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Ochoa-Figueroa M, Valera-Soria C, Pagonis C, Ressner M, Norberg P, Sanchez-Rodriguez V, Frias-Rose J, Good E, Davidsson A. Diagnostic performance of a novel deep learning attenuation correction software for MPI using a cardio dedicated CZT camera. Experience in the clinical practice. Rev Esp Med Nucl Imagen Mol 2024; 43:23-30. [PMID: 37748688 DOI: 10.1016/j.remnie.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/23/2023] [Accepted: 08/26/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE To evaluate the diagnostic performance of a novel deep learning attenuation correction software (DLACS) for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) cardio dedicated camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease (CAD) in a high-risk population. METHODS Retrospective study of 300 patients (196 males [65%], mean age 68 years) from September 2014 to October 2019 undergoing MPI, followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 37% for the whole cohort. The MPI was performed in a dedicated CZT cardio camera (D-SPECT Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. MPI was retrospectively evaluated with and without the DLACS. RESULTS The overall diagnostic accuracy of MPI without DLACS to identify patients with any obstructive CAD at ICA was 87%, sensitivity 94%, specificity 57%, Positive Predictive Value 91% and Negative Predictive Value 64%. Using DLACS the overall diagnostic accuracy was 90%, sensitivity 91%, specificity 86%, Positive Predictive Value 97% and Negative Predictive Value 66%. CONCLUSION Use of the novel DLACS enhances performance of the MPI using the CZT D-SPECT camera and achieves improved results, especially avoiding artefacts and reducing the number of false positive results.
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Affiliation(s)
- Miguel Ochoa-Figueroa
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden; Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.
| | - Carlos Valera-Soria
- Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Christos Pagonis
- Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marcus Ressner
- Department of Medical Physics, Linköping University Hospital, Linköping, Sweden
| | - Pernilla Norberg
- Department of Medical Physics, Linköping University Hospital, Linköping, Sweden
| | - Veronica Sanchez-Rodriguez
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden; Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jeronimo Frias-Rose
- Department of Pathology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Elin Good
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden; Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anette Davidsson
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
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Ochoa-Figueroa M, Frias-Rose J, Good E, Sanchez-Rodriguez V, Davidsson A, Pagonis C. Diagnostic performance of different cardiac stress protocols for myocardial perfusion imaging for the diagnosis of coronary artery disease using a cadmium-zinc-telluride camera with invasive coronary angiography correlation. Rev Esp Med Nucl Imagen Mol 2023; 42:281-288. [PMID: 36103979 DOI: 10.1016/j.remnie.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/08/2021] [Accepted: 01/23/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of three different cardiac stress protocols for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease in a high risk population. METHODS Retrospective study of 263 patients (96 women and 167 males, mean age 68 years) from which 119 patients performed a bicycle stress test (BST), 113 pharmacological stress test (PST) and 31 a combination of the two (CST) between September 2014 and December 2018. The patients then underwent myocardial perfusion imaging (MPI), followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 36% for the whole population. The MPI was performed in a dedicated CZT cardio camera (D-SPECT Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. RESULTS No significant difference was observed between the three stress protocols in terms of diagnostic accuracy (BST 85%, PST 88%, CST 84%). The overall diagnostic accuracy of MPI to identify patients with any obstructive CAD at ICA was 86%, Sensitivity 93%, Specificity 54%, PPV 90% and NPV 63%. CONCLUSION The CZT D-SPECT camera achieves overall satisfactory results in the diagnosis of CAD, observing no significant differences in the diagnostic performance when the stress test was performed as a BST, PST or CST.
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Affiliation(s)
- Miguel Ochoa-Figueroa
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden; Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.
| | - Jeronimo Frias-Rose
- Department of Pathology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Elin Good
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden; Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Veronica Sanchez-Rodriguez
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden; Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anette Davidsson
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Christos Pagonis
- Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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D’Andrea A, Ilardi F, Palermi S, Riegler L, Miele T, Giallauria F, D’Alto M, Russo V, Cice G. Multimodality imaging in decompensated heart failure. Eur Heart J Suppl 2023; 25:C292-C300. [PMID: 37125293 PMCID: PMC10132613 DOI: 10.1093/eurheartjsupp/suad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Heart failure (HF) is usually suspected by clinical history, symptoms, physical examination, electrocardiogram findings, and natriuretic peptides' values. However, echocardiography and other imaging techniques play an essential role in supporting HF diagnosis. Thanks to its non-invasiveness and safety, transthoracic echocardiography is the first-level technique of choice to assess myocardial structure and function, trying to establish the diagnosis of HF with reduced, mildly reduced, and preserved ejection fraction. The role of echocardiography is not limited to diagnosis but it represents a crucial tool in guiding therapeutic decision-making and monitoring response to therapy. Over the last decades, several technological advancements were made in the imaging field, aiming at better understanding the morphofunctional abnormalities occurring in cardiovascular diseases. The purpose of this review article is to summarize the incremental role of imaging techniques (in particular cardiac magnetic resonance and myocardial scintigraphy) in HF, highlighting their essential applications to HF diagnosis and management.
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Affiliation(s)
- Antonello D’Andrea
- Corresponding author. Department of Translational Medical Sciences, Unit of Cardiology, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy; Unit of Cardiology and Intensive Coronary Care, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy.
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
- Public Health Department, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
| | - Stefano Palermi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
| | - Lucia Riegler
- Department of Cardiology, Umberto I Hospital, Via Alfonso de Nicola, 84014 Nocera Inferiore, Italy
| | - Tiziana Miele
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Francesco Giallauria
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Michele D’Alto
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Vincenzo Russo
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Gennaro Cice
- Department of Cardiology, Policlinico Casilino, Via Casilina, 1049, 00169 Rome
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Valensi P, Berkane N, Pinto S, Sellier N, Soussan M, Nguyen MT, Cosson E. Performance of the 2019 ESC/EASD guideline strategy for the screening of silent coronary artery disease in patients with diabetes. Cardiovasc Diabetol 2023; 22:33. [PMID: 36793073 PMCID: PMC9930289 DOI: 10.1186/s12933-023-01760-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/01/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The 2019 guidelines for cardiovascular risk stratification by the European Society of Cardiology and European Association for the Study of Diabetes (ESC-EASD) suggested screening for silent coronary disease in very high risk patients with severe target organ damage (TOD) (i.e. peripheral occlusive arterial disease or severe nephropathy) or high coronary artery calcium (CAC) score. This study aimed to test the validity of this strategy. METHODS In this retrospective study, we included 385 asymptomatic patients with diabetes and no history of coronary disease but with TOD or ≥ 3 risk factors in addition to diabetes. CAC score was measured using computed tomography scan and a stress myocardial scintigraphy was performed to detect silent myocardial ischemia (SMI), with subsequent coronary angiography in those with SMI. Various strategies to select patients to be screened for SMI were tested. RESULTS CAC score was ≥ 100 Agatston units (AU) in 175 patients (45.5%). SMI was present in 39 patients (10.1%) and among the 30 patients who underwent angiography, 15 had coronary stenoses and 12 had a revascularization procedure. The most effective strategy consisted in performing myocardial scintigraphy in the 146 patients with severe TOD and, among the 239 other patients without severe TOD, in those with CAC ≥ 100 AU: this strategy provided 82% sensitivity for SMI diagnosis, and identified all the patients with stenoses. CONCLUSION The ESC-EASD guidelines suggesting SMI screening in asymptomatic patients with very high risk assessed by severe TOD or high CAC score appears effective and could identify all the patients with stenoses eligible for revascularization.
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Affiliation(s)
- Paul Valensi
- Unit of Endocrinology-Diabetology-Nutrition, AP-HP, Jean Verdier Hospital, Paris 13 University, Sorbonne Paris Cité, CRNH-IdF, CINFO, Avenue du 14 Juillet. 93140, Bondy, France.
| | - Narimane Berkane
- Department of Endocrinology-Diabetology-Nutrition, AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, CRNH-IdF, CINFO, Bobigny, France
| | - Sara Pinto
- Unit of Endocrinology-Diabetology-Nutrition, AP-HP, Jean Verdier Hospital, Paris 13 University, Sorbonne Paris Cité, CRNH-IdF, CINFO, Avenue du 14 Juillet. 93140, Bondy, France
| | - Nicolas Sellier
- Department of Radiology, AP-HP, Jean Verdier Hospital, Paris 13 University, Sorbonne Paris Cité, Bondy, France
| | - Michael Soussan
- Department of Nuclear Medicine, AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Bobigny, France
| | - Minh Tuan Nguyen
- Unit of Endocrinology-Diabetology-Nutrition, AP-HP, Jean Verdier Hospital, Paris 13 University, Sorbonne Paris Cité, CRNH-IdF, CINFO, Avenue du 14 Juillet. 93140, Bondy, France
| | - Emmanuel Cosson
- Department of Endocrinology-Diabetology-Nutrition, AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, CRNH-IdF, CINFO, Bobigny, France.,Unité de Recherche Epidémiologique Nutritionnelle, Paris 13 University, Sorbonne Paris Cité, UMR U557 INSERM/U11125 INRAE/CNAM/Université Paris13, Bobigny, France
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Pasteur-Rousseau A, Odouard S, Souibri K, Sebag FA, Deux JF, Damy T. [Cardiac imaging in infiltrative cardiomyopathies. What cardiovascular imaging modalities to propose in hypertrophic cardiomyopathies ?]. Ann Cardiol Angeiol (Paris) 2022; 71:63-74. [PMID: 35184821 DOI: 10.1016/j.ancard.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 12/13/2022]
Abstract
Infiltrative cardiomyopathies are abnormal accumulations or depositions of different substances in cardiac tissue leading to its dysfunction, first diastolic, then systolic. The different infiltrative cardiomyopathies are amyloidosis (both light chain amyloidosis and transthyretin amyloidosis variants), lysosomal and glycogen storage disorders (Fabry-Anderson disease), and iron overload (hemochromatosis and thalassemia associated with blood transfusions), as well as inflammatory diseases such as sarcoidosis. We also evoke hypereosinophilic syndrome associated with endomyocardial fibrosis. Echocardiography is the first essential step after interrogatory and clinical examination and may help the cardiologist as a screening tool. Cardiac MRI is the second fundamental step towards the diagnosis especially due to the late gadolinium enhancement and to the T1-mapping. Cardiac amyloidosis diagnosis also requires the use of nuclear imaging. Cardiac CT-Scan may be useful for estimating the amyloid load, identify potential cardiac thrombus and rule out associated coronaropathy.
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Affiliation(s)
- Adrien Pasteur-Rousseau
- Institut Cœur Paris Centre (ICPC). Clinique Turin (9 rue de Turin, 75008 Paris), Clinique du Parc Monceau (21 rue de Chazelles, 75017 Paris), Clinique Floréal (40 rue Floréal, 93170 Bagnolet), France.
| | - Shirley Odouard
- CHU Henri Mondor, 1 Rue Gustave Eiffel, 94000 Créteil, France.
| | - Karam Souibri
- Institut Cœur Paris Centre (ICPC), Clinique Turin, 75008, Paris.
| | - Frederic A Sebag
- Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.
| | - Jean-François Deux
- Hôpitaux Universitaires de Genève (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Suisse.
| | - Thibaud Damy
- CHU Henri Mondor, 1 Rue Gustave Eiffel, 94000 Créteil.
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Bettencourt N, Mendes L, Fontes JP, Matos P, Ferreira C, Botelho A, Carvalho S, Durazzo A, Faustino A, Ladeiras Lopes R, Vasconcelos M, Vieira C, Correia M, Ferreira AM, Ferreira N, Pires-Morais G, G Almeida A, Ferreira MJV, Teixeira M. Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology's] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation. Rev Port Cardiol 2020; 41:241-251. [PMID: 33342714 DOI: 10.1016/j.repc.2020.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/24/2020] [Accepted: 10/29/2020] [Indexed: 01/19/2023] Open
Abstract
Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.
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Affiliation(s)
| | | | - José Paulo Fontes
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | | | - Catarina Ferreira
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Faculdade de Ciências da Saúde, Universidade da Beira Interior, Vila Real, Portugal
| | - Ana Botelho
- Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Sofia Carvalho
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Anaí Durazzo
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Ana Faustino
- Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Ricardo Ladeiras Lopes
- Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Faculdade de Medicina do Porto, Porto, Portugal
| | - Mariana Vasconcelos
- Faculdade de Medicina do Porto, Porto, Portugal; Centro Hospitalar Universitário São João, Porto, Portugal
| | | | - Miguel Correia
- Centro Hospitalar Tondela/Viseu e Hospital CUF-Viseu, Viseu, Portugal
| | - António M Ferreira
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal; Hospital da Luz, Lisboa, Portugal
| | - Nuno Ferreira
- Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | | | - Ana G Almeida
- Centro Hospitalar Lisboa Norte, Hospital de Santa Maria e Faculdade de Medicina de Lisboa, Lisboa, Portugal
| | - Maria João Vidigal Ferreira
- Centro Hospitalar Universitário de Coimbra e Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Madalena Teixeira
- Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Humbert O, Noirot E, Leclerc T, Mouhat B, Pommier T, Cochet A, Cottin Y. [Comparison of the prognostic value of different clinical, angiographic and scintigraphic scores in stable coronary patients after acute coronary syndrome]. Ann Cardiol Angeiol (Paris) 2020; 69:12-23. [PMID: 31522776 DOI: 10.1016/j.ancard.2019.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/22/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION To date, there is no consensus regarding the follow-up of asymptomatic coronary patients with an intermediate risk of events. Indeed, most of cardiovascular events (CVE) occur in asymptomatic patients, hence the clinician's interest in establishing risk stratification scores. In asymptomatic patient, the risk assessment after acute coronary syndrome (ACS) can currently be based on 3 types of score: clinical with, for example, the REACH score; angiographic with the residual SYNTAX score; imaging with different scintigraphic scores. These scores differ widely in terms of evaluation criteria and period of analysis. The aim of our study was therefore, in stable and asymptomatic coronary patients after ACS, to compare these different predictive scores; to establish that the combination of these scores makes it possible to optimize the risk assessment during the follow-up. METHODS Our retrospective study included 236 revascularized patients after ACS. Three different risk scores were collected: 1) the residual SYNTAX score, calculated at the time of revascularization; 2) the scintigraphic risk score described by Sharir et al., performed 3 to 12 months after the event and taking into account the extent of ischemia (SDS) and the poststress left ventricular ejection fraction (LVEF). Patients with LVEF <50% and/or moderate to severe ischemic disease (SDS≥2) were considered with an intermediate or high scintigraphic risk; 3) the REACH clinical score calculated on the day of the scintigraphic examination. After the myocardial scintigraphic exam, patients had a 1-year follow-up and CVE were recorded. Continuous data were analyzed either by Student's t-test or non-parametric Mann-Whitney test. The dichotomous data were compared either by the χ2 test or by Fisher's exact test. RESULTS Forty-eight patients (20.1%) had a CVE during the 1-year follow-up. Thirty patients (13.8%) had a high residual SYNTAX score (≥8) without any correlation observed between the residual SYNTAX score and CVE (P=0.359). 148 patients (57.7%) had a high REACH clinical score (≥11) with no significant correlation observed with CVE (P=0.079). Lastly, 34 patients (14.4%) had an intermediate or high scintigraphic score, this imaging score being strongly correlated with a greater number of CVE (P<0.001). Multivariate analysis revealed 3 independent factors associated with CVE: a scintigraphic score> 2 (OR [(95% CI): 5.530 [2.426-12.605] P<0.001); Peripheral Arterial Obstructive Disease (PAOD) (OR [95% CI]: 8.531 [2.540-28.660] P<0.001); diabetes (OR [95% CI]: 2.86 [1.262-6.517] P=0,012). CONCLUSION The combination of the scintigraphic score with two clinical factors, such as PAOD and diabetes, provides optimal prognostic value in the evaluation of asymptomatic and stable patients after ACS. Our study therefore highlights the importance of optimizing evaluation strategies in the follow-up of these patients who remain at risk of post-revascularization CVE.
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Affiliation(s)
- O Humbert
- Département de médecine nucléaire, centre Georges-François-Leclerc, 21000 Dijon, France; Département de médecine nucléaire, centre Antoine-Lacassagne, université Côte d'Azur (UCA), 33, avenue de Valombrose, 06189 Nice, France.
| | - E Noirot
- Département de cardiologie, CHU de Dijon, France
| | - T Leclerc
- Département d'imagerie, CHU de Dijon, 21000 Dijon, France; Département de cardiologie, CHU de Dijon, France
| | - B Mouhat
- Département de cardiologie, CHU de Dijon, France
| | - T Pommier
- Département de cardiologie, CHU de Dijon, France
| | - A Cochet
- Département de médecine nucléaire, centre Georges-François-Leclerc, 21000 Dijon, France; Département d'imagerie, CHU de Dijon, 21000 Dijon, France
| | - Y Cottin
- Département de cardiologie, CHU de Dijon, France
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Abstract
Against the background of drastically increased cardiovascular comorbidity in patients with chronic kidney disease (CKD), an effective cardiovascular diagnostic approach appears essential. However, patients with CKD are often underdiagnosed. Prospective randomized studies showing an improved outcome for cardiovascular diagnostic in patients with CKD are limited. Special attention is paid to stress diagnostics in CKD patients. Guidelines recommend cardiovascular diagnostic evaluation prior to inclusion on the transplantation waiting list.
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Affiliation(s)
- Georg Schlieper
- Zentrum für Nieren‑, Hochdruck- und Stoffwechselerkrankungen, Heidering 31, 30625, Hannover, Deutschland.
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Yamada M, Komatsu J, Nakamura K, Sakai K, Samuraki-Yokohama M, Nakajima K, Yoshita M. Diagnostic Criteria for Dementia with Lewy Bodies: Updates and Future Directions. J Mov Disord 2019; 13:1-10. [PMID: 31694357 PMCID: PMC6987529 DOI: 10.14802/jmd.19052] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/06/2019] [Indexed: 12/11/2022] Open
Abstract
The aim of this article is to describe the 2017 revised consensus criteria for the clinical diagnosis of dementia with Lewy bodies (DLB) with future directions for the diagnostic criteria. The criteria for the clinical diagnosis of probable and possible DLB were first published as the first consensus report in 1996 and were revised in the third consensus report in 2005. After discussion at the International DLB Conference in Fort Lauderdale, Florida, USA, in 2015, the International DLB Consortium published the fourth consensus report including the revised consensus criteria in 2017. The 2017 revised criteria clearly distinguish between clinical features and diagnostic biomarkers. Significant new information about previously reported aspects of DLB has been incorporated, with increased diagnostic weighting given to rapid eye movement (REM) sleep behavior disorder (RBD) and iodine-123-metaiodobenzylguanidine (MIBG) myocardial scintigraphy. Future directions include the development of the criteria for early diagnosis (prodromal DLB) and the establishment of new biomarkers that directly indicate Lewy-related pathology, including α-synuclein imaging, biopsies of peripheral tissues (skin, etc.) for the demonstration of α-synuclein deposition, and biochemical markers (cerebrospinal fluid/blood), as well as the pathological evaluation of the sensitivity and specificity of the 2017 revised diagnostic criteria. In conclusion, the revised consensus criteria for the clinical diagnosis of DLB were reported with the incorporation of new information about DLB in 2017. Future directions include the development of the criteria for early diagnosis and the establishment of biomarkers directly indicative of Lewy-related pathology.
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Affiliation(s)
- Masahito Yamada
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Junji Komatsu
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Keiko Nakamura
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kenji Sakai
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Miharu Samuraki-Yokohama
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kenichi Nakajima
- Department of Nuclear Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Mitsuhiro Yoshita
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan.,Department of Neurology, National Hospital Organization, Hokuriku National Hospital, Nanto, Japan
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Miyazaki M, Suematsu Y, Kato S, Miura SI. Type 1 cluster of differentiation 36 deficiency-related cardiomyopathy accelerates heart failure with co-existing mitral valve prolapse: a case report. Eur Heart J Case Rep 2019; 3:ytz116. [PMID: 31660489 PMCID: PMC6764555 DOI: 10.1093/ehjcr/ytz116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/20/2018] [Accepted: 06/20/2019] [Indexed: 11/13/2022]
Abstract
Background Free fatty acid is a major energy source in the healthy heart and cluster of differentiation 36 (CD36) partially regulates the rate of myocardial fatty acid uptake. Here, we report a case of CD36 deficiency-related cardiomyopathy with a unique pathophysiology. Heart failure was accelerated by co-existing mitral valve prolapse (MVP) without a distinct phenotype of hypertrophic or dilated cardiomyopathy. Case summary A middle-aged man was aware of dyspnoea and hospitalized for heart failure with MVP. Cluster of differentiation 36 deficiency was found based on the absence of myocardial 123l-15-(p-iodophenyl)-3-(R,S)-methyl pentadecanoic acid (BMIPP) uptake by myocardial scintigraphy. Type I CD36 deficiency was further diagnosed by the lack of CD36 in both platelets and monocytes by flow cytometry. Left ventricular muscle was obtained intraoperatively, and a histological examination reflected compensative hypertrophy of cardiomyocytes with myofibrillar loss and reactive fibrosis. The microvascular structure around the cardiomyocytes was highlighted by immunohistochemical staining for CD31, while CD36 expression was absent. He had an operation of mitral valve replacement and improved heart failure. Discussion Cluster of differentiation 36 deficiency potentially mediates various pathological conditions in the heart. Incidental CD36 deficiency-related cardiomyopathy may accelerate heart failure in the presence of co-existing heart diseases. BMIPP scintigraphy might be helpful for predicting CD36 deficiency.
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Affiliation(s)
- Midori Miyazaki
- Department of Cardiology, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka, Japan
| | - Yasunori Suematsu
- Department of Cardiology, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka, Japan
| | - Seiya Kato
- Division of Pathology, Saiseikai Fukuoka General Hospital, Tenjin 1-3-46 Fukuoka Chuo-ku, Fukuoka, Japan
| | - Shin-Ichiro Miura
- Department of Cardiology, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka, Japan
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11
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Koyama J, Minamisawa M, Sekijima Y, Kuwahara K, Katsuyama T, Maruyama K. Role of echocardiography in assessing cardiac amyloidoses: a systematic review. J Echocardiogr 2019; 17:64-75. [PMID: 30741395 DOI: 10.1007/s12574-019-00420-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/21/2022]
Abstract
Cardiac amyloidosis is a manifestation of one of several systemic amyloidoses, and is characterized by increased left-ventricular (LV) wall thickness and normal or decreased LV cavity size. Congestive heart failure in cardiac amyloidosis is characterized by a predominant diastolic LV dysfunction, and systolic dysfunction occurs only in late-stage disease. Echocardiography is a noninvasive, reproducible method for assessing cardiac morphology and function in cardiac amyloidosis, and some echocardiographic indices are prognostic for amyloidoses. This review describes the advances in echocardiography and its role in the diagnosis and management of cardiac amyloidoses. Our review suggests that LV longitudinal function and the cyclic variation of myocardial integrated backscatter may be the best predictors of adverse outcomes. In the future, new echocardiographic techniques, such as fully automated echocardiogram interpretation, should provide further useful information for assessing cardiac function and prognosis in cardiac amyloidosis patients.
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12
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Olivola E, Brusa L, Rocchi C, Schillaci O, Liguori C, Cerroni R, Pierantozzi M, Chiaravalloti A, Stefani A, Stocchi F. Does fatigue in Parkinson's disease correlate with autonomic nervous system dysfunction? Neurol Sci 2018; 39:2169-2174. [PMID: 30255487 DOI: 10.1007/s10072-018-3569-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 09/10/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite its negative impact on quality of life, fatigue in Parkinson's disease (PD) remains an under-recognized issue and the underlying pathology is undetermined. OBJECTIVE To contribute at understanding the pathogenesis of fatigue in a naturalistic cohort of cognitively intact PD patients. METHODS In a Caucasian population of PD patients (n = 27), we evaluated to what extent fatigue (quantified as PFS-16 score) is associated with PD duration and with autonomic dysfunction, studied by both MIBG scintigraphy and autonomic nervous system testing. The latter included the head-up tilt test, Valsalva maneuver, deep breathing, and handgrip tests. RESULTS PFS-16 score correlated with disease duration (R = 0.57, p = 0.002). Fatigue showed a clear correlation with deep breathing test (R = - 0.53, p = 0.004) but not with the MIBG H/M ratios. CONCLUSIONS Our data are consistent with a multifactorial pathogenesis of fatigue and with effects of dopamine depletion in PD-related fatigue; on the other hand, our findings do not support a role for sympathetic denervation in PD-related fatigue.
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Affiliation(s)
- Enrica Olivola
- UOSD Parkinson's Center, Department of Systems Medicine, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy.,IRCCS Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy
| | | | - Camilla Rocchi
- UOSD Parkinson's Center, Department of Systems Medicine, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy
| | - Orazio Schillaci
- IRCCS Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy.,Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Claudio Liguori
- UOSD Parkinson's Center, Department of Systems Medicine, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy
| | - Rocco Cerroni
- UOSD Parkinson's Center, Department of Systems Medicine, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy
| | - Mariangela Pierantozzi
- UOSD Parkinson's Center, Department of Systems Medicine, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy
| | - Agostino Chiaravalloti
- IRCCS Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy.,Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Alessandro Stefani
- UOSD Parkinson's Center, Department of Systems Medicine, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy.
| | - Fabrizio Stocchi
- Department of Neurology, Institute for Research and Medical Care, IRCCS San Raffaele, Rome, Italy
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13
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Noordzij W, Özyilmaz A, Glaudemans AWJM, Tio RA, Goet ER, Franssen CFM, Slart RHJA. Investigation into cardiac sympathetic innervation during the commencement of haemodialysis in patients with chronic kidney disease. Eur Radiol Exp 2017; 1:24. [PMID: 29708199 DOI: 10.1186/s41747-017-0027-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/20/2017] [Indexed: 02/02/2023] Open
Abstract
Background Patients with chronic kidney disease (CKD) who undergo chronic haemodialysis (HD) show altered sympathetic tone, which is related to a higher cardiovascular mortality. The purpose of this study was to investigate the effect of transition from pre-HD to HD on cardiac sympathetic innervation. Methods Eighteen patients aged 58 ± 18 years (mean ± standard deviation [SD]), 13 males and five females, with stage 5 CKD and nine healthy control subjects aged 52 ± 17 (mean ± SD), three males and six females, were included in this prospective study between May 2010 and December 2013. All patients underwent 123I-labelled meta-iodobenzylguanidine (123I-MIBG) scintigraphy for cardiac sympathetic innervation and electrocardiographically gated adenosine stress and rest 99mTc-labelled tetrofosmin single-photon emission computed tomography for myocardial perfusion imaging prior to (pre-HD) and 6 months after the start of HD. Results of 123I-MIBG scans in patients were compared to controls. Impaired cardiac sympathetic innervation was defined as late heart-to-mediastinum ratio (HMR) < 2.0. Results Mean late HMR was lower in patients during HD (2.3) than in controls (2.9) (p = 0.035); however, in patients it did not differ between pre-HD and after the start of HD. During HD, two patients showed new sympathetic innervation abnormalities, and in three patients innervation abnormalities seemed to coincide with myocardial perfusion abnormalities. Conclusions CKD patients show cardiac sympathetic innervation abnormalities, which do not seem to progress during the maintenance HD. The relationship between sympathetic innervation abnormalities and myocardial perfusion abnormalities in HD patients needs further exploration.
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14
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Saeed U, Compagnone J, Aviv RI, Strafella AP, Black SE, Lang AE, Masellis M. Imaging biomarkers in Parkinson's disease and Parkinsonian syndromes: current and emerging concepts. Transl Neurodegener 2017; 6:8. [PMID: 28360997 PMCID: PMC5370489 DOI: 10.1186/s40035-017-0076-6] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/28/2017] [Indexed: 12/24/2022] Open
Abstract
Two centuries ago in 1817, James Parkinson provided the first medical description of Parkinson’s disease, later refined by Jean-Martin Charcot in the mid-to-late 19th century to include the atypical parkinsonian variants (also termed, Parkinson-plus syndromes). Today, Parkinson’s disease represents the second most common neurodegenerative disorder with an estimated global prevalence of over 10 million. Conversely, atypical parkinsonian syndromes encompass a group of relatively heterogeneous disorders that may share some clinical features with Parkinson’s disease, but are uncommon distinct clinicopathological diseases. Decades of scientific advancements have vastly improved our understanding of these disorders, including improvements in in vivo imaging for biomarker identification. Multimodal imaging for the visualization of structural and functional brain changes is especially important, as it allows a ‘window’ into the underlying pathophysiological abnormalities. In this article, we first present an overview of the cardinal clinical and neuropathological features of, 1) synucleinopathies: Parkinson’s disease and other Lewy body spectrum disorders, as well as multiple system atrophy, and 2) tauopathies: progressive supranuclear palsy, and corticobasal degeneration. A comprehensive presentation of well-established and emerging imaging biomarkers for each disorder are then discussed. Biomarkers for the following imaging modalities are reviewed: 1) structural magnetic resonance imaging (MRI) using T1, T2, and susceptibility-weighted sequences for volumetric and voxel-based morphometric analyses, as well as MRI derived visual signatures, 2) diffusion tensor MRI for the assessment of white matter tract injury and microstructural integrity, 3) proton magnetic resonance spectroscopy for quantifying proton-containing brain metabolites, 4) single photon emission computed tomography for the evaluation of nigrostriatal integrity (as assessed by presynaptic dopamine transporters and postsynaptic dopamine D2 receptors), and cerebral perfusion, 5) positron emission tomography for gauging nigrostriatal functions, glucose metabolism, amyloid and tau molecular imaging, as well as neuroinflammation, 6) myocardial scintigraphy for dysautonomia, and 7) transcranial sonography for measuring substantia nigra and lentiform nucleus echogenicity. Imaging biomarkers, using the ‘multimodal approach’, may aid in making early, accurate and objective diagnostic decisions, highlight neuroanatomical and pathophysiological mechanisms, as well as assist in evaluating disease progression and therapeutic responses to drugs in clinical trials.
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Affiliation(s)
- Usman Saeed
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,LC Campbell Cognitive Neurology Research Unit, Sunnybrook Research Institute, Toronto, Canada
| | - Jordana Compagnone
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,LC Campbell Cognitive Neurology Research Unit, Sunnybrook Research Institute, Toronto, Canada
| | - Richard I Aviv
- Department of Medical Imaging, University of Toronto and Division of Neuroradiology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Antonio P Strafella
- Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, Canada.,Division of Brain, Imaging & Behaviour - Systems Neuroscience, Toronto Western Hospital, Toronto, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Sandra E Black
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,LC Campbell Cognitive Neurology Research Unit, Sunnybrook Research Institute, Toronto, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada.,Heart & Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada.,Movement Disorders Centre, Toronto Western Hospital, Toronto, Canada.,Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Canada
| | - Mario Masellis
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,LC Campbell Cognitive Neurology Research Unit, Sunnybrook Research Institute, Toronto, Canada.,Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada.,Cognitive & Movement Disorders Clinic, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room A4-55, Toronto, Ontario M4N 3 M5 Canada
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Zavadovsky KV, Gulya MO, Lishmanov YB, Lebedev DI. Perfusion and metabolic scintigraphy with (123)I-BMIPP in prognosis of cardiac resynchronization therapy in patients with dilated cardiomyopathy. Ann Nucl Med 2016; 30:325-33. [PMID: 26872805 DOI: 10.1007/s12149-016-1064-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 01/29/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The objective of the study was to investigate the left ventricular (LV) myocardial perfusion and metabolism in patients with idiopathic dilated cardiomyopathy (DCM) and to identify the scintigraphic predictors of the efficacy of cardiac resynchronization therapy (CRT). METHODS The study comprised 63 patients with DCM and severe heart failure (NYHA class III-IV). Before CRT, all patients received gamma-scintigraphy with (99m)Tc-methoxyisobutylisonitrile ((99m)Tc-MIBI) and with (123)I-β-methyl-iodophenyl pentadecanoic acid ((123)I-BMIPP) for evaluation of myocardial perfusion and metabolism, respectively. Before and after 6 months of CRT, all patients underwent echocardiography study to assess cardiac hemodynamics. RESULTS After 6 months of CRT, patients were divided into two groups: group 1 comprised responders in whom LV end systolic volume (LVESV) decreased by ≥15 % (n = 39); group 2 comprised non-responders in whom LVESV decreased by <15 % (n = 24). Before CRT, LV pumping function did not significantly differ between groups. Significant differences were found in the following preoperative scintigraphic parameters: myocardial perfusion defect size [7.4 % (5.9; 13.2) % and 11.8 (8.8; 16.2) %, p < 0.05] and metabolic defect size [7.4 (4.4; 14.7) % and 8.8 (8.8; 17.6) %, p < 0.05]. Metabolic scintigraphy showed greater diagnostic efficacy in determining the indications for CRT compared with perfusion scintigraphy [areas under the ROC curves (AUC) of 0.722 and 0.612, respectively]. The best metabolic defect size threshold value of 7.35 % predicted CRT efficacy with the sensitivity and specificity rates of 77.8 and 66.7 %, respectively. CONCLUSION Data of metabolic scintigraphy may be useful for the integrated prediction of CRT efficacy.
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Sucato V, Evola S, Novo G, Bronte E, Novo S. Stable microvascular angina: instrumental evaluation of coronary microvascular dysfunction with coronary angiography and myocardial scintigraphy. Int J Cardiol 2014; 171:e127-8. [PMID: 24433618 DOI: 10.1016/j.ijcard.2013.12.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 12/17/2013] [Accepted: 12/20/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Vincenzo Sucato
- Division of Cardiology, Biomedical Department of Internal Medicine and Medical Specialties (DIBIMIS), University Hospital Paolo Giaccone, Palermo, Italy..
| | - Salvatore Evola
- Division of Cardiology, Biomedical Department of Internal Medicine and Medical Specialties (DIBIMIS), University Hospital Paolo Giaccone, Palermo, Italy
| | - Giuseppina Novo
- Division of Cardiology, Biomedical Department of Internal Medicine and Medical Specialties (DIBIMIS), University Hospital Paolo Giaccone, Palermo, Italy
| | - Enrico Bronte
- Division of Cardiology, Biomedical Department of Internal Medicine and Medical Specialties (DIBIMIS), University Hospital Paolo Giaccone, Palermo, Italy
| | - Salvatore Novo
- Division of Cardiology, Biomedical Department of Internal Medicine and Medical Specialties (DIBIMIS), University Hospital Paolo Giaccone, Palermo, Italy
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