Months-long seismicity transients preceding the 2023 MW 7.8 Kahramanmaraş earthquake, Türkiye

Short term prediction of earthquake magnitude, time, and location is currently not possible. In some cases, however, documented observations have been retrospectively considered as precursory. Here we present seismicity transients starting approx. 8 months before the 2023 MW 7.8 Kahramanmaraş earthquake on the East Anatolian Fault Zone. Seismicity is composed of isolated spatio-temporal clusters within 65 km of future epicentre, displaying non-Poissonian inter-event time statistics, magnitude correlations and low Gutenberg-Richter b-values. Local comparable seismic transients have not been observed, at least since 2014. Close to epicentre and during the weeks prior to its rupture, only scarce seismic activity was observed. The trends of seismic preparatory attributes for this earthquake follow those previously documented in both laboratory stick-slip tests and numerical models of heterogeneous earthquake rupture affecting multiple fault segments. More comprehensive earthquake monitoring together with long-term seismic records may facilitate recognizing earthquake preparation processes from other regional deformation transients.

Aneurysmal growth in type-B aortic dissection: assessing the impact of patient-specific inlet conditions on key haemodynamic indices

Type-B aortic dissection is a cardiovascular disease in which a tear develops in the intimal layer of the descending aorta, allowing pressurized blood to delaminate the layers of the vessel wall. In medically managed patients, long-term aneurysmal dilatation of the false lumen (FL) is considered virtually inevitable and is associated with poorer disease outcomes. While the pathophysiological mechanisms driving FL dilatation are not yet understood, haemodynamic factors are believed to play a key role. Computational fluid dynamics (CFD) and 4D-flow MRI (4DMR) analyses have revealed correlations between flow helicity, oscillatory wall shear stress and aneurysmal dilatation of the FL. In this study, we compare CFD simulations using a patient-specific, three-dimensional, three-component inlet velocity profile (4D IVP) extracted from 4DMR data against simulations with flow rate-matched uniform and axial velocity profiles that remain widely used in the absence of 4DMR. We also evaluate the influence of measurement errors in 4DMR data by scaling the 4D IVP to the degree of imaging error detected in prior studies. We observe that oscillatory shear and helicity are highly sensitive to inlet velocity distribution and flow volume throughout the FL and conclude that the choice of IVP may greatly affect the future clinical value of simulations.

Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

Physician Modification of a Custom-Made Fenestrated Endograft By Closure of a Fenestration With Bovine Patch

PURPOSE

Ruptured mycotic pararenal aortic aneurysms are rare and serious condition that requires prompt treatment. Open surgery with aortic resection and in-situ or extra-anatomic reconstruction is the standard treatment. The aim of this technical note is to report urgent endovascular treatment using a readily available custom-made device (created for another patient), with a back-table modification using pericardium patch and a new fenestration.

TECHNIQUE

In preoperative measurements on centerline-based workstation, aortic diameter in proximal and distal landing zone and target vessel position matched the measurements of graft plan of custom-made device (CMD) besides left renal artery. To address current patient`s anatomy, closure of the nonsuitable fenestration with pericardial patch and creation of new fenestration (1 cm above and 1:15 hours posterior to original fenestration) for the respective target vessel have been performed. Postoperative computed tomography angiography (CTA) scan showed complete exclusion of aneurysm, perfused target vessels, and no endoleak. Under resistance-based antibiotic therapy, the patient was asymptomatic and showed normal infection parameters in blood samples postoperatively.

CONCLUSION

In the hands of an experienced endovascular aortic surgeon modification of a custom-made device is a quick and feasible technique in this emergency situation. Long-term follow-up must confirm the durability and reliability of this new technique.

CLINICAL IMPACT

The described technique of modification of a custom-made endograft can provide an alternative endovascular treatment option for urgent complex abdominal aortic pathologies. Compared to the current available treatment modalities, like physician modified endografts, off-the-shelf branched devices, parallel grafts and in-situ fenestration, it can save considerable time and provides reasonable sealing in ruptured cases. The technique offers a valuable add-on to the armamentarium of experienced endovascular physicians.

The Influence of Minor Aortic Branches in Patient-Specific Flow Simulations of Type-B Aortic Dissection

Type-B aortic dissection (TBAD) is a disease in which a tear develops in the intimal layer of the descending aorta forming a true lumen and false lumen (FL). Because disease outcomes are thought to be influenced by haemodynamic quantities such as pressure and wall shear stress (WSS), their analysis via numerical simulations may provide valuable clinical insights. Major aortic branches are routinely included in simulations but minor branches are virtually always neglected, despite being implicated in TBAD progression and the development of complications. As minor branches are estimated to carry about 7-21% of cardiac output, neglecting them may affect simulation accuracy. We present the first simulation of TBAD with all pairs of intercostal, subcostal and lumbar arteries, using 4D-flow MRI (4DMR) to inform patient-specific boundary conditions. Compared to an equivalent case without minor branches, their inclusion improved agreement with 4DMR velocities, reduced time-averaged WSS (TAWSS) and transmural pressure and elevated oscillatory shear in regions where FL dilatation and calcification were observed in vivo. Minor branch inclusion resulted in differences of 60-75% in these metrics of potential clinical relevance, indicating a need to account for minor branch flow loss if simulation accuracy is sought.

Measurements of Normalized Differential Cross Sections of Inclusive π^{0} and K_{S}^{0} Production in e^{+}e^{-} Annihilation at Energies from 2.2324 to 3.6710 GeV

Based on electron positron collision data collected with the BESIII detector operating at the BEPCII storage rings, the differential cross sections of inclusive π^{0} and K_{S}^{0} production as a function of hadron momentum, normalized by the total cross section of the e^{+}e^{-}→hadrons process, are measured at six center-of-mass energies from 2.2324 to 3.6710 GeV. Our results, which cover a relative hadron energy range from 0.1 to 0.9, significantly deviate from several theoretical calculations based on existing fragmentation functions.

Are biters sick? Health status of tail biters in comparison to control pigs

BACKGROUND

Tail biting is a multifactorial problem. As the health status is one of the factors commonly linked to tail biting, this study focuses on the health of identified biters. 30 (obsessive) biters are compared to 30 control animals by clinical and pathological examination as well as blood and cerebrospinal fluid samples. In that way, altogether 174 variables are compared between the groups. Moreover, connections between the variables are analysed.

RESULTS

In the clinical examination, 6 biters, but only 2 controls (P = 0.019) were noticeably agitated in the evaluation of general behaviour, while 8 controls were noticeably calmer (2 biters, P = 0.02). Biters had a lower body weight (P = 0.0007) and 13 biters had overlong bristles (4 controls, P = 0.008). In the pathological examination, 5 biters, but none of the controls had a hyperceratosis or inflammation of the pars proventricularis of the stomach (P = 0.018). However, 7 controls and only 3 biters were affected by gut inflammation (P = 0.03). In the blood sample, protein and albumin levels were below normal range for biters (protein: 51.6 g/l, albumin: 25.4 g/l), but not for controls (protein: 53.7 g/l, albumin: 27.4 g/l), (protein: P = 0.05, albumin: P = 0.02). Moreover, 14 biters, but only 8 controls had poikilocytosis (P = 0.05). Although not statistically different between groups, many animals (36/60) were affected by hypoproteinemia and hyponatremia as well as by hypokalemia (53/60) and almost all animals (58/60) had hypomagnesemia. For hypomagnesemia, significant connections with variables linked to tail damage and ear necrosis were detected (r_s/V/ρ ≥ 0.4, P ≤ 0.05).

CONCLUSION

The results suggest that behavioural tests might be helpful in identifying biters. Moreover, cornification and inflammation of the pars proventricularis is linked to becoming a biter. Furthermore, the results highlight the need for appropriate and adjusted nutrient and mineral supply, especially with regard to magnesium.

Observation of a New X(3872) Production Process e^{+}e^{-}→ωX(3872)

Using 4.7  fb^{-1} of e^{+}e^{-} collision data at center-of-mass energies from 4.661 to 4.951 GeV collected by the BESIII detector at the BEPCII collider, we observe the X(3872) production process e^{+}e^{-}→ωX(3872) for the first time. The significance is 7.8σ, including both the statistical and systematic uncertainties. The e^{+}e^{-}→ωX(3872) Born cross section and the corresponding upper limit at 90% confidence level at each energy point are reported. The line shape of the cross section indicates that the ωX(3872) signals may be from the decays of some nontrivial structures.

Evidence for the Cusp Effect in η' Decays into ηπ^{0}π^{0}

Using a sample of 4.3×10^{5} η^{'}→ηπ^{0}π^{0} events selected from the ten billion J/ψ event dataset collected with the BESIII detector, we study the decay η^{'}→ηπ^{0}π^{0} within the framework of nonrelativistic effective field theory. Evidence for a structure at π^{+}π^{-} mass threshold is observed in the invariant mass spectrum of π^{0}π^{0} with a statistical significance of around 3.5σ, which is consistent with the cusp effect as predicted by the nonrelativistic effective field theory. After introducing the amplitude for describing the cusp effect, the ππ scattering length combination a_{0}-a_{2} is determined to be 0.226±0.060_{stat}±0.013_{syst}, which is in good agreement with theoretical calculation of 0.2644±0.0051.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Study of the Semileptonic Decay Λ_{c}^{+}→Λe^{+}ν_{e}

The study of the Cabibbo-favored semileptonic decay Λ_{c}^{+}→Λe^{+}ν_{e} is reported using a 4.5  fb^{-1} data sample of e^{+}e^{-} annihilations collected at center-of-mass energies ranging from 4.600 GeV to 4.699 GeV with the BESIII detector at the BEPCII collider. The branching fraction of the decay is measured to be B(Λ_{c}^{+}→Λe^{+}ν_{e})=(3.56±0.11_{stat}±0.07_{syst})%, which is the most precise measurement to date. Furthermore, we perform an investigation of the internal dynamics in Λ_{c}^{+}→Λe^{+}ν_{e}. We provide the first direct comparisons of the differential decay rate and form factors with those predicted from lattice quantum chromodynamics (LQCD) calculations. Combining the measured branching fraction with a q^{2}-integrated rate predicted by LQCD, we determine |V_{cs}|=0.936±0.017_{B}±0.024_{LQCD}±0.007_{τ_{Λ_{c}}}.

Measurement of the Absolute Branching Fraction and Decay Asymmetry of Λ→nγ

The radiative hyperon decay Λ→nγ is studied using (10087±44)×10^{6}  J/ψ events collected with the BESIII detector operating at BEPCII. The absolute branching fraction of the decay Λ→nγ is determined to be (0.832±0.038_{stat}±0.054_{syst})×10^{-3}, which is a factor of 2.1 lower and 5.6 standard deviations different than the previous measurement. By analyzing the joint angular distribution of the decay products, the first determination of the decay asymmetry α_{γ} is reported with a value of -0.16±0.10_{stat}±0.05_{syst}.

Observation of an Isoscalar Resonance with Exotic J^{PC}=1^{-+} Quantum Numbers in J/ψ→γηη^{'}

Using a sample of (10.09±0.04)×10^{9}  J/ψ events collected with the BESIII detector operating at the BEPCII storage ring, a partial wave analysis of the decay J/ψ→γηη^{'} is performed. The first observation of an isoscalar state with exotic quantum numbers J^{PC}=1^{-+}, denoted as η_{1}(1855), is reported in the process J/ψ→γη_{1}(1855) with η_{1}(1855)→ηη^{'}. Its mass and width are measured to be (1855±9_{-1}^{+6})  MeV/c^{2} and (188±18_{-8}^{+3})  MeV, respectively, where the first uncertainties are statistical and the second are systematic, and its statistical significance is estimated to be larger than 19σ.

Observation of an a_{0}-like State with Mass of 1.817 GeV in the Study of D_{s}^{+}→K_{S}^{0}K^{+}π^{0} Decays

Using e^{+}e^{-} annihilation data corresponding to an integrated luminosity of 6.32  fb^{-1} collected at center-of-mass energies between 4.178 and 4.226 GeV with the BESIII detector, we perform the first amplitude analysis of the decay D_{s}^{+}→K_{S}^{0}K^{+}π^{0} and determine the relative branching fractions and phases for intermediate processes. We observe an a_{0}-like state with mass of 1.817 GeV in its decay to K_{S}^{0}K^{+} for the first time. In addition, we measure the ratio {B[D_{s}^{+}→K[over ¯]^{*}(892)^{0}K^{+}]/B[D_{s}^{+}→K[over ¯]^{0}K^{*}(892)^{+}]} to be 2.35_{-0.23stat}^{+0.42}±0.10_{syst}. Finally, we provide a precision measurement of the absolute branching fraction B(D_{s}^{+}→K_{S}^{0}K^{+}π^{0})=(1.46±0.06_{stat}±0.05_{syst})%.

The role of cardiac magnetic resonance-based feature-tracking strain analysis in the differential diagnosis and prognostic assessment of patients with left ventricular hypertrophy

Background

Cardiac magnetic resonance (CMR) examinations have an essential role in the diagnosis of myocardial diseases with left ventricular (LV) hypertrophy; however, limited data are available from CMR-based feature-tracking strain analysis in this patient population. The aim of our study was to investigate the differential diagnostic and prognostic importance of feature-tracking strain analysis in patients with LV hypertrophy caused by myocardial disease.

Methods

We investigated 404 patients who underwent CMR examination and were diagnosed with myocardial disease causing LV hypertrophy. Hypertrophic cardiomyopathy (HCM) was detected in 330 patients, cardiac amyloidosis (CA) in 46 patients, Fabry disease (FD) in 12 patients, and endomyocardial fibrosis (EMF) in 16 patients. LV strain analysis was performed with feature-tracking. Global longitudinal (GLS), circumferential (GCS) and radial (GRS) LV strain parameters were measured. Strain values for the six basal, six midventricular, and five apical segments were averaged to obtain regional longitudinal and circumferential strain values (basal LS, midventricular LS, apical LS, basal CS, midventricular CS, apical CS). The apex-to-base regional LS and CS ratios were calculated as apical LS/basal LS and apical CS/basal CS, respectively. To assess global dyssynchrony, mechanical dispersion (MD) was measured. The all-cause mortality of the patients was analyzed.

Results

In the differentiation of CA from HCM, GLS had the highest sensitivity with a cutoff of more than −23%, and basal LS and basal CS had the highest specificity with a cutoff of more than −16% and −38%, respectively (p<0.001). FD patients had the lowest longitudinal and circumferential MD values, meaning that compared to that of other patients with LV hypertrophy, global dyssynchrony is least pronounced in this patient population (p<0.01). EMF patients had impaired global and regional CS and the lowest apex-to-base CS and LS ratios. CA patients had the highest apex-to-base CS and LS ratios, suggestive of apical sparing (p<0.001). CA patients had the worst prognosis; the significant independent predictors of mortality were a diagnosis of CA, the LV stroke volume index and basal LS (p<0.01).

Conclusions

Myocardial diseases with left ventricular hypertrophy have remarkable differences in CMR-based strain characteristics which can be helpful in the differential diagnosis and provides incremental information on adverse outcomes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, Ministry for Innovation and Technology in Hungary

Precise Measurements of Decay Parameters and CP Asymmetry with Entangled Λ-Λ[over ¯] Pairs

Based on 10 billion J/ψ events collected at the BESIII experiment, a search for CP violation in Λ decay is performed in the difference between CP-odd decay parameters α_{-} for Λ→pπ^{-} and α_{+} for Λ[over ¯]→p[over ¯]π^{+} by using the process e^{+}e^{-}→J/ψ→ΛΛ[over ¯]. With a five-dimensional fit to the full angular distributions of the daughter baryon, the most precise values for the decay parameters are determined to be α_{-}=0.7519±0.0036±0.0024 and α_{+}=-0.7559±0.0036±0.0030, respectively. The Λ and Λ[over ¯] averaged value of the decay parameter is extracted to be α_{avg}=0.7542±0.0010±0.0024 with unprecedented accuracy. The CP asymmetry A_{CP}=(α_{-}+α_{+})/(α_{-}-α_{+}) is determined to be -0.0025±0.0046±0.0012, which is one of the most precise measurements in the baryon sector. The reported results for the decay parameter will play an important role in the studies of the polarizations and CP violations for the strange, charmed and beauty baryons.

First Observation of the Direct Production of the χ_{c1} in e^{+}e^{-} Annihilation

We study the direct production of the J^{PC}=1^{++} charmonium state χ_{c1}(1P) in electron-positron annihilation by carrying out an energy scan around the mass of the χ_{c1}(1P). The data were collected with the BESIII detector at the BEPCII collider. An interference pattern between the signal process e^{+}e^{-}→χ_{c1}(1P)→γJ/ψ→γμ^{+}μ^{-} and the background processes e^{+}e^{-}→γ_{ISR}J/ψ→γ_{ISR}μ^{+}μ^{-} and e^{+}e^{-}→γ_{ISR}μ^{+}μ^{-} is observed by combining all the data samples. The χ_{c1}(1P) signal is observed with a significance of 5.1σ. This is the first observation of a C-even state directly produced in e^{+}e^{-} annihilation. The electronic width of the χ_{c1}(1P) resonance is determined to be Γ_{ee}=(0.12_{-0.08}^{+0.13})  eV, which is of the same order of magnitude as theoretical calculations.

Evidence for a Neutral Near-Threshold Structure in the K_{S}^{0} Recoil-Mass Spectra in e^{+}e^{-}→K_{S}^{0}D_{s}^{+}D^{*-} and e^{+}e^{-}→K_{S}^{0}D_{s}^{*+}D^{-}

We study the processes e^{+}e^{-}→K_{S}^{0}D_{s}^{+}D^{*-} and e^{+}e^{-}→K_{S}^{0}D_{s}^{*+}D^{-}, as well as their charge conjugated processes, at five center-of-mass energies between 4.628 and 4.699 GeV, using data samples corresponding to an integrated luminosity of 3.8  fb^{-1} collected by the BESIII detector at the BEPCII storage ring. Based on a partial reconstruction technique, we find evidence of a structure near the thresholds for D_{s}^{+}D^{*-} and D_{s}^{*+}D^{-} production in the K_{S}^{0} recoil-mass spectrum, which we refer to as the Z_{cs}(3985)^{0}. Fitting with a Breit-Wigner line shape, we find the mass of the structure to be (3992.2±1.7±1.6)  MeV/c^{2} and the width to be (7.7_{-3.8}^{+4.1}±4.3)  MeV, where the first uncertainties are statistical and the second are systematic. The significance of the Z_{cs}(3985)^{0} signal is found to be 4.6σ including both the statistical and systematic uncertainty. We report the Born cross section multiplied by the branching fraction at different energy points. The mass of the Z_{cs}(3985)^{0} is close to that of the Z_{cs}(3985)^{+}. Assuming SU(3) symmetry, the cross section of the neutral channel is consistent with that of the charged one. Hence, we conclude that the Z_{cs}(3985)^{0} is the isospin partner of the Z_{cs}(3985)^{+}.

Observation of Resonance Structures in e^{+}e^{-}→π^{+}π^{-}ψ_{2}(3823) and Mass Measurement of ψ_{2}(3823)

Using a data sample corresponding to an integrated luminosity of 11.3  fb^{-1} collected at center-of-mass energies from 4.23 to 4.70 GeV with the BESIII detector, we measure the product of the e^{+}e^{-}→π^{+}π^{-}ψ_{2}(3823) cross section and the branching fraction B[ψ_{2}(3823)→γχ_{c1}]. For the first time, resonance structure is observed in the cross section line shape of e^{+}e^{-}→π^{+}π^{-}ψ_{2}(3823) with significances exceeding 5σ. A fit to data with two coherent Breit-Wigner resonances modeling the sqrt[s]-dependent cross section yields M(R_{1})=4406.9±17.2±4.5  MeV/c^{2}, Γ(R_{1})=128.1±37.2±2.3  MeV, and M(R_{2})=4647.9±8.6±0.8  MeV/c^{2}, Γ(R_{2})=33.1±18.6±4.1  MeV. Though weakly disfavored by the data, a single resonance with M(R)=4417.5±26.2±3.5  MeV/c^{2}, Γ(R)=245±48±13  MeV is also possible to interpret data. This observation deepens our understanding of the nature of the vector charmoniumlike states. The mass of the ψ_{2}(3823) state is measured as (3823.12±0.43±0.13)  MeV/c^{2}, which is the most precise measurement to date.

Observation of a State X(2600) in the π^{+}π^{-}η' System in the Process J/ψ→γπ^{+}π^{-}η'

Based on (10087±44)×10^{6}  J/ψ events collected with the BESIII detector, the process J/ψ→γπ^{+}π^{-}η^{'} is studied using two largest decay channels of the η^{'} meson, η^{'}→γπ^{+}π^{-} and η^{'}→ηπ^{+}π^{-}, η→γγ. A new resonance, which we denote as the X(2600), is observed with a statistical significance larger than 20σ in the π^{+}π^{-}η^{'} invariant mass spectrum, and it has a connection to a structure around 1.5  GeV/c^{2} in the π^{+}π^{-} invariant mass spectrum. A simultaneous fit on the π^{+}π^{-}η^{'} and π^{+}π^{-} invariant mass spectra with the two η^{'} decay modes indicates that the mass and width of the X(2600) state are 2618.3±2.0_{-1.4}^{+16.3}  MeV/c^{2} and 195±5_{-17}^{+26}  MeV, where the first uncertainties are statistical, and the second systematic.

The effect of implantable cardioverter defibrillator in patients with cardiac resynchronizational therapy and diabetes mellitus

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): (NKFIA; NVKP_16-1-2016-0017 National Heart Program).

Background

Heart failure (HF) and diabetes mellitus (DM) are common causes of death on their own, but the coexistance of these two diseases are especially fatal. 1 In DM, sudden cardiac death (SCD) is more common than in non-DM patients, however in many cases, implantable cardioverter defibrillator (ICD) could not prevent SCD. 2

Purpose

Our aim is to decide which device warrant higher life expectancy, cardiac resynchronizational therapy with or without defibrillator.

Methods

We examined retrospectively 2525 CRT implanted patients, with a mean follow-up time of 4.6 years. Implantaions were based on the current guidelines. The primary endpoint was all-cause mortality, while our composite end-point were all-cause mortality and heart failure hospitalization.

Results

In our population, 928 people (36%) had diabetes. We did not find statistical differences between age (68 vs. 68 years; p<0.099), gender (26% women, 23% women; p<0.08) LVEF (28% vs. 29% p<0.1425), incidence of atrial fibrillation (37% vs. 38%; p<0.76), implantation of an ICD (53% vs. 54%; p<0.847), NT-proBNP median levels (2939 pg/ml vs. 2778 pg/ml; p<0.35), and NYHA I (0,5% vs. 0,5%; p<0.898), and NYHA IV stadium (11% vs. 11%; p<0,82). However DM patients had higher BMI (28 kg/m2 vs. 26 kg/m2; p<0.001), lower eGFR levels (57 ml/min/1,73m2 vs. 60 ml/min/1,73m2; p<0.011) higher prevalence of hypertonia (82% vs. 66%; p<0.001), NYHA III stadium (39% vs. 33%; p<0,0008), ischemic etiology (56% vs. 44%; p<0.001), previous acute myocardial infartion (42,9% vs. 36%; p<0.001), a percutan coronaria intervention (35% vs. 25%; p<0.001) compared to non-DM patients. Those patients with DM showed a 25% higher risk of all-cause mortality (HR 1.25; 95% CI 1.12-1.40; p‹0.01) then non-DM patientes, also observable after adjusting for relevant clinical covariates such as age, gender, atrial fibrillation and the addition of an ICD (HR 1.17; 95% CI 1.06-1.31; p‹0.01).

Conclusions

Adding an ICD for CRT patients with diabetes reduces the risk of all-cause mortality significantly by 32% (HR 0,68; CI 0,56-0,82; p‹0.001) during the first six years but diminished on longer follow-up time (HR 0,95; CI 0,80-1,12; p=0,54).

Impact of morphine use on mortality in STEMI patients treated with primary PCI – results from a new registry

Background

Opioids decrease the effect of P2Y12 receptor inhibitors in vitro and observational reports suggest that morphine use may be associated with larger infarct size. Our research group showed previously, using a prospective single-centre registry, that periprocedural morphine use may have no impact on long-term mortality in STEMI patients treated with primary PCI and clopidogrel.

Purpose

We aimed to study this in vitro interaction on clinical outcomes in patients who were predominantly treated with the novel P2Y12 inhibitors prasugrel or ticagrelor, according to the current guidelines.

Methods

From May 2020 through February 2021, we collected demographic, anamnestic, procedural and laboratory data of 297 consecutive STEMI cases who were treated with primary PCI at our tertiary centre. Of them 126 patients (42.4%) received IV morphine during the periprocedural period. Outcome measure was time to all-cause mortality. The median follow-up time was 147 days (IQR 71–242 days), with 39 events. To adjust for confounding, a 1:1 propensity score-matching analysis (PSM) was performed using 186 cases. Absolute difference in survival was analysed using Kaplan-Meier survival curves and the logrank test, whereas the relative change was assessed by univariable Cox regression.

Results

An adequate balance on baseline covariates was achieved by the propensity score-matching. Kaplan-Meier analysis showed no statistically significant difference in all-cause mortality of the treatment groups neither in the original nor in the propensity score-matched population (p=0.220 and 0.762 respectively). In the matched population we found no difference in survival as the HR (Morphine/No Morphine) was 0.88 (95% confidence interval [CI]: 0.39–2.00), p=0.76.

Conclusion

Our preliminary data suggest that morphine may have no impact on mortality in STEMI patients treated with primary PCI and medical therapy according to the current guidelines including novel P2Y12 antagonists.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The research was supported by the Ministry of Innovation and Technology NRDI Office within the framework of the Artificial Intelligence National Laboratory Program. Kaplan-Meier curves: Original populationKaplan-Meier curves: PSM population

The role of feature-tracking strain analysis in the differentiation of cardiac amyloidosis from hypertrophic cardiomyopathy

 

Cardiac magnetic resonance (CMR) examinations have an essential role in the differentiation of cardiac involvement of amyloidosis (CA) from hypertrophic cardiomyopathy (HCM). The CMR diagnosis is traditionally based on morphologic features and the pattern of late gadolinium enhancement (LGE). However, in patients contraindicated for contrast agent administration, the diagnosis can be challenging. Novel CMR techniques, including strain analysis, can help in the differentiation of these patients.

The aim of our study was to investigate the differential diagnostic and prognostic importance of feature-tracking strain analysis in patients with left ventricular hypertrophy caused by CA or HCM.

We investigated 89 HCM patients (48 males; 50±18 years) and 46 CA patients (29 males; 64±10 years) who underwent CMR examination. The left ventricular ejection fraction (LVEF), volumes (end-diastolic volume: LVEDV, end-systolic volume: LVESV, stroke volume: LVSV), mass (LVM), and the amount of LGE were quantified. Global longitudinal (GLS), circumferential (GCS) and radial (GRS) LV strain parameters, and basal, midventricular, and apical LS and CS were measured. The apex-to-base regional LS and CS ratios were calculated. The all-cause mortality of the patients was analyzed. The characteristics of groups were compared with an independent t-test or Mann-Whitney test, as appropriate. ROC curve analysis was performed to analyze the diagnostic accuracy of a parameter and to identify optimal cutoff values. The prognostic value of CMR parameters was assessed with Cox proportional hazard regression analyses. Survival probability was analyzed with Kaplan-Meier curves and compared by the log-rank test.

CA patients had significantly lower LVEF (51±11 vs. 63±8%; p<0.0001), lower LVSVi (43±12 vs. 54±12 ml/m2; p<0.0001), higher LVMi (94±24 vs. 79±24 g/m2; p<0.001), higher amount of LGE (29±15 vs. 8±8%; p<0.0001), and more impaired global and regional strain values (GRS: 55±22 vs. 93±29%; GCS: −33±10 vs. −42±8%; GLS: −18±4 vs. −25±6%; basal CS: −26±9 vs. −39±7%; basal LS: −15±4 vs. −22±6%; p<0.0001) than HCM patients. The apex-to-base CS and LS ratios were higher in CA patients, suggestive of apical sparing (1.71±0.68 vs. 1.29±0.33; p<0.0001; 1.88±0.76 vs. 1.57±0.62; p<0.05; respectively). In the differentiation of CA and HCM, LGE, basal CS, basal LS, GRS, and GLS had the highest diagnostic accuracies (AUCs: 0.911, 0.866, 0.848, 0.859, 0.849). During the mean 2.1±2.0 years of follow-up, three HCM patients (3.4%) and 29 CA patients (63%) died (p<0.0001). The significant independent predictors of mortality were a diagnosis of CA, LVSVi and basal LS.

Our results show that CMR-based strain analysis might be a useful method for differentiating cardiac involvement of amyloidosis from HCM. Furthermore, this technique provides additional information for the assessment of prognosis in this patient population.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Research, Development and Innovation Office of Hungary; Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University

In-hospital and mid-term outcome after complex endovascular aortic repair with fenestrated and branched stent-grafts

Objective

The aim of the study is to evaluate in-hospital and mid-term outcome after complex endovascular aortic repair with fenestrated and branched stent-grafts (fEVAR / bEVAR).

Methods

This is a single-center retrospective analysis from a prospectively collected database of all patients treated electively with fEVAR or bEVAR for para/suprarenal (PAA) and thoraco-abdominal aortic aneurysm (TAAA) between September 2010 and June 2019. In-hospital and mid-term mortality, major adverse events and re-interventions were assessed.

Results

Fifty-one patient (84% male) with a mean age of 74±7 years were analysed. Eighteen patients (35%) had TAAA, four patients (8%) suprarenal, and 29 patients (57%) pararenal aortic aneurysms. Mean aneurysm diameter was 64±8 mm. Thirty-eight patients (75%) underwent fEVAR and 13 patients (25%) bEVAR. A total of 157 target vessels were incorporated: 22 celiac trunks (CT), 40 superior mesenteric arteries (SMA), 92 renal arteries (RA), two separate hepatic arteries and one splenic artery. No in-hospital death or stroke was recorded. One patient suffered from early postoperative paraplegia and did not recover and one had paraparesis after 38 days and recovered completely. Six patients (12%) with patent renal arteries experienced acute postoperative kidney injury; one required temporary dialysis. Five in-hospital re-interventions were stent-graft related (four bridging stents angioplasty and one iliac leg extension) and seven re-interventions were not stent-graft related.

Mean follow-up was 19±17 months. Eleven patients (22%) died during follow-up: nine were not aortic-related and two were unknown. The Kaplan-Meier estimated survival rates at 1 and 2 years were 81% and 77%, respectively. Five renal stents (5%, 5/92) occluded during follow-up: three were successfully recanalized and two remained occluded. Ten stents (three CT, five SMA, and two RA stents required relining after 13±16 months postoperatively, resulting with estimated primary assisted patency at 2 years of 100%, 100%, 93%, and 95% for the CT, SMA, right RA and left RA, respectively.

Conclusion

Complex endovascular aortic repair with fEVAR / bEVAR for PAA and TAAA is safe with very low early mortality and morbidity. In-stent stenosis/occlusions occurred within the first two years. However, primary assisted patency was high. A surveillance program to detect potential stent-graft related complications is mandatory.

Impact of morphine use on mortality in STEMI patients treated with primary PCI - preliminary data from a new registry

Funding Acknowledgements

Type of funding sources: None.

Background

Opioids decrease the effect of P2Y12 receptor inhibitors in vitro and observational reports suggest that morphine use is associated with larger infarct size. Our research group presented previously, using a prospective single-center registry, that periprocedural morphine use may have no impact on long-term mortality in STEMI patients treated with primary PCI and clopidogrel.

Purpose

Our purpose is to check this interaction using a new registry of patients treated according to the current guidelines, including novel antiplatelet agents.

Methods

From May until November 2020, we collected 196 STEMI patients treated with primary PCI. 88 (44.9%) of them got morphine during the prehospital and periprocedural care. Baseline demographic, anamnestic, procedural, and laboratory data were collected. Survival data were analysed using Kaplan-Meier survival curves and the log-rank test. To adjust for confounding, a 1:1 propensity score-matching analysis was performed using 114 cases.

Results

An adequate balance on baseline covariates was achieved during propensity score-matching. Kaplan-Meier analysis showed no difference in 30-days mortality of the patients treated with or without morphine neither in the original nor in the propensity score-matched population (p = 0.094 and p = 0.309, respectively).

Conclusion

Our preliminary data suggest that morphine may have no impact on mortality in STEMI patients treated with primary PCI and medical therapy according to the current guidelines including novel P2Y12 antagonists.

Abstract Figure. Kaplan-Meier curves

Tissue characteristics of the athlete"s heart: differentiation of physiological and pathological hypertrophy using parametric T1 and T2 mapping

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Fund of Hungary

Background

Intensive physical exercise leads to structural and functional cardiac adaptation termed athlete’s heart. Cardiac magnetic resonance (CMR) has an important role in the differentiation of physiological adaptation and pathological conditions. Beside the precise measurement of the ventricular volumes, mass, and function, it provides tissue specific information. Recently, native T1 mapping technique has been applied as a non-contrast method to detect myocardial fibrosis. Previous studies suggested that native T1 mapping can identify myocardial pathology before other CMR imaging techniques. T2 mapping values are elevated in case of myocardial edema.

Purpose

The aim of our study was to investigate the differences in CMR characteristics especially the native T1 and T2 mapping values of highly trained healthy athletes, healthy controls and patients with hypertrophic cardiomyopathy (HCM).

Methods

A total of 43 healthy athletes (water polo, swimming, football, 22 ± 8 training hours/week), 27 non-athlete healthy control and 25 HCM patients were involved in the study. Our inclusion criteria were: age >18 years,  in the athlete group >7 training hours per week . We evaluated the left ventricular (LV) end-systolic, end-diastolic (EDVi) and stroke volume (SVi) index, mass index (LVMi), ejection fraction (EF) and maximal end-diastolic wall thickness (EDWT). In a basal short axis slice the native T1 and T2 mapping values were evaluated.

Results

Athletes had significantly higher LV volumes compared to the control and HCM group (LVEDVi 114 ± 13 vs. 86 ± 11; 84 ± 15  ml/m2, LVSVi 64 ± 7 vs. 51 ± 7; 54 ± 10 ml/m2, respectively, p < 0.0001). HCM patients had the highest LVMi (72 ± 14 g/m2) and EDWT (18 ± 4 mm) compared to athletes and controls, athletes had higher LVMi (60 ± 11 vs. 42 ± 8 g/m2) and EDWT (10 ± 2 vs. 8 ± 1 mm) compared to the controls (p < 0.001). The native T1 mapping values differed significantly in the three groups, athletes had the lowest, HCM patients had the highest T1 values (athletes: 956 ± 19 ms, controls: 971 ± 20 ms, HCM patients: 993 ± 39 ms; p < 0.0001). There was no difference in the T2 mapping values between athletes and controls (44 ± 2 vs. 43 ± 2 ms), HCM patients had higher T2 values (45 ± 2 ms) compared to the other two groups (p < 0.01).

Conclusion

Intensive and regular training may lead to tissue specific changes of the myocardium. T1 and T2 mapping are potentially useful tools for differentiating between athlete"s heart and patients with hypertrophic cardiomyopathy.

Abstract Figure. T1 mapping in HCM and athlete

Diagnostic and prognostic impact of cardiac magnetic resonance, including scar quantification and strain imaging in patients with malignant ventricular arrhythmias and nonobstructed coronary arteries

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, National Research, Development and Innovation Office

Background

In case of malignant ventricular arrhythmias (VA) and nonobstructed coronary arteries, the differential diagnosis of the  underlying diseases is still challenging, due to the board spectrum of possible causes. Cardiac magnetic resonance (CMR) provides functional, morphological and tissue specific information, including necrotic and scar-tissue. 

Aims

  We aimed to assess the diagnostic and prognostic implications of CMR parameters including global strain values and myocardial scar in patients after ventricular fibrillation (VF) or sustained ventricular tachycardia (SVT) and nonobstructed coronary arteries.

Methods

Between 2011 and 2019, 99 patients (42 ±17 years, 54 male) presenting with VF or SVT and nonobstructed coronary arteries, who underwent CMR examination before secondary prevention implantable cardioverter defibrillator (ICD) implantation were included in our study. Post-processing included feature-tracking strain analysis and left ventricular (LV) scar quantification. Patients were followed for the combined endpoint of all-cause-mortality and appropriate ICD therapy.

Results

CMR examination proved structural myocardial disease in 72%: dilated (n = 21), arrhythmogenic (n = 11), hypertrophic cardiomyopathy (n = 7) and other cardiomyopathies (n = 3). We found LGE patterns showing chronic myocardial infarction (n = 4), suggesting chronic myocarditis (n = 4) and aspecific nonischemic scar formation (n = 14). In 7 cases aspecific structural alterations without scar formation were detected. Overall, myocardial scar was found in 52%, with an average extent of 12 ± 8% of the LV myocardium. The CMR examination changed the clinical diagnosis in 55% of the patients.  During a median follow-up at 2 years, 6 patients died and 42 experienced appropriate ICD therapy. We found an association between cardiac events and the presence of structural abnormality and myocardial scar (logrank: 4,553, p < 0.05 and 8.375, p <0.01).  On Cox proportional-hazards modell LV ejection fraction, LV stroke volume index, the presence of structural abnormality, the presence and extent of  myocardial scar, global LV strain parameters including longitudinal and circumferential strain, and a global left ventricular dssynchrony parameter (mechanical dispersion) were univariate predictors of the combined endpoint of all-cause-mortality and appropriate ICD therapy(p < 0.05). 

Conclusion

CMR performed in patients after malignant VA and nonobstructed coronary arteries not only establishes the diagnosis in a high proportion of patients, but may also provide additional prognostic factors. This may indicate that CMR could play a complementary role in the risk stratification in this patient population.

Abstract Figure.

Economic evaluation of adjuvant trastuzumab emtansine in patients with HER2-positive early breast cancer and residual invasive disease after neoadjuvant taxane and trastuzumab-based treatment in Canada

Background

In the katherine trial, adjuvant trastuzumab emtansine [T-DM1, Kadcyla (Genentech, South San Francisco, CA, U.S.A.)], compared with trastuzumab, significantly reduced the risk of recurrence or death by 50% (unstratified hazard ratio: 0.50; 95% confidence interval: 0.39 to 0.64; p < 0.0001) in patients with her2-positive early breast cancer (ebc) and residual invasive disease after neoadjuvant systemic treatment. A cost-utility evaluation, with probabilistic analyses, was conducted to examine the incremental cost per quality-adjusted life-year (qaly) gained associated with T-DM1 relative to trastuzumab, given the higher per-cycle cost of T-DM1.

Methods

A Markov model comprising a number of health states was used to examine clinical and economic outcomes over a lifetime horizon from the Canadian public payer perspective. Patients entered the model in the invasive disease-free survival (idfs) state, where they received either T-DM1 or trastuzumab. Transition probabilities between the health states were derived from the katherine trial, Canadian life tables, and published literature from other relevant clinical trials (emilia, cleopatra, and M77001). Resource use, costs, and utilities were derived from katherine, other clinical trials, published literature, provincial fee schedules, and clinical expert opinion. Sensitivity analyses were conducted for key assumptions and model parameters.

Results

Compared with trastuzumab, adjuvant T-DM1 was associated with a cost savings of $8,300 per patient and a 2.16 incremental qaly gain; thus T-DM1 dominated trastuzumab. Scenario analyses yielded similar results, with T-DM1 dominating trastuzumab or producing highly favourable incremental cost-utility ratios of less than $10,000 per qaly.

Conclusions

Adjuvant T-DM1 monotherapy is a cost-effective strategy compared with trastuzumab alone in the treatment of patients with her2-positive ebc and residual invasive disease after neoadjuvant systemic treatment.

Structural and functional cardiac changes after transplantation: experiences of the first year of the prospective Heart-TIming CMR substudy

Background

In case of heart transplantation (HTX) the heart is affected by several factors e.g. ischaemia/reperfusion, denervation, immunosuppression. During the adaptation, the heart may show marked temporal changes in terms of myocardial mechanics, function and tissue characteristics. To better understand cardiac temporal characteristics after orthotopic bicaval HTX we started the prospective Heart-TIming (Transplantation Imaging) trial in January 2018.

Purpose

In our CMR substudy we aimed to evaluate the physiological structural and functional left and right ventricular characteristics and their temporal changes after HTX using cardiac magnetic resonance.

Methods

As part of the study HTX patients underwent CMR at one, three, six and twelve months after HTX (n=49; 53±11y, 39 male). Cine images, T2-weighted, native T1 and T2 mapping, late gadolinium enhancement (LGE) and adenosine stress perfusion (at 1 and 12 month) images were acquired. In order to describe physiological characteristics of the transplanted heart we excluded pts with significant coronary artery disease, ischaemic scar, ≥Grade II allograft rejection from this present study (n=9). We evaluated the left (LV) and right ventricular (RV) ejection fractions (EF), volumes, masses (M) and the global LV strain values: longitudinal (GLS), circumferential (GCS) strain and the standard deviation (SD) of the peak longitudinal strain (LS) and the mechanical dispersion. In a basal short axis slice the native T1 and T2 mapping values were evaluated. We compared baseline CMR parameters to age and gender matched healthy controls (n=20; 48±10y, 16 male), and analyzed the temporal changes after HTX.

Results

Comparing the HTX patients' CMR parameters at one month with normal controls, HTX patients had lower end-diastolic volumes (LVEDVi: 74±15 vs 89±13 ml/m2; RVEDVi: 72±16 vs 89±15 ml/m2 p&lt;0.05), stroke volumes (LVSVi: 45±7 vs 55±8 ml/m2, RVSVi: 43±8 vs 54±8 ml/m2, p&lt;0.0001), higher LVMi (63±2 vs 55±3 g/m2, p&lt;0.05), increased SD of peak LS (14±2 vs 10±2, p&lt;0.0001) and more pronounced mechanical dispersion (18±5 vs 12±4, p&lt;0.0001). The native T1 mapping values were significantly higher in HTX pts (1007±40 vs 975±24 ms, p&lt;0,01). Examining temporal changes in HTX pts we found a decrease in LVMi (66±14 vs 59±10 g/m2, p&lt;0.01) already at three months. At 12 months LVMi decreased further, less negative GLS (−25±4 vs −20±4, p&lt;0.01) and GCS (−38±7 vs −34±4, p&lt;0.05), and lower SD of the peak LS (14±2 vs 11±2, p&lt;0.01) were measured.

Conclusions

Understanding the temporal changes of cardiac mechanics, function and tissue characteristics, furthermore the establishment of physiological values may help in the early, noninvasive identification of pathological changes in HTX pts.

Tissue specific information in HTX pts

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. Supported by the ÚNKP-18-3-IV New National Excellence Program of Human Capacities.

Safety and efficacy of different arterial pressure bandages following percutaneous coronary interventions from radial access: preliminary data of the RAD-PRESS trial

Background

The overwhelming majority of diagnostic coronary angiographies and percutaneous coronary interventions (PCIs) are performed via radial access as recommended by the current European revascularization guidelines. Using dedicated pressure bandages for the radial access site in high-volume centres can be a significant part of the budget of catheterization laboratories, therefore we developed a cost-effective pressure bandage utilizing wrapped empty glass vials of intravenous medications. Furthermore, compression time of the radial puncture site following PCI is a predictor of radial artery occlusion, therefore shortening the period of compression to as short as possible is feasible.

Purpose

Our aim was to validate efficacy and safety of our cost-effective pressure bandage by comparing it to two dedicated devices, as well as reducing length of compression to as short as possible.

Methods

We designed the RAD-PRESS trial, major inclusion criteria of which were first puncture of a radial artery with a diameter greater than 1.8mm, PCI performed as per guidelines utilizing a 6 French guiding catheter and age below 80 years. Patients were then randomized to receive one of three pressure bandages: the glass vial, Seal-One or the gold standard TR-band. Release of pressure was performed as fast as possible in 10-minute steps, and guided by pulse oximetry. Hematoma formation was thoroughly checked for all patients and categorized using the Easy scale. Radial artery patency was investigated by ultrasound 24 hours after final removal of the bandage. The data of 40 patients of every group was analysed.

Results

Population characteristics were similar among the groups. Length of compression time (126±10, 142±11 and 144±11 mins for Vial, Seal-One and TR-band, respectively, p&gt;0.05), hematoma formation (Easy Grade 1 in 17.5%, 15.0% and 10.0%, Easy Grade 2 in 5.0%, 7.5% and 7.5% for Vial, Seal-One and TR-band, respectively, all p&gt;0.05) were not significantly different among the groups. Radial artery occlusion occurred in only 2 patients (Vial and TR-Band groups), accounting for 1.7% of the cases.

Conclusions

The cost-effective wrapped vial strategy to compress the radial puncture site was comparable to both Seal-One and the gold standard TR-band regarding safety and efficacy. Furthermore, compression time could be safely shortened to approximately 2.5 hours.

Funding Acknowledgement

Type of funding source: None

The diagnostic value of cardiac magnetic resonance in athletes with suspected structural myocardial diseases

Introduction

Sudden cardiac death (SCD) is the leading cause of death in athletes occurring usually during intensive training. Cardiac magnetic resonance (CMR) is a reliable technique to assess ventricular volumes and function. Furthermore, it provides tissue-specific information and has a crucial role in detecting structural myocardial diseases.

Aim

We aimed to investigate the prevalence of myocardial structural heart diseases and the etiology of sudden cardiac death in highly trained athletes and their outcome during follow-up.

Method

We examined athletes (training ≥6 hours/week) who underwent CMR due to suspected structural myocardial disease at Semmelweis University Heart and Vascular Center between 2009 and 2019. Cine movie images and late gadolinium enhanced (LGE) images were performed. Athletes with structural myocardial alterations were followed for the endpoint of all-cause-mortality.

Results

CMR was performed on a total of 338 athletes (280 male, 24±11 age). The indications for CMR were as follows: aborted sudden cardiac death/sustained ventricular tachycardia (SVT) (4%), ECG alterations (36%), echocardiographic alterations (32%), positive family history of SCD or cardiomyopathies (CMP) (3%), and patients' complaints, e.g. palpitation, syncope, dyspnoea, chest complaints (25%). CMR confirmed structural myocardial disease in 82 athletes with the following distribution: 20 hypertrophic (HCM), 10 arrhythmogenic (AC), 8 dilated (DCM), and 7 non-compact (NCCMP) CMP. The CMR images of three patients indicated Fabry disease. We found post-myocardial infarction scars in 7 cases, and atypical non-ischemic scars in 28 athletes. Besides pathological conditions, we identified minor alterations in 58 patients (51 male, 25±12 age) such as: increased trabeculation, nonspecific LGE in left ventricular insertion point and myocardial crypts. Among athletes examined after aborted sudden cardiac death or SVT we found structural heart disease in 11 males and one female: AC (n=7), HCM (n=1), NCCMP (n=1) and atypical non-ischemic scars (n=3, in two patients the localisation was lateral subepicardial) were diagnosed. During the median follow up of five years one patient died in whom CMR showed lateral scar formation and only mildly reduced left ventricular ejection fraction (50%).

Conclusions

The most common structural alteration was non-ischaemic scar, the most common CMP was HCM, and the leading cause of sudden cardiac death or SVT in our competitive athletes was AC and lateral subepicardial scar formation.

LGE pattern in various cardiomyopathies

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Cardiac magnetic resonance features of acute myocarditis presenting as acute coronary syndrome

Background

Clinical presentation of myocarditis varies, one specific form of myocarditis appears with the clinical signs of acute coronary syndrome (ACS). Cardiac magnetic resonance (CMR) is an important method for assessing ventricular function and morphology, additionally provides accurate tissue specific and functional information of the heart.

Aims

Our aim was to investigate the characteristics, and prognosis of myocarditis presenting with ACS symptoms.

Methods

113 patients with the clinical signs of ACS but nonobstructed coronary arteries in whom the CMR revealed acute myocarditis were included in our study. CMR was performed in acute phase and at 3–6-month follow-up. Left ventricular (LV) volumes, mass and strain parameters expressing myocardial deformity were determined. Additional images were taken to represent tissue specific information. Relationships between laboratory and CMR parameters were investigated. Parameters predicting changes in LV ejection fraction (LVEF) were analyzed by logistic regression.

Results

A total of 113 patients with myocarditis (98 males, 31±11 years) underwent acute and follow-up CMR. Sixty two patients reported fever or infection before the beginning of their complaints, most commonly gastroenteritis (33%) and pharyngitis (32%). The creatinine kinase MB value measured in the acute phase showed positive correlation with the extent of necrosis, and the global longitudinal- and circumferential strain. The extent of the LV necrosis showed negative correlation with LVEF and positive correlation with global circumferential strain (GCS) (p&lt;0.05). On the control CMR examination LVEF and all global strain values improved, fibrosis persisted in 82% of cases but shrank (15±11 vs 5±4 g) and LV mass decreased (p&lt;0.01) compared to the acute phase. Compared to the acute phase, 21% of the patients had lower LVEF on the follow-up CMR. Lower initial LVEF, worse acute GCS, and greater LV necrosis were independent predictors of LVEF reduction in the logistic regression model. During a median follow-up of 6-years of patients treated at our clinic (n=39) no patient suffered cardiac death, heart failure, or documented ventricular arrhythmia but 21% of them had recurrent myocarditis.

Conclusion

Myocarditis mimicking ACS affects predominantly young men and shows functional improvement and good prognosis on follow-up, but it may reoccur in some cases. The reduction of LV function on control CMR may be predicted by worse initial LVEF, GCS, and a larger LV scar.

Strain, LGE in acute phase and follow-up

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Diagnostic impact of early cardiac magnetic resonance imaging in patients with the working diagnosis of MINOCA. Does the final diagnosis affect patients outcome?

Introduction

The diagnostic value of cardiac magnetic resonance (CMR) imaging has been suggested in determination of the cause in patients with the working diagnosis of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). According to the current STEMI Guideline CMR is considered to have the best diagnostic performance, when CMR timing is within its optimal ≤2 weeks.

Aims

The aim of our study was to assess the diagnostic value of early (1–7 days) CMR examination in patients with signs of troponin positive acute coronary syndrome (ACS) but with nonobstructive coronary arteries. We also aimed to investigate how early CMR changes the provisional diagnosis. We investigated the mortality in each patient group.

Methods

273 consecutive patients (43±16 years, 64% male) with working diagnosis of MINOCA underwent CMR examination following coronary angiography in a mean length of time of 2.5 days between 2009–2020. Cine movie, T2-weighted and late gadolinium enhanced images (LGE) were performed. Left ventricular end-diastolic and end-systolic volumes (LVESVi), ejection fraction (LVEF), mass (LVM) and myocardial necrosis were evaluated. We analysed the risk factors and laboratory values of our patients. Patients were followed for all-cause mortality.

Results

CMR examination established a definitive diagnosis in 86% of the cases: acute myocardial infarction (MI) in 65 patients (47% male), acute myocarditis in 142 patients (87% male), Tako-Tsubo syndrome (TTS) in 27 woman, myocardial contusion in one case. The diagnosis of four patients remained inconclusive after CMR and in 34 pts (50% male) there was no CMR abnormality. CMR changed the provisional diagnosis in 53% of the patients. LVEF was lower, LVESVi was elevated in TTS patients compared to MI and myocarditis (LVEF: 43±9.5 vs 56±7.7 vs 54±6.7%; LVESVi: 52±12.8 vs 38±13.2 vs 42±9.1 ml/m2 p&lt;0.001). Myocarditis patients were younger (myocarditis: 34±10 vs MI 47±14.8 vs TTS 66±10.7 years; p&lt;0.001) and lower percentage had hypercholesterolaemia (myocarditis:18.8 vs MI: 40 vs TTS:54.5%, p&lt;0.01) or hypertension (myocarditis: 20 vs MI: 49 vs TTS: 60%, p&lt;0.001). Laboratory values showed significant elevation of hsTroponin and CKMB of MI and myocarditis patients compared to other groups (p&lt;0.05), but there was no difference between these two groups. During the median follow-up of 3-years 13 patients died. Mortality rate in deaths per patient-year was as follows: MI 2.6 vs Myocarditis 0.4 vs TTS 7.4%. We found a strong association between CMR diagnosis and mortality (logrank 22.3 p&lt;0.001).

Conclusion

Our study demonstrates the diagnostic value of early CMR in patients with the working diagnosis of MINOCA. It established a definite diagnosis in 86% of our patients and changed the provisional diagnosis in 53%. According to our results there is an association between CMR diagnosis and mortality.

Myocarditis, MI, TakoTsubo syndrome

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

TRIACCESS study: randomized comparison between radial, femoral and transpedal access for for percutanous supertfitial femoral artery angioplasty

Background

Traditional access for the treatment of femoral artery lesions is the femoral artery (FA) approach, but radial (RA) and pedal access (PA) is an alternative access site. The aim of the study was to compare the success rate, complication rate of different access sites for the treatment of superfitial artery stenosis in a randomized study

Methods

180 consecutive patients were randomized in a prospective study to treat symptomatic superficial femoral stenosis, via RA, FA and PA. Primary endpoint: technical success, rate of major and minor access site complications. Secondary endpoints: major adverse events (MAE), procedural factors, cross-over rate, and duration of hospitalization.

Results

Technical success was achieved in 96.6%, 100% and 100% patients in RA, FA and PA group (p=ns). Secondary access site was used in 30%, 3.3% and 30% in the RA, FA and PA access group (p&lt;0.01). Stent implantation was done in the femoral artery in 26.6%, 58.3% and 71.6% cases in RA, FA and PA group (p&lt;0.01). CTO recanalization was performed in 34/36 (100%), 30/30 (100%) and 45/45 (100%) cases successfully in RA, FA and PA group (p=ns). Contrast consumption, fluoroscopy and procedure time was not statistically different, but the X Ray dose was significantly lower in PA than in the RA and FA access group (63.1 vs 162 vs 153 Dyn). The cumulative rate of access site complications in the RA, FA and PA group was 3.3% (0% major and 3.3% minor), 15% (3.3% major and 11.6% minor) and 3.3% (0% major and 3.3% minor) (p&lt;0.01), respectively. The cumulative incidence of MAE's at 6 months in the RA, FA and PA group was 8.3% vs 13.3% and 18.3%. (p&lt;0.05)

Conclusion

Femoral artery intervention can be safely and effectively performed using radial, femoral and pedal access, but radial and pedal access is associated with less access site complication rate. Pedal access is associated with less X Ray dose than radial and femoral access.

Funding Acknowledgement

Type of funding source: None

A Latin American and Spanish pediatric gastroenterology group's understanding of cow's milk protein allergy diagnosis and treatment: Results of a survey by the Food Allergy Working Group of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica

INTRODUCTION

There are discrepancies in the diagnosis and management of cow's milk protein allergy (CMPA) in Spain and Latin America. The aim of the present study was to find out how Spanish and Latin American pediatric gastroenterologists diagnose and treat CMPA.

MATERIAL AND METHODS

Pediatric gastroenterologists, members of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición, were invited to fill out a structured survey, the results of which were then compared with the 2012 and 2014 diagnosis and treatment guidelines, respectively.

RESULTS

The survey results showed that 17% of the participants follow the diagnostic recommendations based on the published consensus and guidelines. To diagnose non-IgE-mediated CMPA, 15% of the participants utilize IgE-specific skin prick tests, 22% use IgE-specific blood tests, and 45% employ oral food challenges. To diagnose IgE-mediated CMPA the percentages for the same diagnostic methods were 57, 83 and 22%, respectively. Once diagnosis is confirmed, 98% of the participants provide dietary recommendations. In children that are not breastfed, 89% of the participants prescribe an initial extensively hydrolyzed formula, 9% an amino acid formula, 1% a soy formula, and 1% a hydrolyzed rice formula. In patients with IgE-mediated CMPA, 34% of the participants carry out an oral challenge once treatment is completed, 39% according to symptom severity, and 27% in relation to IgE-specific testing.

CONCLUSION

CMPA management is diverse and there is poor adherence to the clinical practice guidelines.

P577Effect of adding an implantable cardioverter defibrillator on long-term survival in non-ischemic CRT patients stratified by Goldenberg risk score

Background

There are limited and incomprehensive long-term data on the effects of adding an implantable cardioverter defibrillator (ICD) to cardiac resynchronization therapy (CRT) in patients with non-ischemic heart failure. 

Purpose

We compared the long-term all-cause mortality and relative risk reduction in mortality of non-ischemic patients after CRT-P vs. CRT-D implantation stratified by their Goldenberg risk score.

Methods

In our retrospective registry, data of 1196 non-ischemic patients who underwent CRT implantation between 2000 to 2018 were collected. Goldenberg sudden cardiac risk score was calculated by the presence of atrial fibrillation, NYHA class &gt; 2, age &gt; 70 years, blood urea nitrogen &gt; 26mg/dl and QRS width. 

Results

In our registry from 1196 CRT implanted patients with non-ischemic heart failure, 716 patients had all the required data to calculate the Goldenberg score. From this cohort 379 (53%) had CRT-P and 337 (47%) CRT-D implantation. The mean value of the Goldenberg score was 2.7 in the total cohort, while a significantly higher score was found in the CRT-P group (CRT-P 2.9 ± 1.1 vs. CRT-D 2.5 ± 1.1 p &lt; 0.001). During the median follow-up time of 4.9 years, 345 (48%) patients reached the primary endpoint, 220 patients (64%) with CRT-P and 125 patients (36%) with CRT-D. After comparing patients by low (≤3) and high (&gt;3) Goldenberg score, we found that CRT-D patients with lower risk score showed mortality benefit compared to CRT-P (HR 0.69; 95%, CI 0.53-0.89; p = 0.001). In the contrary there was no apparent mortality benefit in CRT-D patients compared to CRT-P when high Goldenberg score subgroup was analyzed (HR 0.99; 95%, CI 0.67-1.45; p = 0.95).

Conclusions

In non-ischemic heart failure patients, Goldenberg sudden cardiac risk score can be also applied. In CRT-D patients those with less co-morbidities and lower (≤3) Goldenberg risk score showed mortality benefit compared to CRT-P patients, while among patients with higher score (&gt;3) adding an ICD had no additional effect on all-cause mortality.

Cows selected for divergent mastitis susceptibility display a differential liver transcriptome profile after experimental Staphylococcus aureus mammary gland inoculation

Infection and inflammation of the mammary gland, and especially prevention of mastitis, are still major challenges for the dairy industry. Different approaches have been tried to reduce the incidence of mastitis. Genetic selection of cows with lower susceptibility to mastitis promises sustainable success in this regard. Bos taurus autosome (BTA) 18, particularly the region between 43 and 59 Mb, harbors quantitative trait loci (QTL) for somatic cell score, a surrogate trait for mastitis susceptibility. Scrutinizing the molecular bases hereof, we challenged udders from half-sib heifers having inherited either favorable paternal haplotypes for somatic cell score (Q) or unfavorable haplotypes (q) with the Staphylococcus aureus pathogen. RNA sequencing was used for an in-depth analysis of challenge-related alterations in the hepatic transcriptome. Liver exerts highly relevant immune functions aside from being the key metabolic organ. Hence, a holistic approach focusing on the liver enabled us to identify challenge-related and genotype-dependent differentially expressed genes and underlying regulatory networks. In response to the S. aureus challenge, we found that heifers with Q haplotypes displayed more activated immune genes and pathways after S. aureus challenge compared with their q half-sibs. Furthermore, we found a significant enrichment of differentially expressed loci in the genomic target region on BTA18, suggesting the existence of a regionally acting regulatory element with effects on a variety of genes in this region.

Study of Two-Photon Exchange via the Beam Transverse Single Spin Asymmetry in Electron-Proton Elastic Scattering at Forward Angles over a Wide Energy Range

We report on a new measurement of the beam transverse single spin asymmetry in electron-proton elastic scattering, A_{⊥}^{ep}, at five beam energies from 315.1 to 1508.4 MeV and at a scattering angle of 30°<θ<40°. The covered Q^{2} values are 0.032, 0.057, 0.082, 0.218, 0.613 (GeV/c)^{2}. The measurement clearly indicates significant inelastic contributions to the two-photon-exchange (TPE) amplitude in the low-Q^{2} kinematic region. No theoretical calculation is able to reproduce our result. Comparison with a calculation based on unitarity, which only takes into account elastic and πN inelastic intermediate states, suggests that there are other inelastic intermediate states such as ππN, KΛ, and ηN. Covering a wide energy range, our new high-precision data provide a benchmark to study those intermediate states.

A genome-wide significant association on chromosome 15 for congenital entropion in Swiss White Alpine sheep

Entropion is a known congenital disorder in sheep presumed to be heritable but no causative genetic variant has been reported. Affected lambs show a variable inward rolling of the lower eyelids leading to blindness in severe cases. In Switzerland, the Swiss White Alpine (SWA) breed showed a significantly higher prevalence for entropion than other breeds. A GWAS using 150 SWA sheep (90 affected lambs and 60 controls), based on 600k SNP data, revealed a genome-wide significant signal on chromosome 15. The 0.2 Mb associated region contains functional candidate genes, SMTNL1 and CTNND1. Pathogenic variants in human CTNND1 cause blepharocheilodontic syndrome 2, a rare disorder including eyelid anomalies, and SMTNL1 regulates contraction and relaxation of skeletal and smooth muscle. WGS of a single entropion-affected lamb revealed two private missense variants in SMTNL1 and CTNND1. Subsequent genotyping of both variants in 231 phenotyped SWA sheep was performed. The SMTNL1 variant p.(Asp452Asn) affects an evolutionary conserved residue within an important domain and represents a rare allele, which occurred also in controls. The p.(Glu943Lys) variant in CTNND1 represents a common variant unlikely to cause entropion as the mutant allele occurred more frequently in non-affected sheep. Therefore, we propose that these protein-changing variants are unlikely to explain the phenotype. Additionally, WGS of three further disconcordant pairs of full siblings was carried out but revealed no obvious causative variant. Finally, we conclude that entropion represents a more complex disease caused by different non-coding regulatory variants.

P345 Temporal changes of left atrial function after orthotopic heart transplantation in a single-center prospective study

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

The geometry and function of the left atrium (LA) change after orthotopic heart transplantation (HTX) with bicaval technique, as the LA has a recipient part around the pulmonary veins and a donor part, and these often contract separately. Because of this altered LA function, the recognition of left ventricular diastolic dysfunction can be challenging. The standard echocardiographic diastolic parameters are often in abnormal range in HTX patients despite of normal left ventricular diastolic function.

The aim of our prospective study was to investigate the LA volumes and function and their temporal changes after HTX using cardiac magnetic resonance (CMR).

To better understand the cardiac characteristics of HTX patients, we started a prospective trial in January 2018. CMR was performed at one, three and six months after HTX. Left atrial contour detection was performed in 2- and 4-chamber views. Patients who had ≥Grade II allograft rejection before the CMR examination, were excluded (n = 2). In the remaining HTX patients (n = 21) and in a control group (n = 21) LA ejection fraction (EF), BSA-corrected maximum and minimum LA volume (Vi), stroke volume (SVi) were evaluated using bi-plane mode. LA global longitudinal strain (GLS) was defined with CMR based deformation imaging, called feature tracking.

HTX patients had significantly higher LA volumes (maxLAVi 71 ± 22 vs. 47 ± 6 ml/m2, minLAVi 53 ± 22 vs. 18 ± 5 ml/m2) lower LASVi (19 ± 7 vs. 29 ± 4 ml/m2), LAEF (27 ± 10 vs. 62 ± 8%) and LA-GLS (8 ± 3 vs. 39 ± 10%) compared to the control group (p &lt; 0.0001).

Analysing the temporal changes in HTX patients, we found an increase in the LAEF (26 ± 8 vs. 30 ± 5%) and LA-GLS (8 ± 3 vs. 11 ± 3%) at three months (p &lt; 0.05), there was no significant difference between the LA parameters at three and six months.

Better understanding of the changes of left atrial function after HTX could help us to recognise pathological conditions.

Abstract P345 Figure. Strain analysis of the left atrium

1642 Mitral annulus disjunction, a rare form of focal arrhythmogenic cardiomyopathy

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

The rate of sudden cardiac death in mitral valve prolapse (MVP) patients is roughly twice that observed in the general population. Arrhythmogenic bileaflet MVP syndrome has been recently described and mitral annulus disjunction (MAD) has been found associated with papillary muscle fibrosis and ventricular arrhythmias even without severe mitral regurgitation. An underlying primary structural myocardial disease might be expected and the non-invasive imaging techniques are playing an increasingly important role in the detection of myocardial fibrosis as a focal arrhythmogenic substrate. Standard 2D-, 3D- and speckle tracking echocardiography and cardiac MRI can help to differentiate between the benign and malignant forms of MVP.

A 52-year-old man with a history of hypertension was referred for evaluation of frequent palpitations and presyncope. Ambulatory Holter monitoring showed paroxysmal atrial fibrillation and non-sustained ventricular tachycardias. Dilated left ventricle (LVEDD: 65mm, LVESD: 45 mm) and left atrium (LAVi: 52mL/m2), moderately reduced left ventricular (LV) systolic function (LVEF: 42%), and reduced LV global longitudinal strain (GLS: -13.5%) with severely decreased segmental longitudinal strain in the basal inferolateral segment were measured by transthoracic echocardiography. The diastolic function was preserved, however Pickelhaube sign was noticed in the lateral mitral annulus TDI curves. MAD (17 mm) and curling motion of the inferolateral basal segment of the left ventricle was observed. Transesophageal echocardiography showed bileaflet mitral valve prolapse with the involvement of all the six scallops (mitral valve prolapse volume: 10.2 mL). Severe mitral regurgitation (3D vena contracta area: 1cm2) and extremely dilated and dyskinetic mitral annulus (diameters: 55x72x12 mm, area: 34 cm2) was measured by 3D echocardiography. MRI showed transmural late gadolinium enhancement in the underlying myocardium of both papillary muscles and midmyocardial enhancement in the basal inferior, inferolateral and anteroseptal LV segments. During electrophysiology study ventricular fibrillation was easily induced and ICD was placed for primary prevention of sudden cardiac death. The patient was referred to the heart surgeon for mitral valve replacement.

This case highlights the importance of early recognition of MAD and arrhythmogenic MVP syndrome using novel non-invasive imaging techniques. The presence of MAD, the curling motion of the inferolateral basal LV segment, the Pickelhaube sign, the decreased LVEF and GLS, the characteristic segmental longitudinal strain pattern and the presence of late enhancement in the papillary muscles and the surrounding myocardium could be warning signs of the malignant form of MVP.

Abstract 1642 Figure. CMR images of arrhythmogenic MAD

P4429Cardiac magnetic resonance characteristics of professional athletes and hypertrophic cardiomyopathy patients in the grey zone of hypertrophy

Acknowledgement/Funding

National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277). Project no. NVKP_16-1-2016-0017

2388Differential diagnosis of MINOCA patients: the contribution of early cardiac magnetic resonance imaging to the final diagnosis in patients with normal coronary angiography

Introduction

The diagnostic value of cardiac magnetic resonance (CMR) imaging has been suggested in determination of the cause behind Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). According to the current STEMI Guideline CMR is considered to have the best diagnostic performance, when CMR timing is within its optimal ≤2 weeks.

Purpose

The aim of our study was to establish the prevalence of the underlying pathologies using early (1–7 days) CMR examination in patients with signs of troponin positive acute coronary syndrome (ACS) but normal coronary angiography (NCA). We also aimed to investigate how early CMR changes the provisional diagnosis, and to provide detailed information of CMR characteristics of our pts and to compare laboratory parameters and risk factors of each group.

Methods

Between 2010–2018 (n=234) consecutive pts (40.2±12.1y, 159 male) with troponin positive ACS underwent CMR examination following NCA (≤20% stenosis), in a mean length of time of 2.5 days. Cine movie, T2-weighted and late gadolinium enhanced images (LGE) were performed. Left ventricular end-diastolic and end-systolic volumes (LVESVi), ejection fraction (LVEF), mass (LVM) and myocardial necrosis were evaluated. We analysed the risk factors and laboratory values of our patients.

Results

CMR proved acute myocardial infarction (MI) in 42 pts (52% male), acute myocarditis in 138 pts (89% male), Tako-Tsubo cardiomyopathy (TTC) in 25 woman, myocardial contusion in one case, in three cases CMR raised the suspicion of sarcoidosis and in 25 pts (56% male) there was no CMR abnormality. LVEF was lower, LVESVi was elevated in TTC patients compared to MI and myocarditis (LVEF: 44±9.1 vs 56.5±7 vs 55±6.6%; LVESVi: 52.5±12.9 vs 41±16.8 vs 42.1±8.9 ml/m2 p<0.001). The most frequently affected areas of the myocardium by LGE were the basal and mid inferolateral segments in case of myocarditis (69% of pts). In MI pts the anterior wall was affected only in 16%, while the involvement of inferior wall was visible in 57% of the pts. Early CMR examination established a definitive diagnosis in 88% of the cases, in 11% there was no CMR abnormality and it remained inconclusive in only 1% of the cases. CMR changed the provisional diagnosis in 47% of the pts.

Myocarditis pts were younger (myocarditis: 32.5±10.8 vs MI 47.6±15.5 vs TTC 65.5±9.6 y; p<0.001) and lower percentage had hypercholesterinaemia (myocarditis: 18.8 vs MI: 40 vs TTC: 54.5%, p<0.01) or hypertension (myocarditis: 14.3 vs MI: 38.7 vs TTC: 55.6%, p<0.001). Laboratory values showed significant elevation of hsTroponin and CKMB of MI and myocarditis pts compared to other groups (p<0.05), but there was no difference between these two groups.

Underlying pathologies in MINOCA

Conclusion

In patients with the working diagnosis of MINOCA and normal coronary angiography early CMR established a definitive diagnosis in 88% of our patients and changed the provisional diagnosis in 47% of the pts.

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary