Predictors of persistent symptoms after mRNA SARS-CoV-2 vaccine-related myocarditis (myovacc registry)

Aims

Epidemiological surveillance has raised safety concerns for mRNA SARS-CoV-2-vaccination-related myocarditis. We aimed to analyze epidemiological, clinical and imaging findings associated with clinical outcomes in these patients in an international multi-center registry (NCT05268458).

Methods and results

Patients with clinical and CMR diagnosis of acute myocarditis within 30 days after mRNA SARS-CoV-2-vaccination were included from five centers in Canada and Germany between 05/21 and 01/22. Clinical follow-up on persistent symptoms was collected. We enrolled 59 patients (80% males, mean age 29 years) with CMR-derived mild myocarditis (hs-Troponin-T 552 [249-1,193] ng/L, CRP 28 [13-51] mg/L; LVEF 57 ± 7%, LGE 3 [2-5] segments). Most common symptoms at baseline were chest pain (92%) and dyspnea (37%). Follow-up data from 50 patients showed overall symptomatic burden improvement. However, 12/50 patients (24%, 75% females, mean age 37 years) reported persisting symptoms (median interval 228 days) of chest pain (n = 8/12, 67%), dyspnea (n = 7/12, 58%), with increasing occurrence of fatigue (n = 5/12, 42%) and palpitations (n = 2/12, 17%). These patients had initial lower CRP, lower cardiac involvement in CMR, and fewer ECG changes. Significant predictors of persisting symptoms were female sex and dyspnea at initial presentation. Initial severity of myocarditis was not associated with persisting complaints.

Conclusion

A relevant proportion of patients with mRNA SARS-CoV-2-vaccination-related myocarditis report persisting complaints. While young males are usually affected, patients with persisting symptoms were predominantly females and older. The severity of the initial cardiac involvement not predicting these symptoms may suggest an extracardiac origin.

Safety and Effectiveness of Endovascular Therapy for the Treatment of Peripheral Artery Disease in Patients with and without Diabetes Mellitus

This study investigated the distribution of risk factors, lesion characteristics and endovascular revascularization (EVR) strategies in patients with peripheral arterial disease (PAD) with vs without diabetes mellitus (DM). Data were collected within the RECcording COurses of vasculaR Diseases (RECCORD) registry. Demographic data, lesion localization (iliac vs femoropopliteal vs below-the-knee (BTK)) and lesion complexity score (LCS) based on number of affected segments, and lesion length (< 10 vs 10-20 vs > 20 cm), EVR strategies and peri-procedural complications were analysed in 786 patients with and 1337 without diabetes mellitus. Patients with diabetes mellitus were older (71.6 ± 9.6 vs 69.4 ± 10.5 years, P < .001) and had higher LCS and more often BTK lesions (P < .05 for all). Lesions were treated less frequently with stents (48.7 vs 59.6%, P < .001) in patients with diabetes mellitus, whereas a non-significant trend was noticed for higher DCB treatment rates (48.3 vs 44.4%, P = .07). Post-interventional ankle-brachial index (ABI) increase was similar (from .77 ± .28 to .92 ± .25 with diabetes mellitus and from .74 ± .21 to .90 ± .20 without diabetes mellitus, P < .001 for both). Peri-/post-procedural complications were low in both groups (4.6%). Patients with diabetes mellitus, who undergo endovascular revascularization are older, have more comorbidities and higher target lesion complexity. However, treatment success rates are similar and complication rates are low.

Case report: Case series of isolated acute pericarditis after SARS-CoV-2 vaccinations

During the worldwide ongoing immunization campaign against SARS-CoV-2, growing data on very rare but potentially harmful side effects of such vaccines arise since approval trials have not been adequately powered to detect those events. Besides the already reported vaccine-related myocarditis, which primarily occurs in young male individuals, our attention was recently drawn to a series of older male and female patients, who were referred to our institutions with isolated acute pericarditis without myocardial damage, shortly after SARS-CoV-2 vaccination. We describe a series of five adult patients presenting with chest pain, shortness of breath and isolated pericarditis with and without pericardial effusion after SARS-CoV-2 vaccination. All patients underwent echocardiography and cardiac magnetic resonance, and the corresponding findings, including late gadolinium enhancement (LGE) and T1 and T2 mapping are reported herein. To our knowledge, such cases have not been systematically reported in the current literature so far.

Phoenix atherectomy for patients with peripheral artery disease

BACKGROUND

Endovascular atherectomy enables minimally invasive plaque removal in peripheral artery disease (PAD).

AIMS

We aimed to evaluate the safety and the long-term effectiveness of the Phoenix atherectomy for the treatment of complex and calcified lesions in PAD patients.

METHODS

Consecutive all-comer patients with PAD underwent the Phoenix atherectomy. Device safety in terms of perforation and distal embolisation were evaluated. Lesion calcifications were categorised by the Peripheral Arterial Calcium Scoring System (PACSS) and lesion complexity was assessed by the Transatlantic Inter-Society Consensus (TASC). Clinically driven target lesion revascularisation (TLR) was assessed.

RESULTS

A total of 558 lesions were treated in 402 consecutive patients. Clinical follow-up was available at 15.7±10.2 months for 365 (91%) patients. Of 402 patients, 135 (33.6%) had claudication, 37 (9.2%) had ischaemic rest pain and 230 (57%) exhibited ischaemic ulcerations. Lesions were mostly identified in the femoropopliteal segments (55%), followed by below-the-knee (BTK) segments (32%). Complex TASC C/D lesions and moderate to severe calcifications (PACSS score ≥2) were present in 331 (82%) and 323 (80%) patients, respectively. The mean lesion length was 20.6±14.3 cm. Five (1%) perforations and 10 (2%) asymptomatic embolisations occurred. Bail-out stenting was performed in 4%, 16% and 3% of patients with common femoral artery, femoropopliteal and BTK lesions, respectively. During follow-up, 5 (3.9%) patients with claudication and 52 (21.9%) patients with critical limb-threatening ischaemia (CLTI) died (hazard ratio [HR] 3.7; p<0.001). Freedom from TLR was 87.5% (112 of 128) in patients with claudication and 82.3% (195 of 237) in patients with CLTI, respectively (HR 1.8; p=0.03).

CONCLUSIONS

The Phoenix atherectomy can be safely performed in patients with complex lesions with a relatively low rate of bail-out stenting and clinically acceptable TLR rates.

GERMAN CLINICAL TRIALS REGISTER

DRKS00016708.

A case report of distal radial puncture in a patient with acute upper limb ischaemia: the last hope of the cardiologist?

Background

Patients with acute limb ischaemia (ALI) present with acute symptoms, requiring prompt diagnosis and expedited treatment to preserve the viability of the affected ischaemic tissue.

Case summary

We present an 83-year-old female patient with upper ALI due to thrombotic occlusion of the left brachial artery. Concomitantly, the patient had a first diagnosis of atrial fibrillation and was not on treatment with oral anticoagulation. Transfemoral thrombectomy using a 6F Rotarex® catheter resulted in removal of the thrombus from the brachial artery. However, significant amounts of debris embolized distally, causing occlusion of both the radial and ulnar arteries. The debris was successfully removed after puncture of the distal radial artery and retrograde thrombus aspiration using a 5F Envoy catheter. This manoeuver led to flow restoration in both the radial and ulnar arteries and to complete resolution of ischaemic symptoms of the patient.

Discussion

Interventionists may consider distal radial puncture not only as an access site for coronary angiography but also as an option for the endovascular management of ALI in cases of cardiac embolism, as described herein or in cases of thrombotic complications during routine catheterization and percutaneous coronary intervention. Herein, we describe the case of an 83-year-old patient, who presented with acute upper limb ischaemia. Due to embolization of thrombotic debris during Rotarex® catheter thrombectomy, flow further diminished in the ulnar and radial arteries. The last hope for successful interventional treatment was thrombectomy from distally after retrograde puncture of the distal radial artery. This unique manoeuver led to flow restoration and complete recovery of the patient without the need for open surgery.

Case Report: Disappearance of Late Gadolinium Enhancement and Full Functional Recovery in a Young Patient With SARS-CoV-2 Vaccine-Related Myocarditis

Acute myocarditis was recently demonstrated in previously healthy young male patients after receipt of mRNA SARS-CoV-2 vaccines. Herein, we report on a 21-year-old man who presented with acute fatigue, myalgia, and chest pain 2 days after his second SARS-CoV-2 vaccination with BNT162b2. Cardiac magnetic resonance (CMR) showed acute myocarditis, with mildly impaired LV-function and abundant subepicardial late gadolinium enhancement (LGE). Control CMR after 3 months showed full functional recovery and complete disappearance of LGE. The benefits of SARS-CoV-2 vaccination may significantly exceed the very rare and, in this case, fully reversible adverse effects.

Fast-Strain Encoded Cardiac Magnetic Resonance During Vasodilator Perfusion Stress Testing

Background: Cardiac magnetic resonance perfusion imaging during vasodilator stress is an established modality in patients with suspected and known coronary artery disease (CAD). Aim: This study aimed to evaluate the performance of fast-Strain-Encoded-MRI (fast-SENC) for the diagnostic classification and risk stratification of patients with ischemic heart disease. Methods: Perfusion and fast-SENC cardiac magnetic resonance (CMR) images were retrospectively analyzed in 111 patients who underwent stress CMR. The average myocardial perfusion score index, global and segmental longitudinal and circumferential strain (GLS and GCS and SLS and SCS, respectively), were measured at rest and during stress. The combination of SLS and SCS was referred to as segmental aggregate strain (SAS). Segments exhibiting perfusion defects or SAS impairment during stress were defined as "ischemic." All-cause mortality, non-fatal infarction, and urgent revascularization were deemed as our combined clinical endpoint. Results: During adenosine stress testing, 44 of 111 (39.6%) patients exhibited inducible perfusion abnormalities. During a mean follow-up of 1.94 ± 0.65 years, 25 (22.5%) patients reached the combined endpoint (death in n = 2, infarction in n = 3 and urgent revascularization in n = 20). Inducible perfusion defects were associated with higher number of segments with inducible SAS reduction ≥6.5% (χ² = 37.8, AUC = 0.79, 95% CI = 0.71-0.87, p < 0.001). In addition, patients with inducible perfusion defects or SAS impairment exhibited poorer outcomes (AUC_Perf = 0.81 vs. AUC_SAS = 0.74, p = NS vs. each other, and χ² = 30.8, HR = 10.3 and χ² = 9.5, HR = 3.5, respectively, p < 0.01 for both). Conclusion: Purely quantitative strain analysis by fast-SENC during vasodilator stress was related to the diagnosis of ischemia by first-pass perfusion and is non-inferior for the risk stratification of patients with ischemic heart disease. This may bear clinical implications, especially in patients with contraindications for contrast agent administration.

Diagnostic Work-Up of Cardiac Amyloidosis Using Cardiovascular Imaging: Current Standards and Practical Algorithms

Among non-ischemic cardiomyopathies, cardiac amyloidosis is one of the most common, being caused by extracellular depositions of amyloid fibrils in the myocardium. Two main forms of cardiac amyloidosis are known so far, including 1) light-chain (AL) amyloidosis caused by monoclonal production of light-chains, and 2) transthyretin (ATTR) amyloidosis, caused by dissociation of the transthyretin tetramer into monomers. Both AL and ATTR amyloidosis are progressive diseases with median survival from diagnosis of less than 6 months and 3 to 5 years, respectively, if untreated. In this regard, death occurs in most patients due to cardiac causes, mainly congestive heart failure, which can be prevented due to the presence of effective, life-saving treatment regimens. Therefore, early diagnosis of cardiac amyloidosis is crucial more than ever. However, diagnosis of cardiac amyloidosis may be challenging due to variable clinical manifestations and the perceived rarity of the disease. In this regard, clinical and laboratory reg flags are available, which may help clinicians to raise suspicion of cardiac amyloidosis. In addition, advances in cardiovascular imaging have already revealed a higher prevalence of cardiac amyloidosis in specific populations, so that the diagnosis especially of ATTR amyloidosis has experienced a >30-fold increase during the past ten years. The goal of our review article is to summarize these findings and provide a practical approach for clinicians on how to use cardiovascular imaging techniques, such as echocardiography, cardiac magnetic resonance, bone scintigraphy and, if required, organ biopsy within predefined diagnostic algorithms for the diagnostic work-up of patients with suspected cardiac amyloidosis. In addition, two clinical cases and practical tips are provided in this context.

Multi-parametric assessment of left ventricular hypertrophy using late gadolinium enhancement, T1 mapping and strain-encoded cardiovascular magnetic resonance

AIM

To evaluate the ability of single heartbeat fast-strain encoded (SENC) cardiovascular magnetic resonance (CMR) derived myocardial strain to discriminate between different forms of left ventricular (LV) hypertrophy (LVH).

METHODS

314 patients (228 with hypertensive heart disease (HHD), 45 with hypertrophic cardiomyopathy (HCM), 41 with amyloidosis, 22 competitive athletes, and 33 healthy controls) were systematically analysed. LV ejection fraction (LVEF), LV mass index and interventricular septal (IVS) thickness, T1 mapping and atypical late gadolinium enhancement (LGE) were assessed. In addition, the percentage of LV myocardial segments with strain ≤ - 17% (%normal myocardium) was determined.

RESULTS

Patients with amyloidosis and HCM exhibited the highest IVS thickness (17.4 ± 3.3 mm and 17.4 ± 6 mm, respectively, p < 0.05 vs. all other groups), whereas patients with amyloidosis showed the highest LV mass index (95.1 ± 20.1 g/m2, p < 0.05 vs all others) and lower LVEF compared to controls (50.5 ± 9.8% vs 59.2 ± 5.5%, p < 0.05). Analysing subjects with mild to moderate hypertrophy (IVS 11-15 mm), %normal myocardium exhibited excellent and high precision, respectively for the differentiation between athletes vs. HCM (sensitivity and specificity = 100%, Area under the curve; AUC%normalmyocardium = 1.0, 95%CI = 0.85-1.0) and athletes vs. HHD (sensitivity = 83%, specificity = 75%, AUC%normalmyocardium = 0.85, 95%CI = 0.78-0.90). Combining %normal myocardial strain with atypical LGE provided high accuracy also for the differentiation of HHD vs. HCM (sensitivity = 82%, specificity = 100%, AUCcombination = 0.92, 95%CI = 0.88-0.95) and HCM vs. amyloidosis (sensitivity = 83%, specificity = 100%, AUCcombination = 0.83, 95%CI = 0.60-0.96).

CONCLUSION

Fast-SENC derived myocardial strain is a valuable tool for differentiating between athletes vs. HCM and athletes vs. HHD. Combining strain and LGE data is useful for differentiating between HHD vs. HCM and HCM vs. cardiac amyloidosis.

Safety and effectiveness of Phoenix atherectomy for endovascular treatment in calcified common femoral artery lesions

Background: Traditionally endarterectomy has been considered as the gold standard technique for the treatment of common femoral artery (CFA) lesions. The aim of this study is to investigate the procedural safety and mid-term outcomes of minimal invasive Phoenix atherectomy for the treatment of CFA lesions. Patients and methods: Phoenix atherectomy was used for treatment of 61 consecutive, moderately to heavily calcified CFA lesions in 56 patients. Lesions were classified based on the CFA occlusive disease classification (Type I, II&III lesions). Primary endpoints were technical, procedural, and clinical success rate. Safety endpoints (vessel perforation, peripheral embolization) and clinically driven target lesion revascularization (TLR) were also assessed. Results: Of 61 CFA lesions, 58 (95%) exhibited at least moderate/severe calcification (PACSS3 in 38 (62%) and PACSS4 in 20 (33%) cases). Type III lesions were present in 30 (49%), type I/II lesions in 31 (51%) cases. Technical and procedural success was achieved in 30 (49%) and all 61 (100%) lesions, respectively with low complication rates (0% perforation, 2% embolization). Adjunctive treatment after atherectomy was performed using drug-coated balloon (DCB) in 35 (57%) and bail-out stenting in 6 (10%) cases. Target lesion revascularization (TLR) occurred in 4 (7%) cases during a mean follow-up duration of 11±7months. All patients exhibited clinical improvement at follow-up, showing mean Rutherford category reduction from 3.7±1.1 to 1.5±1.1 (p<0.001). Conclusions: The Phoenix device can be used for the effective endovascular treatment of CFA lesions, due to its reasonable safety profile and mid-term results.

Fast Strain-Encoded Cardiac Magnetic Resonance for Diagnostic Classification and Risk Stratification of Heart Failure Patients

OBJECTIVES

The purpose of this study was to compare the ability of fast-strain encoded magnetic resonance (fast-SENC) cardiac magnetic resonance (CMR) to classify and risk stratify all-comer patients with different stages of chronic heart failure (Stages of heart failure A to D) based on American College of Cardiology/American Heart Association guidelines with standard clinical and CMR imaging data.

BACKGROUND

Heart failure is a major cause of morbidity and mortality, resulting in millions of deaths and hospitalizations annually.

METHODS

The study population consisted of 1,169 consecutive patients between September 2017 and February 2019 who underwent CMR for clinical reasons, and 61 healthy volunteers. In addition, clinical follow-up was performed in Stages A and B patients after 1.9 ± 0.4 years. Wall motion score and late gadolinium enhancement score indexes, left ventricular (LV) ejection fraction, and global circumferential and longitudinal strain based on fast-SENC acquisitions, were calculated in all subjects. The percentage of myocardial segments with strain ≤-17% (% normal myocardium) was determined in all subjects.

RESULTS

LV ejection fraction, global circumferential and longitudinal strain, and % normal myocardium significantly decreased with increasing heart failure stages (p < 0.001 for all by analysis of variance). By multivariable analysis, % normal myocardium remained an independent predictor of heart failure stages, exhibiting closer association than LV ejection fraction (rpartial = 0.76 vs. rpartial = 0.30; p < 0.001). Importantly, 149 of 399 (37%) with Stage A were reclassified to Stage B, that is, as having subclinical LV dysfunction based on % normal myocardium <80%. Such patients exhibited significantly higher rates of all-cause mortality and hospital stay due to heart failure during follow-up, compared with patients with % normal myocardium ≥80% (chi-square = 6.9; p = 0.03).

CONCLUSIONS

The % normal myocardium, determined by fast-SENC, enables improved identification of asymptomatic patients with subclinical LV dysfunction compared with LV ejection fraction and risk stratification of patients with so far asymptomatic heart failure. The identification of such presumably healthy patients at high risk for heart failure-related outcomes may bear important medical implications.

Multiparametric Early Detection and Prediction of Cardiotoxicity Using Myocardial Strain, T1 and T2 Mapping, and Biochemical Markers: A Longitudinal Cardiac Resonance Imaging Study During 2 Years of Follow-Up

BACKGROUND

Our goal was to evaluate the ability of cardiovascular magnetic resonance for detecting and predicting cardiac dysfunction in patients receiving cancer therapy. Left ventricular ejection fraction, global and regional strain utilizing fast-strain-encoded, T1 and T2 mapping, and cardiac biomarkers (troponin and BNP [brain natriuretic peptide]) were analyzed.

METHODS

Sixty-one patients (47 with breast cancer, 11 with non-Hodgkin lymphoma, and 3 with Hodgkin lymphoma) underwent cardiovascular magnetic resonance scans at baseline and at regular intervals during 2 years of follow-up. The percentage of all left ventricular myocardial segments with strain ≤-17% (normal myocardium [%]) was analyzed. Clinical cardiotoxicity (CTX) and sub-CTX were defined according to standard measures.

RESULTS

Nine (15%) patients developed CTX, 26 (43%) had sub-CTX. Of the 35 patients with CTX or sub-CTX, 24 (69%) were treated with cardioprotective medications and showed recovery of cardiac function. The amount of normal myocardium (%) exhibited markedly higher accuracy for the detection of CTX and sub-CTX compared with left ventricular ejection fraction, T1, and T2 mapping as well as troponin I (Δareas under the curve=0.20, 0.24, and 0.46 for normal myocardium (%) versus left ventricular ejection fraction, troponin I, and T1 mapping, P<0.001 for all). In addition, normal myocardium (%) at baseline accurately identified patients with subsequent CTX (P<0.001), which was not achieved by any other markers.

CONCLUSIONS

Normal myocardium (%) derived by fast-strain-encoded cardiovascular magnetic resonance, is an accurate and sensitive tool that can establish cardiac safety in patients with cancer undergoing cardiotoxic chemotherapy not only for the early detection but also for the prediction of those at risk of developing CTX. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03543228.

Clinical safety of low-dose anticoagulation with fondaparinux in patients undergoing peripheral endovascular treatment due to critical limb-threatening ischaemia - a pilot study

AIMS

To evaluate the safety and effectiveness of fondaparinux in addition to dual antiplatelet therapy (DAPT) in patients with critical limb-threatening ischaemia (CLTI).

METHODS

Fondaparinux (2.5 mg/d) was administered for 1-4 weeks after endovascular procedures together with DAPT (fondaparinux arm). Patients who received standard DAPT were retrospectively matched and generated the control arm. Demographic, angiographic and follow-up data, including (i) clinically relevant bleeding and (ii) target vessel revascularisation or major amputation after 12 months was analysed.

RESULTS

Twenty-four patients (78.7 ± 6.9 years, 14 [58%] female, 4 TASC B, 10 TASC C and 10 TASC D lesions, total lesion length = 210 ± 98 mm, mean Rutherford class = 4.7 ± 0.6) received fondaparinux (over a period of 22 ± 9 d, range 7-28 d) and DAPT versus 24 control patients who received standard DAPT (78.3 ± 8.4 years, 14 [58%] female, 4 TASC B, 8 TASC C and 12 TASC D lesions, total lesion length = 204 ± 73 mm, mean Rutherford class = 4.6 ± 0.6). During follow-up, 3(13%) patients in the fondaparinux arm exhibited significant bleeding versus 5 (21%) in the control arm (p = ns). Four (17%) patients of the fondaparinux arm underwent target vessel revascularisation or major amputation versus 6 (25%) in the control group (p = ns).

CONCLUSIONS

Adding fondaparinux to DAPT does not seem to result in excess of clinically relevant bleeding. Our preliminary data suggest that prospective studies are now warranted in larger patient cohorts.

GERMAN CLINICAL TRIALS REGISTER

DRKS00015856.

Left and right ventricular strain using fast strain-encoded cardiovascular magnetic resonance for the diagnostic classification of patients with chronic non-ischemic heart failure due to dilated, hypertrophic cardiomyopathy or cardiac amyloidosis

AIMS

To compare the ability of left ventricular (LV) and right ventricular (RV) strain measured by fast-strain encoded cardiovascular magnetic resonance (CMR) (fast-SENC) with LV- and RV-ejection fraction for the diagnostic classification of patients with different stages of chronic heart failure (stages A-D based on American College of Cardiology/American Heart Association guidelines) due to non-ischemic cardiomyopathies.

METHODS

Our study population consisted of 276 consecutive patients who underwent CMR for clinical reasons, and 19 healthy subjects. Wall motion score index and non-infarct related late gadolinium enhancement (LGE), LV ejection fraction (LVEF) and RV ejection fraction (RVEF) and global LV- and RV-longitudinal (GLS) and circumferential strain (GCS) based on fast-SENC acquisitions, were calculated in all subjects. The percentage of LV and RV myocardial segments with strain ≤ - 17% (%normal LV and RV myocardium) was determined in all subjects.

RESULTS

LVEF and RVEF, LV-GLS, LV-GCS, RV-GLS, RV-GCS and %normal LV- and RV myocardium depressed with increasing heart failure stage (p < 0.001 for all by ANOVA). By multivariable analysis, %normal LV and RV myocardium exhibited closer associations to heart failure stages than LVEF and RVEF (r_partial = 0.79 versus r_partial = 0.21 for %normal LV myocardium versus LVEF and r_partial = 0.64 versus r_partial = 0.20 for %normal RV myocardium versus RVEF, respectively). Furthermore, %normal LV and RV myocardium exhibited incremental value for the identification of patients (i) with subclinical myocardial dysfunction and (ii) with symptomatic heart failure, surpassing that provided by LVEF and RVEF (ΔAUC = 0.22 for LVEF and ΔAUC = 0.19 for RVEF with subclinical dysfunction, and ΔAUC = 0.19 for LVEF and ΔAUC = 0.22 for RVEF with symptomatic heart failure, respectively, p < 0.001 for all). %normal LV myocardium reclassified 11 of 31 (35%) patients judged as having no structural heart disease by clinical and imaging data to stage B, i.e., subclinical LV-dysfunction.

CONCLUSIONS

In patients with non-ischemic cardiomyopathy, %normal LV and RV myocardium, by fast-SENC, enables improved identification of asymptomatic patients with subclinical LV-dysfunction. This technique may be useful for the early identification of such presumably healthy subjects at risk for heart failure and for monitoring LV and RV deformation during pharmacologic interventions in future studies.

Left and right ventricular strain using fast strain-encoded cardiovascular magnetic resonance for the diagnostic classification of patients with chronic non-ischemic heart failure due to dilated, hypertrophic cardiomyopathy or cardiac amyloidosis

AIMS

To compare the ability of left ventricular (LV) and right ventricular (RV) strain measured by fast-strain encoded cardiovascular magnetic resonance (CMR) (fast-SENC) with LV- and RV-ejection fraction for the diagnostic classification of patients with different stages of chronic heart failure (stages A-D based on American College of Cardiology/American Heart Association guidelines) due to non-ischemic cardiomyopathies.

METHODS

Our study population consisted of 276 consecutive patients who underwent CMR for clinical reasons, and 19 healthy subjects. Wall motion score index and non-infarct related late gadolinium enhancement (LGE), LV ejection fraction (LVEF) and RV ejection fraction (RVEF) and global LV- and RV-longitudinal (GLS) and circumferential strain (GCS) based on fast-SENC acquisitions, were calculated in all subjects. The percentage of LV and RV myocardial segments with strain ≤ - 17% (%normal LV and RV myocardium) was determined in all subjects.

RESULTS

LVEF and RVEF, LV-GLS, LV-GCS, RV-GLS, RV-GCS and %normal LV- and RV myocardium depressed with increasing heart failure stage (p < 0.001 for all by ANOVA). By multivariable analysis, %normal LV and RV myocardium exhibited closer associations to heart failure stages than LVEF and RVEF (rpartial = 0.79 versus rpartial = 0.21 for %normal LV myocardium versus LVEF and rpartial = 0.64 versus rpartial = 0.20 for %normal RV myocardium versus RVEF, respectively). Furthermore, %normal LV and RV myocardium exhibited incremental value for the identification of patients (i) with subclinical myocardial dysfunction and (ii) with symptomatic heart failure, surpassing that provided by LVEF and RVEF (ΔAUC = 0.22 for LVEF and ΔAUC = 0.19 for RVEF with subclinical dysfunction, and ΔAUC = 0.19 for LVEF and ΔAUC = 0.22 for RVEF with symptomatic heart failure, respectively, p < 0.001 for all). %normal LV myocardium reclassified 11 of 31 (35%) patients judged as having no structural heart disease by clinical and imaging data to stage B, i.e., subclinical LV-dysfunction.

CONCLUSIONS

In patients with non-ischemic cardiomyopathy, %normal LV and RV myocardium, by fast-SENC, enables improved identification of asymptomatic patients with subclinical LV-dysfunction. This technique may be useful for the early identification of such presumably healthy subjects at risk for heart failure and for monitoring LV and RV deformation during pharmacologic interventions in future studies.

Distal retrieval of dislodged and migrated guidewires after retrograde puncture of the deep femoral and dorsal pedal artery. A case series

We report on retrograde retrieval of the soft end of dislodged guidewires during complex interventions. Interventionalists may consider this as an option for the endovascular management of this complication if an antegrade retrieval is not possible or fails.

‘Pave-and-crack’ technique for the recanalization of severely calcified occlusive aorto-ilio-femoral disease in type-III Leriche syndrome: a case report

Background 

Leriche syndrome is the result of the atherosclerotic occlusion of the distal aorta that may also involve pelvic arteries. The standard treatment for this condition is considered surgical with various techniques available for establishing appropriate flow to both limbs. However, due to the technical advances in the last decades, endovascular approaches are now also capable to tackle such lesions. The ‘pave-and-crack’ technique enables the treatment of severely calcified lesions. This two-step procedure consists of firstly placing a covered stent prothesis (VIABAHN) into the severely calcified segment, which is afterwards aggressively dilated with high-pressure balloons. Subsequently, an interwoven nitinol SUPERA stent with high radial forces is placed within the prothesis.

Case summary 

Herein, we describe the case of an 81-year-old male patient, who presented with critical limb-threatening ischaemia of his right leg. Doppler ultrasound revealed a long occlusion of the right external iliac artery, common femoral, superficial femoral, and deep femoral artery. The lesion was successfully tackled using antegrade and retrograde punctures and the ‘pave-and-crack’ technique.

Discussion 

The ‘pave-and-crack’ technique is an endovascular approach for the treatment of severe circumferential calcified lesions. Based on this technique covered stents are initially placed to prevent vessel rupture, which might occur during the aggressive balloon dilatation. Subsequently, the covered stents are relined by interwoven Supera stents, which provide high radial force preventing recoil and restenosis.

CMR fast-SENC segmental intramyocardial LV strain monitors decline in heart function before ejection fraction in patient with arterial hypertension

Background

Left ventricular ejection fraction (LVEF) is commonly used to assess cardiac function for patients with chronic cardiac diseases. LVEF, like most systemic function assessments, detects dysfunction once enough damage has occurred to prevent common compensatory mechanisms from maintaining cardiac output. More sensitive metrics are being evaluated to more accurately identify subclinical regional dysfunction before cardiac remodeling results in changes in LVEF and global longitudinal strain (GLS). Fast-SENC intramyocardial strain (fSENC) is a unique cardiac magnetic resonance imaging (CMR) modality that measures intramyocardial contraction in 1 heartbeat per image plane. This prospective registry compares segmental fSENC to standard CMR calculations (e.g. LVEF, volumes, mass, etc.) for patients with arterial hypertension in the absence of non-ischemic cardiomyopathy.

Methods

A single center, prospective registry of CMR scans acquired with a 1.5T scanner were evaluated for standard CMR calculations as well as fSENC scans. Intramyocardial LV & RV strain was quantified with MyoStrain software. Three short axis scans (basal, midventricular, & apical) were used to calculate peak strain in 16 LV & 6 RV longitudinal segments while three long axis scans (2-, 3-, & 4-chamber) were used to calculate 21 LV & 5 RV circumferential segments.

Results

A total of 773 scans in 650 patients with arterial hypertension but without non-ischemic cardiomyopathies were included in the study. Patients had an average (± stdev) age of 64 (13) yrs and BMI of 28 (5) kg/m2; 24% diabetes mellitus, 10% atrial fibrillation, 15% pulmonary disease, and 39% coronary artery disease. Figure 1 shows a Box & Whisker's plot demonstrating the non-linear relationship between segmental fSENC strain (% of normal LV segments ≤−17%) versus LVEF. The progression of hypertensive heart disease was associated with reduction in septal circumferential contraction despite normal LVEF.

Conclusion

Segmental fSENC detects subclinical LV dysfunction in patients with early hypertensive heart disease before changes in LVEF. Evaluating segmental longitudinal and circumferential fSENC peak strain provides an alternative metric that shows consistent changes in cardiac function in patients with arterial hypertension.

Figure 1

Funding Acknowledgement

Type of funding source: None

CMR fast-SENC segmental intramyocardial LV strain monitors decline in heart function before ejection fraction in patient with mitral valve disease

Background

Ejection fraction is the standard metric to analyze cardiac function in the left (LV) or right (RV) ventricles. However, these global metrics are not able to characterize patients in which the heart compensates for regional dysfunction. More sensitive metrics are needed to detect subclinical regional dysfunction before cardiac remodeling results in changes in ejection fraction (EF) and global longitudinal strain (GLS). Fast-SENC intramyocardial strain (fSENC) is a unique cardiac magnetic resonance imaging (CMR) modality that measures intramyocardial contraction in 1 heartbeat per image plane. This prospective registry compares segmental fSENC to standard CMR calculations (e.g. LVEF, volumes, mass, etc.) in patients with mitral valve disease.

Methods

A single center, prospective registry of CMR scans acquired with a 1.5T scanner were evaluated for standard CMR calculations as well as fSENC scans. Intramyocardial LV & RV strain was quantified with MyoStrain software. Three short axis scans (basal, midventricular, & apical) were used to calculate peak strain in 16 LV & 6 RV longitudinal segments while three long axis scans (2-, 3-, & 4-chamber) were used to calculate 21 LV & 5 RV circumferential segments.

Results

A total of 493 scans in 424 patients with moderate or severe mitral regurgitation were included in the study. Patients had an average (± stdev) age of 60 (15) yrs and BMI of 27 (4) kg/m2; 63% had arterial hypertension, 19% diabetes mellitus, 10% atrial fibrillation, 15% pulmonary disease, and 32% coronary artery disease. Figure 1 shows the non-linear relationship between segmental fSENC strain (% of normal LV segments ≤−17%) versus LVEF (R=0.81).

Conclusion

Segmental fSENC detects subclinical LV dysfunction before changes in LVEF. Evaluating segmental longitudinal and circumferential fSENC peak strain provides an alternative metric that shows consistent changes in cardiac function in patients with mitral valve disease irrespective of global calculations that are dependent on loading conditions.

Funding Acknowledgement

Type of funding source: None

Intramyocardial fast-SENC is less impacted by compensatory mechanisms while monitoring cardiotoxic effects of chemotherapy than echocardiography and conventional CMR: the PREFECT study

Background

Cancer treatments (CT) have been shown to occasionally elicit a toxic reaction on the heart. Echocardiography (ECHO) and cardiac magnetic resonance imaging (CMR) have been used to monitor cardiotoxicity through left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). Fast-SENC (fSENC) CMR testing directly measures intramyocardial contraction to quantify subtle changes in function capable of detecting cardiotoxicity missed by conventional imaging modalities. The PREFECT study compares fast-SENC vs ECHO in terms of sensitivity of predicting and detecting subclinical (sCTX) or clinical cardiotoxicity (cCTX) irrespective of loading conditions or changes in cardiac output.

Methods

A single center, prospective clinical trial of patients receiving anthracycline-based CT had fSENC acquired during CMR exams with a 1.5T scanner. Intramyocardial LV & RV strain was quantified with MyoStrain software. Three short axis scans (basal, midventricular, & apical) were used to calculate peak strain in 16 LV & 6 RV longitudinal segments while three long axis scans (2-, 3-, & 4-chamber) were used to calculate 21 LV & 5 RV circumferential segments.

Results

63 patients had 323 scans; 41% experienced sCTX and 15% cCTX. Figure 1 shows a Box and Whisker's plot for the % of fSENC ≤−17 by cardiotoxicity status. Both fSENC and CMR LVEF detected sCTX and cCTX based on ANOVA analysis (p&lt;0.001) although fSENC had better delineation of both sCTX and cCTX. However, ECHO LVEF and GLS did not detect sCTX or cCTX (p=NS). CMR stroke volume index decreased while blood pressure and heart rate increased for both sCTX and cCTX (p&lt;0.001). Meanwhile, mass index and end-systolic volume index increased for cCTX (p&lt;0.001).

Conclusion

Segmental fSENC detected early CT-induced sCTX regardless of loading conditions. ECHO did not detect sCTX potentially due to compensatory mechanisms or acoustic window limitations in breast cancer and lymphoma patients that had less effect on CMR.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Myocardial solution (MSI)

Safety, effectiveness and mid-term follow-up in 136 consecutive patients with moderate to severely calcified lesions undergoing phoenix atherectomy

To investigate the safety and effectiveness of the Phoenix atherectomy device for the treatment of complex and calcified lesions in patients with peripheral artery disease (PAD). 136 consecutive all-comer patients with chronic PAD underwent Phoenix atherectomy. Safety in terms of vessel injury and embolism, efficacy and clinical success in terms of ≥ 1Rutherford class (RF) improvement during follow-up were systematically analyzed. Lesion calcification was categorized by the Peripheral Arterial Calcium Scoring System (PACSS), whereas lesion complexity was classified by the Transatlantic Inter-Society Consensus (TASC). 151 lesions were treated in 136 consecutive patients. Clinical follow-up was available at 10.3 ± 4.2 months in 132 (97%) patients. 55 patients (40%) had intermittent claudication, 16 (12%) rest pain and 65 (48%) had ischemic ulcerations (mean RF class = 4.2 ± 1.1). 15 (11%) patients had TASC B lesions, whereas the majority 72 (53%) and 49 (36%) exhibited TASC C and D lesions, respectively. Mean PACSS score was 3.3 ± 0.9. Mean lesion length was 106 ± 92 mm. Atherectomy was combined with drug-coated balloon (DCB) in 129 (95%) patients. Nine (6.6%) patients with infra-inguinal lesions received stents. Technical and procedural success were recorded in 102 (75%) and 135 (99%), respectively. Perforation was noticed in 2 (1%), whereas asymptomatic embolism occurred in 6 (4%) patients. Clinical success was present in 54 (100%) patients with claudication and in 65 of 78 (83%) patients with critical limb ischemia (CLI). Atherectomy in combination with DCB angioplasty can be safely performed in patients with complex, calcified peripheral lesions with a relatively low rate of bail-out stenting and promising clinical mid-term results.German Clinical Trials Register: DRKS00016708.

Splenic Switch-Off for Determining the Optimal Dosage for Adenosine Stress Cardiac MR in Terms of Stress Effectiveness and Patient Safety

BACKGROUND

Adenosine stress MRI is well established for the evaluation of known and suspected coronary artery disease. However, a proportion of patients might be "under-stressed" using the standard adenosine dose.

PURPOSE

To compare three different adenosine dosages for stress MRI in terms of stress adequacy based on splenic switch-off (SSO) and limiting side effects.

STUDY TYPE

Prospective.

POPULATION

In all, 100 patients were randomized in group 1 (33 pts), group 2 (34 pts), and group 3 (33 pts), receiving dosages of 140 μg/kg/min, 175 μg/kg/min, or 210 μg/kg/min, respectively. SSO was evaluated visually and quantitatively.

SEQUENCE

Stress perfusion was performed using a 1.5T scanner in three short axes using a standard single-shot, saturation recovery gradient-echo sequence.

ASSESSMENT

Three blinded experienced operators evaluated SSO on stress and rest perfusion acquisitions in the three groups. The signal intensity of the spleen and myocardium and the presence of inducible ischemia and late gadolinium enhancement were assessed.

STATISTICAL ANALYSIS

T-test, analysis of variance (ANOVA), chi-squared test, and Pearson's correlation coefficient.

RESULTS

SSO was present more frequently in patients receiving 175 μg/kg/min and 210 μg/kg/min (31/33 [94%] and 27/29 [93%], respectively) compared to those receiving the standard dose (19/33 [58%], P < 0.05). A positive stress result was noted in 3/33 (9%) patients receiving 140 μg/kg/min vs. 9/33 (27%) patients receiving 175 μg/kg/min and 10/31 (33%) patients receiving 210 μg/kg/min (P < 0.05 for all, P < 0.05 for group 1 vs. groups 2, 3). The relative decrease of splenic signal intensity at hyperemia vs. baseline was significantly lower in group 1 compared to groups 2 and 3 (-33% vs. -54%, -56%, respectively; P < 0.05). No adverse events during scanning were noted in groups 1 and 2, whereas in group 3 four examinations were stopped due to severe dyspnea (n = 2) and AV-blockage (n = 2).

DATA CONCLUSION

A dosage of 175 μg/kg/min adenosine results in a higher proportion of SSO, which may be an indirect marker of adequate coronary vasodilatation and simultaneously offers similar safety compared to the standard 140 μg/kg/min dosage.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2 J. MAGN. RESON. IMAGING 2020;52:1732-1742.

Comparison of ante-versus retrograde access for the endovascular treatment of long and calcified, de novo femoropopliteal occlusive lesions

To compare antegrade versus retrograde recanalization, in terms of procedural time, radiation and contrast agent exposure, number and total length of implanted stents and procedural complications, in long and calcified, de novo femoropopliteal occlusions. We performed retrospective matching of prospectively acquired data by lesion length, occlusion length and lesion calcification by the peripheral arterial calcium scoring system (PACSS) score in patients who were referred for endovascular treatment due to symptomatic peripheral artery disease (PAD). Forty-two consecutive patients with antegrade and 23 patients with retrograde after failed antegrade recanalization were identified (mean lesion length = 32.1 ± 6.9 cm; mean occlusion length = 24.6 ± 7.7 cm; PACSS score = 3.25 ± 0.91). 23% of the patients had intermittent claudication, whereas 77% exhibited critical limb ischemia (CLI). Patients who underwent retrograde versus antegrade recanalization required a significantly lower number of stents (0.9 ± 1.0 versus 1.8 ± 1.4, p = 0.01) and a lower total stent length (6.8 ± 8.5 cm versus 11.7 ± 9.9 cm, p < 0.05) in the interest of more extensive coverage of the lesions using drug coated balloons (DCB) (28.5 ± 12.0 cm versus 18.2 ± 16.0 cm, p = 0.01). No re-entry device was required with the retrograde versus 9 of 42 (21%) with the antegrade recanalization group (p = 0.02). The rate of complications due to retrograde puncture was low (one patient with hematoma and one with distal pseudoaneurysm, both managed conservatively). In long and calcified femoropopliteal occlusions, the retrograde approach is associated with a lower number of re-entry devices and stents and with more extensive lesion coverage with DCB, in the interest of costs and possibly long-term patency.German Clinical Trials Register: DRKS00015277.

Comparison of feature tracking, fast-SENC, and myocardial tagging for global and segmental left ventricular strain

AIMS

A multitude of cardiac magnetic resonance (CMR) techniques are used for myocardial strain assessment; however, studies comparing them are limited. We sought to compare global longitudinal (GLS), circumferential (GCS), segmental longitudinal (SLS), and segmental circumferential (SCS) strain values, as well as reproducibility between CMR feature tracking (FT), tagging (TAG), and fast-strain-encoded (fast-SENC) CMR techniques.

METHODS AND RESULTS

Eighteen subjects (11 healthy volunteers and seven patients with heart failure) underwent two CMR scans (1.5T, Philips) with identical parameters. Global and segmental strain values were measured using FT (Medis), TAG (Medviso), and fast-SENC (Myocardial Solutions). Friedman's test, linear regression, Pearson's correlation coefficient, and Bland-Altman analyses were used to assess differences and correlation in measured GLS and GCS between the techniques. Two-way mixed intra-class correlation coefficient (ICC), coefficient of variance (COV), and Bland-Altman analysis were used for reproducibility assessment. All techniques correlated closely for GLS (Pearson's r: 0.86-0.92) and GCS (Pearson's r: 0.85-0.94). Intra-observer and inter-observer reproducibility was excellent in all techniques for both GLS (ICC 0.92-0.99, CoV 2.6-10.1%) and GCS (ICC 0.89-0.99, CoV 4.3-10.1%). Inter-study reproducibility was similar for all techniques for GLS (ICC 0.91-0.96, CoV 9.1-10.8%) and GCS (ICC 0.95-0.97, CoV 7.6-10.4%). Combined segmental intra-observer reproducibility was good in all techniques for SLS (ICC 0.914-0.953, CoV 12.35-24.73%) and SCS (ICC 0.885-0.978, CoV 10.76-19.66%). Combined inter-study SLS reproducibility was the worst in FT (ICC 0.329, CoV 42.99%), while fast-SENC performed the best (ICC 0.844, CoV 21.92%). TAG had the best reproducibility for combined inter-study SCS (ICC 0.902, CoV 19.08%), while FT performed the worst (ICC 0.766, CoV 32.35%). Bland-Altman analysis revealed considerable inter-technique biases for GLS (FT vs. fast-SENC 3.71%; FT vs. TAG 8.35%; and TAG vs. fast-SENC 4.54%) and GCS (FT vs. fast-SENC 2.15%; FT vs. TAG 6.92%; and TAG vs. fast-SENC 2.15%). Limits of agreement for GLS ranged from ±3.1 (TAG vs. fast-SENC) to ±4.85 (FT vs. TAG) for GLS and ±2.98 (TAG vs. fast-SENC) to ±5.85 (FT vs. TAG) for GCS.

CONCLUSIONS

We found significant differences in measured GLS and GCS between FT, TAG, and fast-SENC. Global strain reproducibility was excellent for all techniques. Acquisition-based techniques had better reproducibility than FT for segmental strain.

Successful Endovascular Treatment of Acute Thromboembolic Upper Limb Ischemia in a Patient with Atrial Fibrillation

Acute limb ischemia represents a medical emergency that requires prompt diagnosis and treatment to preserve the viability of the affected tissue. The majority of the ischemic events are thrombotic in nature, especially in patients with atrial fibrillation. To date, surgical thrombectomy is usually used for the treatment of acute thromboembolic upper limb ischemia. Herein, we present a case of an 88-year-old patient who presented with right upper limb pain, pulselessness, and paresthesia. Duplex sonography revealed thrombotic occlusion and the absence of flow in both the ulnar and radial arteries. Electrocardiogram exhibited atrial fibrillation with a heart rate of 88 bpm. Antegrade puncture of the brachial artery was performed, and digital subtraction angiography confirmed fresh occlusion of the ulnar and radial arteries with some residual flow in the accessory brachial artery. Thrombus aspiration using a 6-Fr Eliminate aspiration catheter (Terumo Interventional Systems, Eschborn, Germany) was repeatedly performed, resulting in thrombolysis in myocardial infarction (TIMI) III antegrade flow to the right hand, promptly filling of the palmar arch and retrograde filling of the ulnar artery. Pain and paresthesia immediately resolved without need for further pharmacological interventions. The patient was discharged without functional deficits of his right hand, and duplex sonography after 4 weeks and 6 months revealed triphasic flow of the brachial and radial arteries and retrograde flow of the ulnar artery.

Syncope in a female patient. Echocardiography and cardiac computed tomography reveal an unexpected diagnosis

Papillary fibroelastoma is a benign cardiac tumor with a high potential of embolization. Coronary computed tomography is a valuable tool for the work-up of patients with papillary fibroelastoma, providing accurate information regarding the coronary circulation and morphology of the cardiac mass.

Strain-encoded magnetic resonance: a method for the assessment of myocardial deformation

This study aims to assess the usefulness of strain‐encoded magnetic resonance (SENC) for the quantification of myocardial deformation (‘strain’) in healthy volunteers and for the diagnostic workup of patients with different cardiovascular pathologies. SENC was initially described in the year 2001. Since then, the SENC sequence has undergone several technical developments, aiming at the detection of strain during single‐heartbeat acquisitions (fast‐SENC). Experimental and clinical studies that used SENC and fast‐SENC or compared SENC with conventional cine or tagged magnetic resonance in phantoms, animals, healthy volunteers, or patients were systematically searched for in PubMed. Using ‘strain‐encoded magnetic resonance and SENC’ as keywords, three phantom and three animal studies were identified, along with 27 further clinical studies, involving 185 healthy subjects and 904 patients. SENC (i) enabled reproducible assessment of myocardial deformation in vitro, in animals and in healthy volunteers, (ii) showed high reproducibility and substantially lower time spent compared with conventional tagging, (iii) exhibited incremental value to standard cine imaging for the detection of inducible ischaemia and for the risk stratification of patients with ischaemic heart disease, and (iv) enabled the diagnostic classification of patients with transplant vasculopathy, cardiomyopathies, pulmonary hypertension, and diabetic heart disease. SENC has the potential to detect a wide range of myocardial diseases early, accurately, and without the need of contrast agent injection, possibly enabling the initiation of specific cardiac therapies during earlier disease stages. Its one‐heartbeat acquisition mode during free breathing results in shorter cardiovascular magnetic resonance protocols, making its implementation in the clinical realm promising.

The Role of Atherectomy in Peripheral Artery Disease: Current Evidence and Future Perspectives

An ageing population and the increasing prevalence of cardiovascular risk factors have aggravated the burden of peripheral artery disease (PAD). Despite advances in the pharmacological treatment of atherosclerosis, many patients with symptomatic PAD require invasive procedures to reduce the symptoms of claudication, salvage tissue and prevent amputation and subsequent disability in those with critical limb ischaemia. After significant advances in endovascular treatment over the past two decades, these techniques are widely accepted as first-choice treatment in the majority of patients with PAD. However, in patients with severely calcified lesions, standard endovascular treatment such as plain or drug-coated balloon (DCB) angioplasty may fail due to vessel recoil or severe dissection in the acute setting, and intimal hyperplasia in the long term. With the use of percutaneous plaque modification and debulking techniques based on atherectomy, such calcified lesions can be tackled more easily after removal or fragmentation of atherosclerotic plaque. More homogeneous balloon expansion at lower pressures can be achieved after atherectomy, which reduces barotrauma while allowing better drug delivery to the vessel wall during DCB angioplasty avoids the need for stent placement. There are four principal methods of direct atherectomy available at the present time: directional atherectomy, rotational atherectomy, orbital atherectomy and hybrid atherectomy. In this article, we provide a short overview of these techniques and the current evidence from clinical trials to support their use.

Strain-encoded cardiac magnetic resonance imaging: a new approach for fast estimation of left ventricular function

Background

Recently introduced fast strain-encoded (SENC) cardiac magnetic resonance (CMR) imaging (fast-SENC) provides real-time acquisition of myocardial performance in a single heartbeat. We aimed to test the ability and accuracy of real-time strain-encoded CMR imaging to estimate left ventricular volumes, ejection fraction and mass.

Methods

Thirty-five subjects (12 healthy volunteers and 23 patients with known or suspected coronary artery disease) were investigated. All study participants were imaged at 1.5 Tesla MRI scanner (Achieva, Philips) using an advanced CMR study protocol which included conventional cine and fast-SENC imaging. A newly developed real-time free-breathing SENC imaging technique based on the acquisition of two images with different frequency modulation was employed.

Results

All parameters were successfully derived from fast-SENC images with total study time of 105 s (a 15 s scan time and a 90 s post-processing time). There was no significant difference between fast-SENC and cine imaging in the estimation of LV volumes and EF, whereas fast-SENC underestimated LV end-diastolic mass by 7%.

Conclusion

The single heartbeat fast-SENC technique can be used as a good alternative to cine imaging for the precise calculation of LV volumes and ejection fraction while the technique significantly underestimates LV end-diastolic mass.

Successful endovascular treatment in patients with acute thromboembolic ischemia of the lower limb including the crural arteries

AIM

To examine the efficacy and safety of the 6 French (6F) Rotarex^®S catheter system in patients with acute limb ischemia (ALI) involving thromboembolic occlusion of the proximal and mid-crural vessels.

METHODS

The files of patients in our department with ALI between 2015 and 2017 were examined. In seven patients, the Rotarex^®S catheter was used in the proximal segment of the crural arteries. Data related to the clinical examination, Doppler sonography, angiography and follow-up from these patients were further used for analysis.

RESULTS

Two patients (29%) had thrombotic occlusion of the common femoral artery, and the remaining five exhibited thrombosis of the superficial femoral artery and popliteal artery. Mechanical thrombectomy was performed in all cases using a 6F Rotarex^®S catheter. Additional Rotarex^®S catheter thrombectomy due to remaining thrombus formation with no reflow was performed in the anterior tibial artery in two of seven cases (29%), in the tibiofibular tract and posterior tibial artery in two of seven cases (29%) and in the tibiofibular tract and fibular artery in the remaining three of seven cases (43%). Ischemic symptoms resolved promptly in all, and none of the patients experienced a procedural complication, such as crural vessel dissection, perforation or thrombus embolization.

CONCLUSION

Mechanical debulking using the 6F Rotarex^®S catheter system may be a safe and effective treatment option in case of thrombotic or thromboembolic occlusion of the proximal and mid-portion of crural arteries.

Reproducibility study on myocardial strain assessment using fast-SENC cardiac magnetic resonance imaging

Myocardial strain is a well validated parameter for estimating left ventricular (LV) performance. The aim of our study was to evaluate the inter-study as well as intra- and interobserver reproducibility of fast-SENC derived myocardial strain. Eighteen subjects (11 healthy individuals and 7 patients with heart failure) underwent a cardiac MRI examination including fast-SENC acquisition for evaluating left ventricular global longitudinal (GLS) and circumferential strain (GCS) as well as left ventricular ejection fraction (LVEF). The examination was repeated after 63 [range 49‒87] days and analyzed by two experienced observers. Ten datasets were repeatedly assessed after 1 month by the same observer to test intraobserver variability. The reproducibility was measured using the intraclass correlation coefficient (ICC) and Bland-Altman analysis. Patients with heart failure demonstrated reduced GLS and GCS compared to healthy controls (−15.7 ± 3.7 vs. −20.1 ± 1.4; p = 0.002 for GLS and −15.3 ± 3.7 vs. −21.4 ± 1.1; p = 0.001 for GCS). The test-retest analysis showed excellent ICC for LVEF (0.92), GLS (0.94) and GCS (0.95). GLS exhibited excellent ICC (0.99) in both intra- and interobserver variability analysis with very narrow limits of agreement (−0.6 to 0.5 for intraobserver and −1.3 to 0.96 for interobserver agreement). Similarly, GCS showed excellent ICC (0.99) in both variability analyses with narrow limits of agreement (−1.1 to 1.2 for intraobserver and −1.7 to 1.3 for interobserver agreement), whereas LVEF showed larger limits of agreement (−14.4 to 10.1). The analysis of fast-SENC derived myocardial strain using cardiac MRI provides a highly reproducible method for assessing LV functional performance.

Successful recanalization of long femoro-crural occlusive disease after failed bypass surgery

Patients with critical limb ischemia necessitate immediate intervention to restore blood flow to the affected limb. Endovascular procedures are currently preferred for these patients. We describe the case of an 80-year-old female patient who presented to our department with ischemic rest pain and ulceration of the left limb. The patient had history of left femoral popliteal bypass surgery, femoral thromboendarterectomy and patch angioplasty of the same limb 2 years ago. Doppler sonography and magnetic resonance angiography revealed an occlusion of the left superficial femoral artery (SFA) and popliteal artery and of all three infra-popliteal arteries. Due to severe comorbidities, the patient was scheduled for a digital subtraction angiography. An antegrade approach was first attempted, however the occlusion could not be passed. After revision of the angiography acquisition, a stent was identified at the level of the mid SFA, which was subsequently directly punctured, facilitating the retrograde crossing of the occlusion. Thereafter, balloon angioplasty was performed in the SFA, popliteal artery and posterior tibial artery. The result was considered suboptimal, but due to the large amount of contrast agent used, a second angiography was planned in 4 wk. In the second session, drug coated balloons were used to optimize treatment of the SFA, combined with recanalization of the left fibular artery, to optimize outflow. The post-procedural course was uneventful. Ischemic pain resolved completely after the procedure and at 8 wk of follow-up and the foot ulceration completely healed.

Influence of irregular heart rhythm on radiation exposure, image quality and diagnostic impact of cardiac computed tomography angiography in 4,339 patients. Data from the German Cardiac Computed Tomography Registry

BACKGROUND

Coronary computed tomography angiography (coronary CTA) provides non-invasive evaluation of the coronary arteries with high precision for the detection of significant coronary artery disease (CAD).

AIM

To investigate whether irregular heart rhythm including atrial fibrillation and premature beats during data acquisition influences (i) radiation and contrast media exposure, (ii) number of non-evaluable coronary segments and (iii) diagnostic impact of coronary CTA.

METHODS

Twelve tertiary care centers with ≥64 slice CT scanners and ≥5 years of experience with cardiovascular imaging participated in this registry. Between 2009 and 2014, 4339 examinations were analysed in patients who underwent clinically indicated coronary CTA for suspected CAD. Clinical and epidemiologic data were gathered from all patients. In addition, clinical presentation, heart rate and rhythm during the scan, Agatston score, radiation and contrast media exposure and the diagnostic impact of coronary CTA were systematically analysed.

RESULTS

Of 4339 patients in total, 260 (6.0%) had irregular heart rhythm, whereas the remaining 4079 (94.0%) had stable sinus rhythm. Patients with irregular heart rhythm were older (63.2 ± 12.5yrs versus 58.6 ± 11.4yrs. p < 0.001), exhibited a higher rate of pathologic stress tests before CTA (37.1% versus 26.1%, p < 0.01) and higher heart rates during CTA compared to those with sinus rhythm (62.5 ± 11.6bpm versus 58.9 ± 8.5bpm, p < 0.001). Both contrast media exposure and radiation exposure were significantly higher in patients with irregular heart rhythm (90 mL (95%CI = 80-110 mL) versus 80 mL (95%CI = 70-90 mL) and 6.2 mSv (95%CI = 2.5-11.7) versus 3.3 mSv (95%CI = 1.7-6.9), p < 0.001 for both). Coronary CTA excluded significant CAD less frequently in patients with irregular heart rhythm (32.9% versus 44.8%, p < 0.001). This was attributed to the higher rate of examinations with at least one non-diagnostic coronary segment in patients with irregular heart rhythm (10.8% versus 4.6%, p < 0.001). Subsequent invasive angiography could be avoided in 47.2% of patients with irregular heart rhythm compared to 52.9% of patients with sinus rhythm (p = NS), whereas downstream stress testing was recommended in 3.2% of patients with irregular heart rhythm versus 4.0% of patients with sinus rhythm (p = NS).

CONCLUSION

A significant number of patients scheduled for coronary CTA have irregular heart rhythm in a real-world clinical setting. In such patients, heart rate during coronary CTA is higher, possibly resulting in (i) higher radiation and contrast agent exposure and (ii) more frequent coronary CTA examinations with at least one non-diagnostic coronary artery segment. However, this does not seem to lead to increased downstream stress testing or subsequent invasive procedures.

Incremental value of cardiac magnetic resonance for the evaluation of cardiac tumors in adults: experience of a high volume tertiary cardiology centre

To assess the value of cardiac magnetic resonance imaging (CMR) in evaluating cardiac tumours in a tertiary cardiology centre. Between 2004 and 2014, 125 patients (pts.) from a total of 17000 who received a CMR examination in our institution were referred with the suspicion of cardiac tumours. A dedicated protocol was used that included standard cine SSFP acquisitions as well as tissue characterization using T1 and T2 black-blood (T1 BB and T2 BB respectively) with and without fat suppression, perfusion of the structure and late gadolinium enhancement. Patients' files were retrospectively analysed and data related to clinical status, results from other examinations (echocardiography), therapeutic approach and histology results, when performed, were collected. In 65 pts., a diagnosis of cardiac tumour was reached. 45 Pts had a biopsy. The CMR examination was concordant with the histology results in 35 (76%) pts. superior to that showed by echocardiography, 26 (58%) pts., p = 0.03. Forty-two (65%) pts. had a benign tumour and 23 (35%) a malignant process. Myxoma was the most frequent benign tumour, 27 (65%) and cardiac metastases were the most frequent form of malignancies, 21 (91%), with B cell non-Hodgkin lymphoma being the most frequent one, 4 (19%). Benign tumours were mostly located in the left atrium, 27 (64%) versus 6 (26%), p = 0.007, whereas malignant tumours had a predilection for the right atrium und left ventricle [11 (48%) vs. 3 (7%), p = 0.001 and 8 (35%) vs. 3 (7%), p = 0.03]. All benign cardiac tumours were single and did not show signs of infiltration. Conversely, malignant cardiac tumours were larger (43 ± 35 vs. 24 ± 16, p = 0.007) with a significant proportion (65%) showing myocardial infiltration. Pts with malignant cardiac tumours had a higher proportion of LGE (82 vs. 60%, p = 0.05) and exhibited more frequently an isointense signal in T1 BB images (78 vs. 61%, p = 0.04). Both groups showed similar proportion of perfusion and signal intensity in the T2 BB acquisitions (p = NS). CMR is a valuable tool in evaluating cardiac tumours, proving superior to echocardiography in establishing the type of cardiac tumour.

Successful carbon dioxide angiography guided endovascular thrombectomy of the superficial femoral artery in a young patient with critical limb ischemia

Currently, the treatment of thromboembolic ischemia of the lower extremities includes percutaneous rotational thrombectomy and aspiration devices. However, the standard approach for endovascular treatment requires the administration of iodine contrast agents, which is problematic in patients with pre-existing renal disease and diabetes. Herein, we describe a case of a CO₂ angiography guided endovascular thrombectomy of the superficial femoral artery (SFA) in a young patient with critical limb ischemia. Mechanical thrombectomy using the Rotarex system, catheter aided aspiration and subsequent stent placement in the SFA was entirely guided using CO₂ angiography.