Left ventricular thrombosis following apical myocardial infarction: may CMR strain analysis tell us something?

Funding Acknowledgements

Type of funding sources: None.

Background

 Left ventricular thrombosis (LVT) is a possible complication following myocardial infarction (MI). Besides infarct size, risk factors for LVT include ST-elevated MI (STEMI), anterior and apical location, reduced left ventricular ejection fraction (LVEF) and the presence of microvascular obstruction. Echocardiography quantified myocardial strain has been associated with LVT following MI. Recently, global longitudinal strain, calculated with feature tracking (FT) - CMR, emerged as an independent predictor of major cardiovascular events following MI. Anyway, the relationship between abnormalities on FT-CMR and LVT following MI is still unexplored. Aim of our study is to investigate the possible association between abnormal strain on FT-CMR and LVT following apical STEMI.

Methods

 We performed a retrospective analysis including all patients with a previous apical STEMI, who underwent CMR at our Institute between August 2013 and October 2020. Patients with ongoing anticoagulant therapy were excluded. Differences in global and segmental strain on CMR between patients with and without LVT were tested in a propensity-matched sample, using LVEF, age, gender, time from MI diagnosis and number of LV segments with transmural late gadolinium enhancement (LGE) as covariates to assign propensity score. Furthermore, difference in terms of apical to global radial strain percentual deviation (AGD), calculated as [(Global Radial Strain – Apical Radial Strain)/Global Radial Strain] * 100, was tested. 

Results

 Of 356 patients with apical STEMI undergoing CMR at our center, 37 (10.4%) were diagnosed with LVT. After performing a propensity score matching, we obtained a sample of 36 pairs, with a mean age of 65 (SD 11) years, and a median EF of 35% (IQR 27-42); 59 (82%) of them were male. A significant difference in terms of apical radial strain was found between the two groups, with a median strain of 10.75 (IQR 6.8–16.5) in patients without LVT compared to a value of 5.25 (IQR 2.7–9-6) in patients with LVT (p = 0.007). No differences were found in terms of global longitudinal, radial and circumferential strain (p = 0.19, p= 0.2 and p= 0.49 respectively) and segmental circumferential and longitudinal strain. When considering the AGD parameter, a significant difference was found between the two groups, with a median deviation of 12% (IQR -20; +48) in patients without LVT and 51% (IQR +47; +75) in patients with LVT (p= 0.0003). Furthermore, an AGD value of 26% was found to be the most accurate in terms of sensitivity and specificity applying a Receiver Operating Characteristic (ROC) curve analysis (AUC 0.74; CI 0.62-0.85).

Conclusions

 Among patients with transmural MI involving LV apex, reduced apical radial strain on FT-CMR is associated with the presence of LV thrombosis. Furthermore, among patients developing LV thrombi, a greater apical radial strain deviation from the global one was found, with a threshold value of 26% at ROC curve analysis.

Left ventricular myocardial deformation abnormalities in arrhythmic mitral valve prolapse: which comes first?

Funding Acknowledgements

Type of funding sources: None.

Background. Arrhythmic mitral valve prolapse (MVP) is characterized by left ventricular (LV) fibrosis in the basal inferolateral wall and papillary muscles. We hypothesized that LV fibrosis are driven by excessive mechanical forces acting on myocardial susceptible cells, representing the last step in the MVP-induced myocardial stretch process. Purpose. We aimed to evaluate the LV myocardial deformation, using strain assessed with cardiac magnetic resonance (CMR), in arrhythmic MVP patients with normal LV ejection fraction (LVEF) and absent/trivial mitral regurgitation (MR) and its correlation with the presence of LV fibrosis, detected by late gadolinium enhancement (LGE) in post-contrast CMR images. Methods. We enrolled consecutive arrhythmic MVP patients with normal LVEF and no/trivial MR. Sixty-nine (39 female; median age: 40 years) patients without MVP, arrhythmias or cardiovascular history served as control group. All patients underwent CMR for identification of LGE and evaluation of LV myocardial deformation. Results. A total of 66 patients were enrolled (47 female; median age: 44 years). In the overall MVP population, LGE was present in 41 patients (62.1%). MVP patients without LGE (25 patients, 37.9%) presented a higher global radial (median: 42.19 vs 33; p: <0.0001) and higher global longitudinal strain (median: -21.61 vs -18.10; p: <0.0001), compared to the control group. A reduction of regional basal posterolateral radial (BPL median: 50.60 vs 67.30; p: 0.0015) and longitudinal strain (BPL median: -23.50 vs -26.70; p: 0.0186) were observed in the MVP patients as compared with controls (Figures A-D). Conversely to the basal region, mid anterolateral and posterolateral region presented a higher radial (MAL median: 52.60 vs 31.10; p: < 0.0001 and MPL median: 52.80 vs 21.50; p: < 0.0001) and longitudinal strain (MAL median: -24.80 vs -18.30; p: < 0.0001 and MPL median: -25.30 vs -14.80; p: < 0.0001), when compared to control group. MVP patients with LGE had a lower global radial (median: 36.48 vs 42.19; p: <0.0047), longitudinal (median: -19.18 vs -21.61; p: 0.0013) and circumferential strain (median: -17.80 vs -19.28; p: 0.0134) compared with those without fibrosis. According to MVP patients without LGE, the presence of fibrosis is associated with a lower regional radial (BAL median: 64.40 vs 82.80; p: 0.0481; MAL median: 42.60 vs 52.60; p: 0.0287) and circumferential strain (BAL median: -21.90 vs -24.20; p: 0.0174; BPL median: -16.80 vs -18.80; p: 0.0411; MPL median: -15.50 vs -19.40; p: 0.0077) in the LV basal-mid lateral walls (Figures E-I). Conclusions. Arrhythmic MVP patients with normal LV systolic function and absent/trivial MR presented an abnormal myocardial deformation pattern. The reduced strain in BPL wall of MVP patients without LGE could be considered as an early marker of MVP-induced myocardial stress, that could promote, time by time, LV fibrosis and arrhythmias in MVP patients.

Osteosynthesis of subtrochanteric fractures. A review of different methods

The authors analysed the long-term results of 72 subtrochanteric fractures treated surgically over a period of 13 years. The case material was subdivided according to type of fracture and method of osteosynthesis and the results were evaluated with a view to ascertaining the best method of treatment in each type of fracture. The best results were obtained with osteosynthesis using an angled nail plate.

Arthrography in the investigation of persistent pain after meniscectomy

The authors report 62 patients in whom arthrography of the knee had been performed because of persistent pain after menisectomy. In about 60% of the cases the interval between operation and arthrography was less than 18 months. The causes of residual pain identified by arthrography were divided into meniscal and extra meniscal. The most frequent findings were remnants of pathological meniscal tissue; lesions of the anterior cruciate ligament; synovial and chondral pathology. Thirty patients were checked by arthroscopy and were subjected to further operation. In 80% of these cases the arthrographic findings corresponded exactly with the operative findings. The writers confirm that arthrography is still a valid method of investigation in patients affected by persisting pain after meniscectomy.

The C-band pattern of a Ph− mutant of durum wheat

A mutation of the Ph gene which normally suppresses heterogenetic chromosome pairing was obtained in cultivar 'Cappelli' of Triticum turgidum L. em Morris et Sears var. durum. The chromosomes of 'Cappelli,' the Ph− mutant, and another 'Cappelli' line suspected to have a duplication of part of arm 5Bq (5BL) were C-banded. Compared with arm 5Bq of the parental cultivar, the 5Bq arm of the Ph− mutant was shorter owing to a deletion of one of two interband regions in the middle of the arm. In the line suspected to have a duplication, the 5Bq arm was longer than in 'Cappelli' and the interband region that was absent in Ph− was twice as long. An interchange between sister chromatids or homologous chromosomes is suggested to be responsible for the deletion and tandem duplication of the chromosome region. The C-band patterns are used to infer the approximate location of the Ph gene in the 5Bq arm.Key words: wheat, C-band, deletion, duplication, Triticum, 5B chromosome.

Evaluation of double contrast arthrography in pigmented villonodular synovitis of the knee

The authors report the arthrographic findings in 9 cases of diffuse villonodular pigmented synovitis of the knee in various phases of development before and after synovectomy. Arthrography was negative in only one case, while in the other cases the findings were significant but not pathognomonic.

Genetic analysis of tetraploid and hexaploid wheat by utilization of monopentaploid hybrids

This report deals with a method of analysis which uses existing hexaploid wheat monosomics to establish gene-chromosome associations in a tetraploid variety. Monosomics of Triticum aestivum cv. Chinese Spring belonging to the 14 lines of A and B genomes were crossed as female parents with Triticum durum cv. Capeiti, a spring type at present widely grown in Italy. For each line, two F 1 populations were obtained, normal pentaploids (2 n = 35) and monopentaploid (2 n = 34), in which, in turn, the monosomic A or B chromosome present was supplied by the tetraploid wheat. The morphological and physiological differences observed in the monopentaploid lines are attributed to differential expression of the genetic information concerning the character investigated, carried by the chromosome present in hemizygous condition. Then, only recessive or partially dominant alleles of the variety to be tested can be identified and attributed to a specific chromosome in the F 1 generation.Eight parameters were analyzed: culm and spike length, length and width of 1st (flag) and 2nd uppermost leaves, days from germination to heading and awn development.As far as culm length is concerned, although heterotic effect is present, seven chromosomes seem to be responsible for the modification of this character (1A, 2A, 2B, 3B, 4B, 5B, and 6 A); chromosomes 2A and 2B in particular, carry major factor (s) for plant height. A similar picture is presented by spike length which seems to be controlled by factors located in several chromosomes belonging to homoeologous groups 1, 2, 3 and 5, as well as the chromosome 4B.Leaf length, also, shows a complex pattern of inheritance. Monosomic conditions for chromosomes 1A and 1B increased, while monosomy for 5A and 5B significantly decreased, leaf length. A highly significant correlation was found between the mean lengths of the 1st and 2 nd leaves (= 0.74). Some monosomic lines (4A, 4B, 5A; 5B; 6A; 7A and 7B) had leaves significantly narrower than in the control and only monosomic 2A had broader leaves. The period from germination to heading seems to be influenced by at least 6 chromosomes. Three monosomic lines are significantly earlier (mono 1A, 7A and 5B) and three (mono 5A, 2B and 7B) are significantly later than the hybrid control.Finally, 8 monosomic lines were found to interfere significantly with awn development. Three lines (mono 2A, 2B and 7A) show a decrease and 5 (mono 1B; 3A, 3B; 4B and 6B) show an increase in awn development. On the basis of evidence in the literature and our own results, it appears that this analysis fits previous results perfectly and actually adds to the picture two further awn-promoting factors, A9 and A10, located on the 7A and 1B chromosomes respectively.