 0.80). Ten different machine learning algorithms were used for classification and different metrics used for evaluation and various parameters used for models' evaluation.

RESULTS

In univariate analysis, the highest area under the curve (AUC) of receiver operating characteristic (ROC) value was achieved for the Maximum 2D diameter slice (M2DS) shape feature (AUC = 0.88, q-value = 1.02E-7), while the average of univariate AUCs was 0.62 ± 0.08. In multivariate analysis, Logistic Regression (AUC = 0.93 ± 0.03, Accuracy = 0.86 ± 0.05, Recall = 0.87 ± 0.1, Precision = 0.93 ± 0.03 and F1 Score = 0.90 ± 0.04) and SVM (AUC = 0.92 ± 0.05, Accuracy = 0.85 ± 0.04, Recall = 0.92 ± 0.01, Precision = 0.88 ± 0.04 and F1 Score = 0.90 ± 0.02) yielded optimal performance as the best machine learning algorithm for this radiomics analysis.

CONCLUSION

This study demonstrated that using radiomics analysis on non-contrast Cine-CMR images enables to accurately detect MI, which could potentially be used as an alternative diagnostic method for Late Gadolinium Enhancement Cardiac Magnetic Resonance (LGE-CMR).

Altered Cardiac Energetics and Mitochondrial Dysfunction in Hypertrophic Cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is a complex disease partly explained by the effects of individual gene variants on sarcomeric protein biomechanics. At the cellular level, HCM mutations most commonly enhance force production, leading to higher energy demands. Despite significant advances in elucidating sarcomeric structure-function relationships, there is still much to be learned about the mechanisms that link altered cardiac energetics to HCM phenotypes. In this work, we test the hypothesis that changes in cardiac energetics represent a common pathophysiologic pathway in HCM.

METHODS

We performed a comprehensive multiomics profile of the molecular (transcripts, metabolites, and complex lipids), ultrastructural, and functional components of HCM energetics using myocardial samples from 27 HCM patients and 13 normal controls (donor hearts).

RESULTS

Integrated omics analysis revealed alterations in a wide array of biochemical pathways with major dysregulation in fatty acid metabolism, reduction of acylcarnitines, and accumulation of free fatty acids. HCM hearts showed evidence of global energetic decompensation manifested by a decrease in high energy phosphate metabolites (ATP, ADP, and phosphocreatine) and a reduction in mitochondrial genes involved in creatine kinase and ATP synthesis. Accompanying these metabolic derangements, electron microscopy showed an increased fraction of severely damaged mitochondria with reduced cristae density, coinciding with reduced citrate synthase activity and mitochondrial oxidative respiration. These mitochondrial abnormalities were associated with elevated reactive oxygen species and reduced antioxidant defenses. However, despite significant mitochondrial injury, HCM hearts failed to upregulate mitophagic clearance.

CONCLUSIONS

Overall, our findings suggest that perturbed metabolic signaling and mitochondrial dysfunction are common pathogenic mechanisms in patients with HCM. These results highlight potential new drug targets for attenuation of the clinical disease through improving metabolic function and reducing mitochondrial injury.

Non-invasive Imaging in Coronary Syndromes - Recommendations of the European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with the American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance

Coronary artery disease (CAD) is one of the major causes of mortality and morbidity worldwide, with a high socioeconomic impact.(1) Non-invasive imaging modalities play a fundamental role in the evaluation and management of patients with known or suspected CAD. Imaging end-points have served as surrogate markers in many observational studies and randomized clinical trials that evaluated the benefits of specific therapies for CAD.(2) A number of guidelines and recommendations have been published about coronary syndromes by cardiology societies and associations, but have not focused on the excellent opportunities with cardiac imaging. The recent European Society of Cardiology (ESC) 2019 guideline on chronic coronary syndromes (CCS) and 2020 guideline on acute coronary syndromes in patients presenting with non-ST-segment elevation (NSTE-ACS) highlight the importance of non-invasive imaging in the diagnosis, treatment, and risk assessment of the disease.(3)(4) The purpose of the current recommendations is to present the significant role of non-invasive imaging in coronary syndromes in more detail. These recommendations have been developed by the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE), in collaboration with the American Society of Nuclear Cardiology, the Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance, all of which have approved the final document.

Prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions: a Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

A substantial number of chronic coronary syndrome (CCS) patients undergoing percutaneous coronary intervention (PCI) experience periprocedural myocardial injury or infarction. Accurate diagnosis of these PCI-related complications is required to guide further management given that their occurrence may be associated with increased risk of major adverse cardiac events (MACE). Due to lack of scientific data, the cut-off thresholds of post-PCI cardiac troponin (cTn) elevation used for defining periprocedural myocardial injury and infarction, have been selected based on expert consensus opinions, and their prognostic relevance remains unclear. In this Consensus Document from the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI), we recommend, whenever possible, the measurement of baseline (pre-PCI) cTn and post-PCI cTn values in all CCS patients undergoing PCI. We confirm the prognostic relevance of the post-PCI cTn elevation >5× 99th percentile URL threshold used to define type 4a myocardial infarction (MI). In the absence of periprocedural angiographic flow-limiting complications or electrocardiogram (ECG) and imaging evidence of new myocardial ischaemia, we propose the same post-PCI cTn cut-off threshold (>5× 99th percentile URL) be used to define prognostically relevant ‘major’ periprocedural myocardial injury. As both type 4a MI and major periprocedural myocardial injury are strong independent predictors of all-cause mortality at 1 year post-PCI, they may be used as quality metrics and surrogate endpoints for clinical trials. Further research is needed to evaluate treatment strategies for reducing the risk of major periprocedural myocardial injury, type 4a MI, and MACE in CCS patients undergoing PCI.

Focus on Autoimmune Myocarditis in Graves' Disease: A Case-Based Review

The manifestations of hyperthyroidism-related myocardial damage are multitudinous, including arrhythmia, dilated cardiomyopathy, valvular diseases, and even cardiogenic shock. Acute myocarditis induced by thyrotoxicosis had been reported in a few studies. However, attention on its prevalence and underlying mechanisms is sorely lacking. Its long-term harm is often ignored, and it may eventually develop into dilated cardiomyopathy and heart failure. We report a case of Graves' disease with a progressive elevation of hypersensitive cardiac troponin-I at several days after discontinuation of the patient's anti-thyroid drugs. Cardiac magnetic resonance imaging (CMRI) showed inflammatory edema of some cardiomyocytes (stranded enhanced signals under T2 mapping), myocardial necrosis (scattered enhanced signals under T1 late gadolinium enhancement) in the medial and inferior epicardial wall, with a decreased left ventricular systolic function (48%), which implied a possibility of acute myocarditis induced by thyrotoxicosis. The patient was then given a transient glucocorticoid (GC) treatment and achieved a good curative effect. Inspired by this case, we aim to systematically elaborate the pathogenesis, diagnosis, and treatment of hyperthyroidism-induced autoimmune myocarditis. Additionally, we emphasize the importance of CMRI and GC therapy in the diagnosis and treatment of hyperthyroidism-related myocarditis.

Impact of Antecedent Aspirin Use on Infarct Size, Bleeding and Composite Endpoint in Patients with de Novo Acute Myocardial Infarction

BACKGROUND

The study aimed to evaluate the impact of antecedent aspirin use on infarct size, bleeding and composite endpoint in patients with de novo acute myocardial infarction.

PATIENTS AND METHODS

A total of 562 consecutive patients with de novo acute myocardial infarction were included in this prospective cohort study. Patients were assigned into two groups based on presence (n=212) and absence (n=350) of prior aspirin use. Primary endpoint was myocardial infarct size, as estimated by troponin I peak. In-hospital mortality, bleeding and composite clinical endpoint including cardiogenic shock, stroke, in-hospital mortality and major bleeding were also evaluated.

RESULTS

Although GRACE and CRUSADE scores were higher, troponin I peak was lower in prior aspirin users. This result was maintained after adjustment for baseline ischemic risk profile and other major confounders including MI type and location. Despite high CRUSADE score, there was no increase in major and minor bleeding. Minimal bleeding was higher in antecedent aspirin users. When it was adjusted for the CRUSADE score, a similar risk was reported.

CONCLUSION

Patients with de novo acute myocardial infarction using aspirin for primary prevention have an unexpectedly smaller infarct size and similar bleeding rates.

LDL-C and Total Stent Length are Independent Predictors of Periprocedural Myocardial Injury and Infarction for Unstable Angina Patients Undergoing Elective Percutaneous Coronary Intervention

BACKGROUND

To investigate the predictive value of low-density lipoprotein cholesterol (LDL-C), total stent length and number of implanted stents in patients with unstable angina (UA) regarding myocardial injury and infarction during perioperative period.

METHODS

Three hundred and fifteen consecutive UA patients between January 2015 and June 2018 were retrospectively recruited from two cardiac centers of Hebei Province, China. These patients had normal preprocedural cardiac troponin I (cTnI) and underwent uneventful revascularizations. The predictive value of baseline LDL-C level and total stent length was investigated by linking to post procedural cTnI value in this cohort. Meanwhile, other related clinical and procedural variables were analyzed.

RESULTS

Baseline LDL-C level or LDL-C grade was correlated with post percutaneous coronary intervention (PCI) cTnI levels (r = 0.120, P = 0.01; r = 0.157, P = 0.004). LDL-C grade was an independent risk factor of perioperative myocardial injury and infarction (P < 0.05) after multivariable adjustment. The risk increased with the elevation of baseline LDL-C level. Compared to the lowest level group (<70 mg/dl), the group with 70-99 mg/dl carried three times higher risk (OR = 3.318; 95% CI: 1.167-9.436; P < 0.05). And, patients with LDL-C level ≥100 mg/dl had the worst prognosis (OR = 4.783; 95% CI: 1.736-13.180; P = 0.002). Besides, the study also found that the total length of stent was predictive of perioperative myocardial injury and infarction independently (OR = 1.037; 95% CI: 1.017-1.058; P = 0.001).

CONCLUSION

Baseline LDL-C level and total stent length were independent predictors of periprocedural myocardial injury and infarction in UA patients undergoing elective PCI.

Multimodality Imaging of Myocardial Viability

PURPOSE OF REVIEW

Myocardial viability is an important pathophysiologic concept which may have significant clinical impact in patients with left ventricular dysfunction due to ischemic heart disease. Understanding the imaging modalities used to assess viability, and the clinical implication of their findings, is critical for clinical decision-making in this population.

RECENT FINDINGS

The ability of dobutamine echocardiography, single-photon emission computed tomography, positron emission tomography, and cardiac magnetic resonance imaging to predict functional recovery following revascularization is well-established. Despite different advantages and disadvantages for each imaging modality, each modality has demonstrated reasonable performance characteristics in identifying viable myocardium. Recent data, however, has called into question whether this functional recovery leads to improved clinical outcomes. Although the assessment of viability can be used to aid in clinical decision-making prior to revascularization, its broad application to all patients is limited by a lack of data confirming improvement in clinical outcomes. Thus, viability assessments may be best applied to select patients (such as those with increased surgical risk) and integrated with clinical, laboratory, and imaging data to guide clinical care. Future research efforts should be aimed at establishing the impact of viability on clinical outcomes.

Using Cardiac Magnetic Resonance Imaging to Evaluate Patients with Chest Pain in the Emergency Department

Chest pain is one of the most common presenting symptoms in the emergency department (ED). Among patients with abnormal troponins, it is imperative to quickly and accurately distinguish type 1 acute myocardial infarction (AMI) from other etiologies of myocardial injury. Although high-sensitivity troponin assays introduced a high negative predictive value for AMI, they have exposed the need for diagnostic modalities that can determine the etiology of acute myocardial injury. Cardiac magnetic resonance imaging (CMR) is an effective tool to risk stratifying chest pain among patients in the ED. CMR is non-invasive and has a lower cost of care and shorter length of stay compared to those of invasive coronary angiography. It also provides detailed information on cardiac morphology, function, tissue edema, and location and pattern of tissue damage that can help to differentiate many etiologies of cardiac injury. CMR is particularly useful to distinguish chest pain due to type 1 AMI versus supply-demand mismatch due to acute cardiac noncoronary artery disease. A detailed review of the literature has shown that CMR with stress testing is safe to use in patients presenting to the ED with chest pain, with or without abnormal troponins. CMR is a useful, safe, economical, and effective alternative to the traditional diagnostic tools that are typically used in this patient population. It is a practical tool to risk-stratify patients with possible cardiac pathology and to clarify diagnosis without invasive testing.

Long-term prognostic value of late gadolinium enhancement and periprocedural myocardial infarction after uncomplicated revascularization: MASS-V follow-up

AIMS

Cardiac biomarkers elevation is common after revascularization, even in absence of periprocedural myocardial infarction (PMI) detection by imaging methods. Thus, late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) may be useful on PMI diagnosis and prognosis. We sought to evaluate long-term prognostic value of PMI and new LGE after revascularization.

METHODS AND RESULTS

Two hundred and two patients with multivessel coronary disease and preserved ventricular function who underwent elective revascularization were included, of whom 136 (67.3%) underwent coronary artery bypass grafting and 66 (32.7%) percutaneous coronary intervention. The median follow-up was 5 years (4.8-5.8 years). Cardiac biomarkers measurement and LGE-CMR were performed before and after procedures. The Society for Cardiovascular Angiography and Interventions definition was used to assess PMI. Primary endpoint was composed of death, infarction, additional revascularization, or cardiac hospitalization. Primary endpoint was observed in 29 (14.3%) patients, of whom 13 (14.9%) had PMI and 16 (13.9%) did not (P = 0.93). Thirty-six (17.8%) patients had new LGE. Twenty (12.0%) events occurred in patients without new LGE and 9 (25.2%) in patients with it (P = 0.045). LGE was also associated to increased mortality, with 4 (2.4%) and 4 (11.1%) deaths in subjects without and with it (P = 0.02). LGE was the only independent predictor of primary endpoint and mortality (P = 0.03 and P = 0.02). Median LGE mass was estimated at 4.6 g. Patients with new LGE had a greater biomarkers release (median troponin: 8.9 ng/mL vs. 1.8 ng/mL and median creatine kinase-MB: 38.0 ng/mL vs. 12.3 ng/mL; P < 0.001 in both comparisons).

CONCLUSIONS

New LGE was shown to be better prognostic predictor than biomarker-only PMI definition after uncomplicated revascularization. Furthermore, new LGE was the only independent predictor of cardiovascular events and mortality.

CLINICAL TRIAL REGISTRATION

http://www.controlled-trials.com/ISRCTN09454308.

Myocardial involvement in eosinophilic granulomatosis with polyangiitis evaluated with cardiopulmonary magnetic resonance

Patients with eosinophilic granulomatosis with polyangiitis (EGPA) most commonly die from cardiac causes, however, cardiac involvement remains poorly characterised and the relationship between cardiac and pulmonary disease is not known. This study aimed to characterise myocardial and pulmonary manifestations of EGPA, and their relationship. Prospective comprehensive cardiopulmonary investigation, including a novel combined cardiopulmonary magnetic resonance imaging (MRI) technology, was performed in 13 patients with stable EGPA. Comparison was made with 11 prospectively recruited matched healthy volunteers. Stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis (myocardial extracellular volume 26.9% vs. 24.7%; p = 0.034), which drove a borderline increase in left ventricular mass (56  ±  9 g/m2 vs. 49  ±  8 g/m2; p = 0.065). Corrected QT interval was significantly prolonged and was associated with the severity of myocardial fibrosis (r = 0.582, p = 0.037). Stable EGPA was not associated with increased myocardial capillary permeability or myocardial oedema. Pulmonary tissue perfusion and capillary permeability were normal and there was no evidence of pulmonary tissue oedema or fibrosis. Forced expiratory volume in one second showed a strong inverse relationship with myocardial fibrosis (r = -0.783, p = 0.038). In this exploratory study, stable EGPA was associated with focal replacement and diffuse interstitial myocardial fibrosis, but no evidence of myocardial or pulmonary inflammation or pulmonary fibrosis. Myocardial fibrosis was strongly associated with airway obstruction and abnormal cardiac repolarisation. Further investigation is required to determine the mechanisms underlying the association between heart and lung disease in EGPA and whether an immediate immunosuppressive strategy could prevent myocardial fibrosis formation.

Multimodal and multifunctional nanoparticles with platelet targeting ability and phase transition efficiency for the molecular imaging and thrombolysis of coronary microthrombi

Recently, coronary microthrombosis has received attention owing to its involvement in the pathophysiological process of no-reflow after acute myocardial ischemia/reperfusion. Due to the small size of coronary microthrombi, there are no precise detection and treatment methods available in the clinic so far. In experimental study, bimodal molecular probes for both detecting and dissolving coronary microthrombi have not yet been reported. In this study, multimodal and multifunctional PLGA-cRGD-PFH-ICG NPs (PLGA: poly(lactic-co-glycolic) acid, cRGD: cyclic arginine-glycine-aspartic acid, PFH: perfluorohexane, ICG: indocyanine green, NPs: nanoparticles) were constructed through a three-step emulsification process, and the corresponding physical and chemical characteristics of the NPs were also tested. The in vitro and in vivo experiments showed that PLGA-cRGD-PFH-ICG NPs could bind to the activated platelets of coronary microthrombi through cRGD and could achieve bimodal molecular imaging (photoacoustic and near-infrared fluorescence) through ICG. Moreover, the PLGA-cRGD-PFH-ICG NPs could permeate more deeply into the thrombus than other common NPs before being triggered by low-intensity focused ultrasound (LIFU), and thrombolysis was carried out through the cavitation effect of PFH after triggering by LIFU. In summary, PLGA-cRGD-PFH-ICG NPs, constructed with safe and approved materials, serve as an excellent theranostic contrast agent that paves the way for the clinical diagnosis and treatment of coronary microthrombosis.

Imaging tools for assessment of myocardial fibrosis in humans: the need for greater detail

Myocardial fibrosis is recognized as a key pathological process in the development of cardiac disease and a target for future therapeutics. Despite this recognition, the assessment of fibrosis is not a part of routine clinical practice. This is primarily due to the difficulties in obtaining an accurate assessment of fibrosis non-invasively. Moreover, there is a clear discrepancy between the understandings of myocardial fibrosis clinically where fibrosis is predominately studied with comparatively low-resolution medical imaging technologies like MRI compared with the basic science laboratories where fibrosis can be visualized invasively with high resolution using molecularly specific fluorescence microscopes at the microscopic and nanoscopic scales. In this article, we will first review current medical imaging technologies for assessing fibrosis including echo and MRI. We will then highlight the need for greater microscopic and nanoscopic analysis of human tissue and how this can be addressed through greater utilization of human tissue available through endomyocardial biopsies and cardiac surgeries. We will then describe the relatively new field of molecular imaging that promises to translate research findings to the clinical practice by non-invasively monitoring the molecular signature of fibrosis in patients.

Left ventricular mass and myocardial scarring in women with hypertensive disorders of pregnancy

AIMS

Hypertensive disorders of pregnancy (HDP) predict future cardiovascular events. We aim to investigate relations between HDP history and subsequent hypertension (HTN), myocardial structure and function, and late gadolinium enhancement (LGE) scar.

METHODS AND RESULTS

We evaluated a prospective cohort of women with suspected ischaemia with no obstructive coronary artery disease (INOCA) who underwent stress/rest cardiac magnetic resonance imaging (cMRI) with LGE in the Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction study. Self-reported history of pregnancy and HDP (gestational HTN, pre-eclampsia, toxaemia and eclampsia) were collected at enrollment. In our cohort of 346, 20% of women report a history of HDP. HDP history was associated with 3.2-fold increased odds of HTN. Women with a history of both HDP and HTN had higher cMRI measured left ventricular (LV) mass compared with women with HDP only (99.4±2.6 g vs 87.7±3.2 g, p=0.02). While we found a similar frequency of LGE scar, we observed a trend towards increased LGE scar size (5.1±3.4 g vs 8.0±3.4 g, p=0.09) among the women with HDP history compared to women without.

CONCLUSION

In a high-risk cohort of women with suspected INOCA, 20% had a history of HDP. Women with HDP history were more likely to develop HTN. Our study demonstrates higher LV mass in women with HDP and concomitant HTN. Although the presence of LGE scar was not different in women with and without HDP history, we observed a trend towards larger scar size in women with HDP. Future studies are needed to better assess the relationship of HDP and cardiac morphology and LGE scarring in a larger cohort of women.

The Value of T1 Mapping Techniques in the Assessment of Myocardial Interstitial Fibrosis

Cardiac fibrosis, characterized by net accumulation of extracellular matrix in the myocardium, is a common final pathway of heart failure. This myocardial fibrosis (MF) is not necessarily the primary cause of dysfunction; it often results from a reparative process activated in response to cardiomyocyte injury. In light of currently available treatments, late-identified MF could be definitive or irreversible, associated with worsening ventricular systolic function, abnormal cardiac remodeling, and increased ventricular stiffness and arrhythmia. T1 mapping should be used to detect incipient changes leading to myocardial damage in several clinical conditions and also in subclinical disease. This article reviews available techniques for MF detection, focusing on noninvasive quantification of diffuse fibrosis and clinical applications.

Molecular markers relevant to myocardial injury following dental extraction in patients with or without coronary artery disease

Objectives

The aim of this study was to characterize biological changes following dental extractions in patients with and without coronary artery disease (CAD).

Materials and methods

Forty-five patients (36 males and 9 females) referred for dental extraction underwent treatment and provided blood samples before, immediately after, and 24 h after the procedure. A broad array of biomarkers was employed to assess myocardial injury (highly sensitive troponin T, hs-TnT), bacterial burden (LPS endotoxin activity), and systemic inflammation (CRP, fibrinogen, IFN-γ, IL-1β, IL-6, IL-8, IL-10, IL-12, and TNF-α).

Results

Dental extraction in patients with and without CAD was associated with rises in hs-TnT (p = 0.013), hs-CRP (p < 0.001), fibrinogen (p = 0.005), endotoxin activity (p < 0.001), IFN-γ (p < 0.001), IL-6 (p < 0.001), IL-8 (p = 0.011), and IL-12 (p < 0.001) at 24 h compared with immediately post procedure. Changes in systemic inflammation and endotoxin activity were more evident in those with hs-TnT rise.

Conclusions

Simple dental extractions may cause mild increase in hs-TnT, indicating minor myocardial injury in both patients with and without CAD. Acute systemic inflammation and endotoxemia could represent a possible link between invasive dental treatment and increased risk of acute cardiovascular events. These findings indicate that invasive dental treatment (as simple as a single dental extraction) may impact negatively on clinical outcomes in dental patients, especially those with CAD.

Imaging the myocardial ischemic cascade

Non-invasive imaging plays a growing role in the diagnosis and management of ischemic heart disease from its earliest manifestations of endothelial dysfunction to myocardial infarction along the myocardial ischemic cascade. Experts representing the North American Society for Cardiovascular Imaging and the European Society of Cardiac Radiology have worked together to organize the role of non-invasive imaging along the framework of the ischemic cascade. The current status of non-invasive imaging for ischemic heart disease is reviewed along with the role of imaging for guiding surgical planning. The issue of cost effectiveness is also considered. Preclinical disease is primarily assessed through the coronary artery calcium score and used for risk assessment. Once the patient becomes symptomatic, other imaging tests including echocardiography, CCTA, SPECT, PET and CMR may be useful. CCTA appears to be a cost-effective gatekeeper. Post infarction CMR and PET are the preferred modalities. Imaging is increasingly used for surgical planning of patients who may require coronary artery bypass.

Comparison of Magnetic Resonance Analysis of Myocardial Scarring With Biomarker Release Following S-T Elevation Myocardial Infarction

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.

A correlative study of myocardial infarction scar characteristics by DE-MR and the Lown's classification of ventricular premature beats

OBJECTIVE

Correlation between myocardial infarction (MI) scar by cardiac magnetic resonance and the Lown's classification of ventricular premature beats (VPBs) is poorly understood. This study aims to investigate the correlation between the MI scar characteristics by delayed-enhancement magnetic resonance imaging (DE-MRI) and the Lown's classification of VPBs.

METHODS

Sixty-five patients, in the convalescence stage and consolidation phase of MI, were included in this retrospective study. All patient were divided into VPBs group (n = 39) and non-VPBs group (n = 26 patients) according to the clinical diagnostic criteria of Universal Definition of MI scar. VPBs patients were assigned to Lown's I-II group and Lown's III-IV subgroup in accordance with the Lown classification criteria. Cardiac function parameters and MI scar characteristics were detected by cardiac magnetic resonance (CMR) and DE-MRI, respectively.

RESULTS

Lown's classification was negatively correlated with left ventricular ejection fraction (LVEF), peak ejection rate (PER) and peak filling rate (PFR) (-0.724, -0.628, -0.559), and positively correlated with MI area, MI integral, MI segments number and left ventricular end systolic volume (LVESV) (0.673, 0.655, 0.586, and 0.514), respectively.CONCLUSIONSThe study indicated that MI area and MI integral were strongly associated with Lown's classification.

Stress Induced Cardiomyopathy Triggered by Acute Myocardial Infarction: A Case Series Challenging the Mayo Clinic Definition

Case series

Patient: Male, 56 • Female, 70 • Female, 55 • Female, 55

Final Diagnosis: Stress induced cardiomyopathy

Symptoms: Chest pain • shortness of breath

Medication:—

Clinical Procedure: Cardiac catheterization

Specialty: Cardiology

Contrast-enhanced cardiac Magnetic Resonance: distinction between cardiac sarcoidosis and infarction scar

Objectives: To review the value of delayed contrast-enhanced cardiac magnetic resonance (CECMR) in differentiating patients with cardiac sarcoidosis (CS) from those with coronary artery disease and recent myocardial infarctions. Background: Late gadolinium enhancement (LGE) accurately delineates myocardial necrosis or fibrosis. The pattern of LGE in ischemic and non-ischemic myocardial disease is different, and might be helpful in distinguishing CS from ischemic disease. Methods: The CECMR studies of 30 patients with CS were compared to those performed in 30 consecutive infarct patients, who had been managed with primary coronary interventions, and 10 healthy controls. Two experienced blinded observers classified patients by assessing the distribution of LGE. Results: LV LGE was present in 29/30 CS (mean 3.8 segments, range 0-12), all infarct (mean 4.3 segments, range 0-9), and none of the patients in the control group. The amount of LV LGE did not differ significantly between CS and infarct patients (19 ± 11% and 19 ± 12%, P= 0.8). The CS group exhibited a predominantly patchy, 3 layer LGE (P = 0.01), whereas confluent transmural LGE (P = 0.04) with a vascular distribution (P < 0.001) was prevalent in the infarct group. Significantly more RV LGE (P = 0.01) and dilation (P = 0.02) were found in the CS group. The two observers classified patients correctly as CS in 72% and 83% of cases, as ischemic in nature in 77% and 80% of cases, and as normal in 90% and 100% respectively. Conclusions: Gadolinium CMR was helpful in differentiating patients with CS from patients with ischemic heart disease and previous myocardial infarctions. In a subgroup of ischemic patients the pattern of LGE was atypical, and suggestive of non-ischemic etiology. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 307-314).

Myocardial Damage Detected by Late Gadolinium Enhancement Cardiac Magnetic Resonance Is Uncommon in Peripartum Cardiomyopathy

BACKGROUND

In peripartum cardiomyopathy, the prevalence of focal myocardial damage detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance is important to elucidate mechanisms of myocardial injury and cardiac dysfunction. LGE equates irreversible myocardial injury, but LGE prevalence in peripartum cardiomyopathy is uncertain.

METHODS AND RESULTS

Among 100 women enrolled within the Investigations of Pregnancy Associated Cardiomyopathy cohort, we recruited 40 women at 13 centers to undergo LGE cardiovascular magnetic resonance, enrolled within the first 13 weeks postpartum. Follow-up scans occurred at 6 months postpartum, and death/transplant rates at 12 months. Baseline characteristics did not differ significantly in the parent cohort according to cardiovascular magnetic resonance enrollment except for mechanical circulatory support. LGE was noted only in 2 women (5%) at baseline. While left ventricular dysfunction with enlargement was prevalent at baseline cardiovascular magnetic resonance scans (eg, ejection fraction 38% [Q1-Q3 31-50%], end diastolic volume index=108 mL/m² [Q1-Q3 83-134 mL/m²]), most women demonstrated significant improvements at 6 months, consistent with a low prevalence of LGE. LGE was not related to baseline clinical variables, ejection fraction, New York Heart Association heart failure class, or mortality. Neither of the 2 women who died exhibited LGE. LGE was inversely associated with persistent left ventricular ejection fraction at 6 months (P=0.006).

CONCLUSIONS

Factors other than focal myocardial damage detectable by LGE explain the initial transient depressions in baseline left ventricular ejection fraction, yet focal myocardial damage may contribute to persistent myocardial dysfunction and hinder recovery in a small minority. Most women exhibit favorable changes in ventricular function over 6 months.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01085955.

Congenital partial absence of the pericardium presenting with a rare concurrent abnormality of vascular ring diagnosed by cardiac magnetic resonance imaging

Congenital absence of the pericardium is a rare abnormality that can be diagnosed by cardiac imaging procedures. A 49-year-old male needed medical attention due to the appearance of palpitation with a systolic murmur, and a notable aortic arch deviation was seen in the chest X-ray. In the echocardiogram, a poor echo window was detected. A cardiac magnetic resonance imaging (MRI) showed a rare concomitant anomaly of partial absence of the pericardium including a rare defect of the right-sided aortic arch. Using cardiac MRI, the pericardium can be easily visualized, and thus, its absence more easily detected, aiding appropriate clinical decision-making.

The Use of Cardiac Magnetic Resonance in Patients with Suspected Coronary Artery Disease: A Clinical Practice Perspective

Cardiac magnetic resonance imaging (CMR) is a useful diagnostic imaging modality in patients with known or suspected coronary artery disease (CAD). It provides unique information not available from other modalities, however, it is complex. CMR is not a single technique. Instead, it consists of multiple distinct techniques and a lack of understanding of which techniques to perform and how to interpret the findings in combination limits its efficacy and widespread use. Conversely, its multiparametric nature can provide a comprehensive assessment with the potential for higher accuracy than is achievable by other modalities. Moreover, its ability to directly assess myopathic processes often contributes insights that change patient management. In this article we provide a brief technical overview and focus on specific clinical scenarios in patients with known or suspected CAD. We highlight the multiparametric nature of CMR and discuss cases which illustrate the unique information that CMR can contribute.

Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging?

Management of patients with acute chest pain remains challenging. Cardiac biomarker testing reduces the likelihood of erroneously discharging patients with acute myocardial infarction (AMI). Despite normal contemporary troponins, physicians have still been reluctant to discharge patients without additional testing. Nowadays, the extremely high negative predictive value of current high-sensitivity cardiac troponin (hs-cTn) assays challenges this need. However, the decreased specificity of hs-cTn assays to diagnose AMI poses a new problem as noncoronary diseases (eg, pulmonary embolism, myocarditis, cardiomyopathies, hypertension, renal failure, etc) may also cause elevated hs-cTn levels. Subjecting patients with noncoronary diseases to unnecessary pharmacological therapy or invasive procedures must be prevented. Attempts to improve the positive predictive value to diagnose AMI by defining higher initial cutoff values or dynamic changes over time inherently lower the sensitivity of troponin assays. In this review, we anticipate a potential changing role of noninvasive imaging from ruling out myocardial disease when troponin values are normal toward characterizing myocardial disease when hs-cTn values are (mildly) abnormal.

Contribution of various lipid profile parameters in determining creatine kinase-MB levels in unstable angina patients

Context:

In India, the correlation of severity of minor myocardial damage with dyslipidemia has rarely been studied in patients of unstable angina (UA). Dyslipidemia is proven to be a major risk factor for developing acute coronary syndrome (ACS) but still there is doubt about the type of lipoproteins involved in causing minor myocardial damage occurring in UA patients of ACS.

Aims:

The aim of our study was to find out the contribution of various types of lipoproteins to predict the severity of minor myocardial damage occurring in the patients of UA.

Settings and Design:

Correlation design was used for the study. A single group of individuals was selected. Data were collected on dependent variable creatine kinase-MB (CK-MB) and independent variables (lipid profile parameters).

Subjects and Methods:

The study comprised fifty patients admitted in cardiac care unit with typical history of UA with electrocardiogram showing no ST-segment elevation. The severity of myocardial damage was assessed from on admission CK-MB levels. The lipid profile was estimated from fasting blood samples of all the patients.

Statistical Analysis Used:

For the purpose of the study, Pearson correlation and multiple linear regression analysis methods were applied.

Results:

The triacylglycerol (TAG), very-low-density lipoprotein (VLDL), total cholesterol/high-density lipoprotein (TC/HDL) showed significant positive correlation whereas HDL was negatively correlating with CK-MB levels.

Conclusions:

The TAG, VLDL, and TC/HDL were found to be significantly affecting the severity of myocardial damage in the patients of UA.

Comparison of Low-Dose Higher-Relaxivity and Standard-Dose Lower-Relaxivity Contrast Media for Delayed-Enhancement MRI: A Blinded Randomized Crossover Study

OBJECTIVE

The gadolinium-based MRI contrast agent gadobenate dimeglumine has nearly twice the MR relaxivity of gadopentetate dimeglumine at 1.5 T. The purpose of this study was to determine whether a lower dose (0.1 mmol/kg) of gadobenate dimeglumine can be used to obtain delayed-enhancement MR images comparable to those obtained with a standard dose (0.2 mmol/kg) of gadopentetate dimeglumine.

SUBJECTS AND METHODS

In this blinded randomized crossover study, 20 patients with known myocardial infarction underwent two separate delayed-enhancement MRI examinations after receiving 0.1 mmol/kg gadobenate dimeglumine and 0.2 mmol/kg gadopentetate dimeglumine (random administration). The conspicuity of lesion enhancement 5, 10, and 20 minutes after contrast administration was quantified as relative enhancement ratio (RER).

RESULTS

With either gadolinium-based contrast agent, damaged myocardium had higher signal intensity than normal remote myocardium (RER > 4) on delayed-enhancement MR images, and the blood RER declined over time after contrast administration. The blood RER was not significantly higher for gadobenate dimeglumine than for gadopentetate dimeglumine at 5 and 10 minutes. Nevertheless, there was a larger reduction in blood RER for gadobenate dimeglumine than for gadopentetate dimeglumine between 5 and 10 minutes and between 10 and 20 minutes. The volumes of enhancement were similar for gadobenate dimeglumine (13.6 ± 8.8 cm(3)) and gadopentetate dimeglumine (13.5 ± 8.9 cm(3)) (p = 0.98). The mean difference in Bland-Altman analysis for delayed-enhancement volume between the agents was 0.1 cm(3).

CONCLUSION

Qualitatively and quantitatively, delayed-enhancement MR images of ischemic myocardium obtained with 0.1 mmol/kg gadobenate dimeglumine are comparable to those obtained with 0.2 mmol/kg gadopentetate dimeglumine 5, 10, and 20 minutes after contrast administration.