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Martínez-Solano J, Martínez-Sellés M. Sudden Death in Men Versus Women with Heart Failure. Curr Heart Fail Rep 2023; 20:129-137. [PMID: 36881322 DOI: 10.1007/s11897-023-00596-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW Sudden cardiac death (SCD) represents the most feared complication of heart failure (HF). This review intends to provide insight on our current knowledge of sex differences in SCD mechanisms, prevention, and management in HF patients. RECENT FINDINGS Women with HF present a better prognosis than men and have a lower incidence of SCD, irrespective of the presence of ischemic heart disease and age. The influence of sex hormones, sex differences in intracellular calcium handling, and a differential myocardial remodeling may explain such a gap between men and women. Both HF drugs and ventricular arrhythmias ablation seems also useful for the management of women at risk of SCD, but special care must be taken with the use of antiarrhythmic QT-prolonging drugs. However, implantable cardioverter defibrillator (ICD) use has not been shown to be equally effective in women than men. Sex-specific recommendations regarding SCD in HF are still lacking due to the scarcity of information and the under-representation of women in clinical trials. Further investigation is required to provide specific risk stratification models in women. Cardiac magnetic resonance imaging, genetics development, and personalized medicine will probably play an increasing role in this evaluation.
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Affiliation(s)
- Jorge Martínez-Solano
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain. .,Universidad Europea, Universidad Complutense, Madrid, Spain.
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2
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Stendahl JC, Kwan JM, Pucar D, Sadeghi MM. Radiotracers to Address Unmet Clinical Needs in Cardiovascular Imaging, Part 2: Inflammation, Fibrosis, Thrombosis, Calcification, and Amyloidosis Imaging. J Nucl Med 2022; 63:986-994. [PMID: 35772956 PMCID: PMC9258561 DOI: 10.2967/jnumed.121.263507] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 02/22/2022] [Indexed: 01/03/2023] Open
Abstract
Cardiovascular imaging is evolving in response to systemwide trends toward molecular characterization and personalized therapies. The development of new radiotracers for PET and SPECT imaging is central to addressing the numerous unmet diagnostic needs that relate to these changes. In this 2-part review, we discuss select radiotracers that may help address key unmet clinical diagnostic needs in cardiovascular medicine. Part 1 examined key technical considerations pertaining to cardiovascular radiotracer development and reviewed emerging radiotracers for perfusion and neuronal imaging. Part 2 covers radiotracers for imaging cardiovascular inflammation, thrombosis, fibrosis, calcification, and amyloidosis. These radiotracers have the potential to address several unmet needs related to the risk stratification of atheroma, detection of thrombi, and the diagnosis, characterization, and risk stratification of cardiomyopathies. In the first section, we discuss radiotracers targeting various aspects of inflammatory responses in pathologies such as myocardial infarction, myocarditis, sarcoidosis, atherosclerosis, and vasculitis. In a subsequent section, we discuss radiotracers for the detection of systemic and device-related thrombi, such as those targeting fibrin (e.g., 64Cu-labeled fibrin-binding probe 8). We also cover emerging radiotracers for the imaging of cardiovascular fibrosis, such as those targeting fibroblast activation protein (e.g., 68Ga-fibroblast activation protein inhibitor). Lastly, we briefly review radiotracers for imaging of cardiovascular calcification (18F-NaF) and amyloidosis (e.g., 99mTc-pyrophosphate and 18F-florbetapir).
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Affiliation(s)
- John C Stendahl
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Darko Pucar
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut; and
| | - Mehran M Sadeghi
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut;
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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3
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Gender Differences in Implantable Cardioverter-Defibrillator Utilization for Primary Prevention of Sudden Cardiac Death. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00954-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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4
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Contemporary Role of Cardiac Magnetic Resonance in the Management of Patients with Suspected or Known Coronary Artery Disease. ACTA ACUST UNITED AC 2021; 57:medicina57070649. [PMID: 34202588 PMCID: PMC8303732 DOI: 10.3390/medicina57070649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/21/2021] [Accepted: 06/21/2021] [Indexed: 11/19/2022]
Abstract
Cardiac magnetic resonance imaging (CMR) is a useful non-invasive radiation-free imaging modality for the management of patients with coronary artery disease (CAD). CMR cine imaging provides the “gold standard” assessment of ventricular function, late gadolinium enhancement (LGE) provides useful data for the diagnosis and extent of myocardial scar and viability, while stress imaging is an established technique for the detection of myocardial perfusion defects indicating ischemia. Beyond its role in the diagnosis of CAD, CMR allows accurate risk stratification of patients with established CAD. This review aims to summarize the data regarding the role of CMR in the contemporary management of patients with suspected or known coronary artery disease.
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Delayed Echo Enhancement Imaging to Quantify Myocardial Infarct Size. J Am Soc Echocardiogr 2021; 34:898-909. [PMID: 33711458 DOI: 10.1016/j.echo.2021.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/07/2021] [Accepted: 02/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perfluoropropane droplets formulated from commercial microbubbles exhibit different acoustic characteristics than their parent microbubbles, most likely from enhanced endothelial permeability. This enhanced permeability may permit delayed echo-enhancement imaging (DEEI) similar to delayed enhancement magnetic resonance imaging (DE-MRI). We hypothesized this would allow detection and quantification of myocardial scar. METHODS In 15 pigs undergoing 90 minutes of left anterior descending ischemia by either balloon (n = 13) or thrombotic occlusion (n = 2), DE-MRI was performed at 2-24 days postocclusion. Delayed echo-enhancement imaging was performed at 2-4 minutes following an intravenous injection of 1 mL of 50% Definity (Lantheus Medical) compressed into 180 nm droplets; DEEI was attempted in all pigs with single-pulse harmonic imaging at 1.7 transmit/3.4 MHz receive. Myocardial defects observed with DEEI were quantified (percentage of infarct area) and compared with DE-MRI as well as postmortem staining. In six pigs, multipulse low-mechanical index (MI) fundamental nonlinear imaging (FNLI) with intermittent high-MI impulses was performed to determine whether droplet activation within the infarct zone was achievable with a longer pulse duration. RESULTS The range of infarct size area by DE-MRI ranged from 0% to 46% of total left ventricular area. Single-pulse harmonic imaging detected a contrast defect that correlated closely with infarct area by DE-MRI (r = 0.81, P = .0001). The FNLI high-MI impulses resulted in droplet activation in both the infarct and normal zones. Harmonic subtraction of the FNLI images resulted in infarct zone enhancement that also correlated closely with infarct size (r = 0.83; P = .04). Droplets were observed on postmortem transmission electron microscopy within myocytes of the infarct and remote normal zone. CONCLUSION Intravenously Definity nanodroplets can be utilized to detect and quantify infarct zone at the bedside using DEEI techniques.
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Prognostic value of myocardial fibrosis on cardiac magnetic resonance imaging in patients with ischemic cardiomyopathy: A systematic review. Am Heart J 2020; 229:52-60. [PMID: 32916608 PMCID: PMC7417269 DOI: 10.1016/j.ahj.2020.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 08/03/2020] [Indexed: 01/15/2023]
Abstract
The use of cardiac magnetic resonance imaging (c-MRI) in risk stratification for clinical outcomes of patients with ischemic cardiomyopathy (ICM) remains low. This systematic review investigated the prognostic value of myocardial fibrosis as assessed by late gadolinium enhancement (LGE) on c-MRI in patients with ICM for ventricular tachyarrhythmia, sudden cardiac death (SCD), or all-cause mortality. Methods We conducted a systematic review of the electronic databases Pubmed and Embase for relevant prospective English-language studies published between January 1990 and February 2019. All included articles were prospective studies that comprised of human participants older than 18 years with ICM and a primary or secondary prevention implantable cardioverter/defibrillator (ICD); had a sample size >30 participants; had at least 6 months of follow-up; and reported on ventricular tachyarrhythmia, SCD, and all-cause mortality. A total of 90 articles related to ICM were identified and were subsequently screened independently by 2 authors. Pooled sensitivity and specificity of LGE were calculated using random-effects model. Results Eight studies with 1,085 participants were included in the final analysis. The mean age of patients varied from 43 to 83 years, with most patients being men. The most common comorbidities reported included history of diabetes mellitus (22%-62%), hyperlipidemia (40%-86%), and hypertension (35%-88%). The ejection fraction of each study was reported as mean or median and varied from 22% to 35%. During a follow-up that ranged from 8.5 to 65 months, there were 110 ventricular arrhythmic events reported. The pooled sensitivity and specificity of LGE for ICD therapy delivered for ventricular arrhythmias were 0.79 (95% CI: 0.66-0.87) and 0.28 (95% CI: 0.14-0.46), respectively. For all-cause mortality, the pooled sensitivity and specificity of LGE were 0.76 (95% CI: 0.40-0.93) and 0.41 (95% CI: 0.14-0.75), respectively. Although SCD was of significant interest to our review, only 1 of the studies reported on the association between LGE and SCD, leading to the subsequent exclusion of SCD from the end point analysis. Conclusions LGE has high prognostic value in predicting adverse outcomes in patients with ICM and may provide helpful information for clinical decision making related to SCD prevention. Our findings illustrate how LGE may improve current risk stratification, prognostication, and selection of patients with ICM for ICD therapy.
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Reichlin T, Asatryan B, Vos MA, Willems R, Huikuri HV, Junttila MJ, Schlögl SC, Hnatkova K, Schaer BA, Malik M, Zabel M, Sticherling C. Automated electrocardiographic quantification of myocardial scar in patients undergoing primary prevention implantable cardioverter-defibrillator implantation: Association with mortality and subsequent appropriate and inappropriate therapies. Heart Rhythm 2020; 17:1664-1671. [PMID: 32428669 DOI: 10.1016/j.hrthm.2020.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Myocardial scarring from infarction or nonischemic fibrosis forms an arrhythmogenic substrate. The Selvester QRS score has been developed to estimate myocardial scar from the 12-lead electrocardiogram. OBJECTIVE We aimed to assess the value of an automated version of the Selvester QRS score for the prediction of implantable cardioverter-defibrillator (ICD) therapy and death in patients undergoing primary prevention ICD implantation. METHODS Unselected patients undergoing primary prevention ICD implantation were included in this retrospective, observational, multicenter study. The QRS score was calculated automatically from a digital standard preimplantation 12-lead electrocardiogram and was correlated to the occurrence of death and appropriate and inappropriate shocks during follow-up. Analyses were performed in groups defined by QRS duration < 130 ms vs ≥ 130 ms. RESULTS Overall, 1047 patients (872 [83%] men; median age 64 years IQR [55-71]) with ischemic (648, 62%) or nonischemic (399, 38%) cardiomyopathy were included. The median QRS duration was 123 ms (interquartile range [IQR] 111-157 ms), and the median QRS score was 5 (IQR 2-8). The QRS duration was <130 ms in 59% and ≥130 ms in 41%. During a median follow-up of 45 months (IQR 24-72 months), a QRS score of ≥5 was independently associated with a significantly higher risk of mortality (hazard ratio [HR] 1.67; 95% confidence interval [CI] 1.05-2.66; P = .031) and appropriate (HR 1.83; 95% CI 1.07-3.14; P = .028) and inappropriate (HR 2.32; 95% CI 1.04-5.17; P = .039) shocks in patients with QRS duration ≥ 130 ms. No association of the QRS score and outcome was observed in patients with QRS duration < 130 ms (P > .05). CONCLUSION The automatically calculated Selvester QRS score, an indicator of myocardial scar burden, predicts mortality and appropriate and inappropriate shocks in patients undergoing primary prevention ICD implantation with a prolonged QRS duration.
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Affiliation(s)
- Tobias Reichlin
- Department of Cardiology, University Hospital Basel, Basel, Switzerland; Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc A Vos
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rik Willems
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Simon C Schlögl
- Department of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany
| | - Katerina Hnatkova
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Beat A Schaer
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Markus Zabel
- Department of Cardiology and Pneumology, Heart Center, University Medical Center, Göttingen, Germany
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Vajapey R, Eck B, Tang W, Kwon DH. Advances in MRI Applications to Diagnose and Manage Cardiomyopathies. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:74. [PMID: 31773390 DOI: 10.1007/s11936-019-0762-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The prevalence of heart failure continues to rise, and imaging characterization of the cardiomyopathic process is important for identifying myocardial disease, initiating appropriate treatment, and improving outcomes. We aimed to summarize recent advances in cardiac magnetic resonance imaging (CMR) applications for the diagnosis, characterization, and implications on management of various cardiomyopathies. RECENT FINDINGS Parametric mapping by CMR has emerged as an important advancement in quantification of myocardial fibrosis, increased extracellular space, and myocardial edema. In addition, improved assessment of myocardial function with myocardial strain assessment may provide early identification of patients at risk and determining responsiveness to therapeutic interventions. Novel MRI techniques and the advent of artificial intelligence may help to uncover important mechanistic insights into the cardiomyopathic process. Innovative CMR techniques continue to evolve, and it will be of interest to determine how these advances can be incorporated into clinical practice to improve diagnosis, treatment, and management of patients with cardiomyopathies.
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Affiliation(s)
- Ramya Vajapey
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Brendan Eck
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Wilson Tang
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA
| | - Deborah H Kwon
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH, USA. .,Department of Cardiovascular Medicine, Cleveland Clinic, Imaging Institute, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, 44195, USA.
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Nelson T, Garg P, Clayton RH, Lee J. The Role of Cardiac MRI in the Management of Ventricular Arrhythmias in Ischaemic and Non-ischaemic Dilated Cardiomyopathy. Arrhythm Electrophysiol Rev 2019; 8:191-201. [PMID: 31463057 PMCID: PMC6702467 DOI: 10.15420/aer.2019.5.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular tachycardia (VT) and VF account for the majority of sudden cardiac deaths worldwide. Treatments for VT/VF include anti-arrhythmic drugs, ICDs and catheter ablation, but these treatments vary in effectiveness and carry substantial risks and/or expense. Current methods of selecting patients for ICD implantation are imprecise and fail to identify some at-risk patients, while leading to others being overtreated. In this article, the authors discuss the current role and future direction of cardiac MRI (CMRI) in refining diagnosis and personalising ventricular arrhythmia management. The capability of CMRI with gadolinium contrast delayed-enhancement patterns and, more recently, T1 mapping to determine the aetiology of patients presenting with heart failure is well established. Although CMRI imaging in patients with ICDs can be challenging, recent technical developments have started to overcome this. CMRI can contribute to risk stratification, with precise and reproducible assessment of ejection fraction, quantification of scar and ‘border zone’ volumes, and other indices. Detailed tissue characterisation has begun to enable creation of personalised computer models to predict an individual patient’s arrhythmia risk. When patients require VT ablation, a substrate-based approach is frequently employed as haemodynamic instability may limit electrophysiological activation mapping. Beyond accurate localisation of substrate, CMRI could be used to predict the location of re-entrant circuits within the scar to guide ablation.
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Affiliation(s)
- Tom Nelson
- Sheffield Teaching Hospitals NHS Foundation Trust Sheffield, UK.,Department of Immunity, Infection and Cardiovascular Disease, University of Sheffield Sheffield, UK
| | - Pankaj Garg
- Sheffield Teaching Hospitals NHS Foundation Trust Sheffield, UK.,Department of Immunity, Infection and Cardiovascular Disease, University of Sheffield Sheffield, UK
| | - Richard H Clayton
- INSIGNEO Institute for In-Silico Medicine, University of Sheffield Sheffield, UK.,Department of Computer Science, University of Sheffield Sheffield, UK
| | - Justin Lee
- Sheffield Teaching Hospitals NHS Foundation Trust Sheffield, UK.,Department of Immunity, Infection and Cardiovascular Disease, University of Sheffield Sheffield, UK
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Abdul Ghaffar Y, Maskoun W, Mustafa NG, Feigenbaum H, Sawada SG. Low dose wall motion score predicts the short and long-term benefit of surgical revascularization in patients with ischemic left ventricular dysfunction. Int J Cardiovasc Imaging 2019; 35:1651-1659. [PMID: 31053980 DOI: 10.1007/s10554-019-01614-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
We investigated the influence of the extent of viability using low dose dobutamine wall motion score index (WMS) on the survival benefit of surgical revascularization (CABG) versus medical therapy. In the STICH trial, viability assessment was not helpful in determining the benefit of CABG. However, the extent of viable myocardium with contractile function was not assessed in the trial. Dobutamine echocardiography was performed in 250 patients with ischemic left ventricular dysfunction (125-medically treated, 125-CABG). The mean ejection fraction (EF) was 32% in both groups. WMS during low dose dobutamine infusion was used to classify patients into groups with extensive (WMS < 2.00), intermediate (WMS 2.00-2.49), and limited (WMS ≥ 2.50) viability. Survival free of cardiac death was assessed at 2 years and for the complete duration of follow-up. There were 44 (35.2%) and 67 (53.6%) cardiac deaths in the revascularized and medically treated patients respectively (follow-up of 5.7 ± 5.8 years). Revascularized and medically treated patients with extensive viability had similar 2-year survival (p = 0.567) but revascularized patients had improved long-term survival (p = 0.0001). In those with intermediate viability, revascularization improved both 2 year (p = 0.014) and long-term survival (p = 0.0001). In patients with limited viability, 2-year survival was worse in revascularized patients (p = 0.04) and long-term survival was similar (p = 0 .25) in revascularized and medically treated groups. Patients with extensive and intermediate amounts of viability have improved survival with CABG but those with limited viability have poorer short-term outcome and no long-term benefit.
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Affiliation(s)
- Yasir Abdul Ghaffar
- Department of Cardiology, West Virginia University, Morgantown, WV, 26505, USA
| | - Waddah Maskoun
- Department of Cardiology, Henry Ford Hospital, Detroit, MI, 48020, USA
| | | | - Harvey Feigenbaum
- Indiana University School of Medicine, IU Health Methodist Hospital, Indianapolis, IN, 46202, USA
| | - Stephen G Sawada
- Indiana University School of Medicine, IU Health Methodist Hospital, Indianapolis, IN, 46202, USA. .,Krannert Institute of Cardiology, 1801 N. Senate Blvd, M.P.C. II, Suite D4000, Indianapolis, IN, 46202, USA.
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11
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Diemberger I, Marazzi R, Casella M, Vassanelli F, Galimberti P, Luzi M, Borrelli A, Soldati E, Golzio PG, Fumagalli S, Francia P, Padeletti L, Botto G, Boriani G. The effects of gender on electrical therapies for the heart: procedural considerations, results and complications: A report from the XII Congress of the Italian Association on Arrhythmology and Cardiostimulation (AIAC). Europace 2018; 19:1911-1921. [PMID: 28520959 DOI: 10.1093/europace/eux034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 05/02/2017] [Indexed: 12/28/2022] Open
Abstract
Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.
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Affiliation(s)
- Igor Diemberger
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico S.Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy
| | - Raffaella Marazzi
- Department of Heart and Vessels, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Michela Casella
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Francesca Vassanelli
- Chair and Unit of Cardiology, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Paola Galimberti
- Electrophysiology and Pacing Unit, Humanitas Clinical and Research Center, Rozzano-Milano, Italy
| | - Mario Luzi
- Cardiology Clinic, Marche Polytechnic University, Ancona, Italy
| | | | - Ezio Soldati
- Cardiac Thoracic and Vascular Department, University Hospital of Pisa, Italy
| | - Pier Giorgio Golzio
- Division of Cardiology, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Stefano Fumagalli
- Intensive Care Unit, Geriatric Cardiology and Medicine Division, Experimental and Clinical Medicine Department, University of Florence and AOU Careggi, Florence, Italy
| | - Pietro Francia
- Cardiac Electrophysiology Unit, Cardiology, St. Andrea Hospital, University "Sapienza", Rome, Italy
| | - Luigi Padeletti
- University of Florence, Florence, Italy IRCCS MultiMedica, Sesto San Giovanni, Italy
| | - Gianluca Botto
- EP Unit, Department of Medicine, Sant'Anna Hospital, Como, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
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12
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Safety and Effectiveness of Medical Device Therapy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:107-121. [DOI: 10.1007/978-3-319-77932-4_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Amini-Nik S. Time Heals all Wounds- but Scars Remain. Can Personalized Medicine Help? Front Genet 2018; 9:211. [PMID: 29988374 PMCID: PMC6023985 DOI: 10.3389/fgene.2018.00211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/25/2018] [Indexed: 01/24/2023] Open
Affiliation(s)
- Saeid Amini-Nik
- Sunnybrook Research Institute, Toronto, ON, Canada.,Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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14
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Zhang J, Guo F, Wu H, Wei J, Xian M, Fan F, Tang S, Zhao Y, Zhang Y, Li D, Yang H. Yixin-Shu facilitated cardiac-like differentiation of mesenchymal stem cells in vitro. RSC Adv 2018; 8:10032-10039. [PMID: 35540854 PMCID: PMC9078824 DOI: 10.1039/c7ra13326j] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/20/2018] [Indexed: 11/21/2022] Open
Abstract
Yixin-Shu capsules (YXS) are a Chinese Materia Medica standardized product used for heart disease and their effectiveness has been demonstrated through both clinical and experimental research. However, the mechanism involved has remained unclear. The effect of YXS on the cardiac-like differentiation of mesenchymal stem cells was investigated in this study. The intestinal absorption liquid of YXS was prepared using an in vitro intestinal absorption method and 62 compounds have been identified. A compound-target-function network constructed by a network pharmacology-based approach indicated that these compounds had an effect on cell differentiation. The effects of YXS on cardiac-like differentiation of mesenchymal stem cells was verified by detecting cardiac-specific protein expression such as α-actinin, cardiac troponin-I and desmin through real time-PCR, western blotting and immunofluorescence staining. A network pharmacology analysis indicated that the facilitation of YXS on the cardiac-like differentiation may be through the TGF-β signaling pathway, Wnt signaling pathway and MAPK signaling pathway. The observed improvements on cardiac differentiation may be due to the novel molecular mechanism for YXS that could also benefit developments in cardiac tissue engineering.
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Affiliation(s)
- Jingjing Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Feifei Guo
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Hongwei Wu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Junying Wei
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Minghua Xian
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Fangfang Fan
- College of Ethnic Medicine, Chengdu University of TCM Chengdu 610072 China
| | - Shihuan Tang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Ye Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Yi Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Defeng Li
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
| | - Hongjun Yang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences Beijing 100700 China +86-10-64013996 +86-10-64032656
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de Arenaza DP. RESONANCIA MAGNÉTICA CARDÍACA: NUEVOS DESARROLLOS Y PERSPECTIVAS FUTURAS. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2017.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Magri CJ, Tian TX, Camilleri L, Xuereb R, Galea J, Fava S. Red blood cell distribution width and myocardial scar burden in coronary artery disease. Postgrad Med J 2017; 93:607-612. [PMID: 28490545 DOI: 10.1136/postgradmedj-2016-134781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/19/2017] [Accepted: 04/02/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Red blood cell distribution width (RDW) is a novel independent marker of cardiovascular disease including heart failure, coronary artery disease and myocardial ischaemia. The aim of the study was to investigate a possible relationship between RDW and myocardial scar burden, as assessed by a MIBI viability scan. A secondary objective was to assess whether there is an association between RDW and left ventricular ejection fraction (LVEF). METHODS The study comprised 123 subjects with ischaemic heart disease who underwent a myocardial viability scan between June 2008 and July 2014. Haemoglobin, mean corpuscular volume, RDW, platelet count, mean platelet volume (MPV), estimated glomerular filtration rate, fasting blood glucose, liver and lipid profiles were evaluated for all patients. The extent of myocardial scarring and LVEF were noted. Data were analysed using IBM SPSS Statistics 22.0. Univariate followed by multivariate analyses were performed to assess for independent predictors of myocardial scarring and LVEF, respectively. RESULTS The mean age of the study population was 63.5 years; most of the subjects were men. The median LVEF was 31% and median percentage of myocardial scarring was 8.7%. Multivariate analyses revealed that RDW, HDL-cholesterol and alanine transaminase were independent predictors of myocardial scarring while RDW, MPV, LDL-cholesterol and gamma-glutamyl transpeptidase were independent predictors of LVEF. CONCLUSIONS Increased RDW is an independent predictor both of myocardial scar burden and of impaired left ventricular function in subjects with coronary artery disease.
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Affiliation(s)
- Caroline Jane Magri
- Department of Cardiology, Mater Dei Hospital, Msida, Malta.,University of Malta Medical School, University of Malta, Tal-Qroqq, Msida, Malta
| | - Tan Xiao Tian
- Department of Medicine, Mater Dei Hospita, Tal-Qroqq, Msida, Malta
| | - Liberato Camilleri
- Statistics & Operations Research, Faculty of Science, University of Malta, Msida, Malta
| | - Robert Xuereb
- Department of Cardiology, Mater Dei Hospital, Msida, Malta.,University of Malta Medical School, University of Malta, Tal-Qroqq, Msida, Malta
| | - Joseph Galea
- University of Malta Medical School, University of Malta, Tal-Qroqq, Msida, Malta.,Department of Cardiac Services, Mater Dei Hospital, Tal-Qroqq, Msida, Malta
| | - Stephen Fava
- University of Malta Medical School, University of Malta, Tal-Qroqq, Msida, Malta.,Department of Medicine, Mater Dei Hospita, Tal-Qroqq, Msida, Malta
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Xuereb R, Magri CJ, Xuereb S, Xuereb M, Mangion MZ, Xuereb RG. Female gender and cardiovascular disease. Br J Hosp Med (Lond) 2016; 77:454-9. [DOI: 10.12968/hmed.2016.77.8.454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Rachel Xuereb
- Third year medical student at the University of Malta, Malta
| | - Caroline J Magri
- Resident Specialist in the Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Msida MSD 2090, Malta, and Visiting Lecturer, University of Malta, Malta
| | - Sara Xuereb
- Foundation Year 2 Doctor in the Department of Medicine, Mater Dei Hospital, Malta
| | - Mariosa Xuereb
- Consultant Cardiologist in the Department of Cardiology, Mater Dei Hospital, and Visiting Senior Lecturer, University of Malta, Malta
| | | | - Robert G Xuereb
- Chairman and Consultant Cardiologist in the Department of Cardiology, Mater Dei Hospital, and Visiting Senior Lecturer, University of Malta, Malta
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Prediction of Outcomes in Patients with Chronic Ischemic Cardiomyopathy by Layer-Specific Strain Echocardiography: A Proof of Concept. J Am Soc Echocardiogr 2016; 29:412-20. [PMID: 26969138 DOI: 10.1016/j.echo.2016.02.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiac magnetic resonance imaging (CMR) has been established as a powerful tool for predicting mortality. However, its application is limited by availability and various contraindications. The aim of this study was to evaluate the predictive value of layer-specific myocardial deformation analysis as assessed by strain echocardiography for cardiac events in patients with chronic ischemic left ventricular dysfunction in comparison with CMR. METHODS Three hundred ninety patients (mean age, 63 ± 4 years; 69% men; mean left ventricular ejection fraction [LVEF], 41 ± 7%) with chronic ischemic cardiomyopathy were prospectively enrolled and underwent strain echocardiography and CMR within 3 ± 1 days. LVEF, wall motion score index, and circumferential strain (CS), longitudinal strain, and radial strain for total wall thickness and for three myocardial layers (endocardial, midmyocardial, and epicardial) were determined by echocardiography. The extent of total myocardial scar (TMS) was determined by CMR. Follow-up was obtained for a mean of 4.9 ± 2.2 years. Cardiac events were defined as readmission for worsening of heart failure, ventricular arrhythmias, or death of any cause. The incremental value of LVEF, strain parameters, and TMS to relevant clinical variables was determined in nested Cox models. RESULTS There were 133 cardiac events (34%). Baseline clinical data associated with outcomes were age (hazard ratio [HR], 1.27; P = .04), diabetes mellitus (HR, 1.52; P = .001), and renal insufficiency (HR, 1.77; P = .001) by multivariate analysis. The addition of LVEF, global and endocardial strain parameters, and TMS increased the predictive power, but endocardial CS (HR, 1.52; P < .01) caused the greatest increment in model power (χ(2) = 39.2, P < .001). Endocardial CS < -20% was found to be the optimal predictor of prognosis. CONCLUSIONS Endocardial CS is a powerful predictor of cardiac events and appears to be a better parameter than LVEF, TMS by CMR, and other strain variables by echocardiography.
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Abstract
Cardiac resynchronisation therapy (CRT) is an effective intervention for appropriately selected patients with heart failure, but exactly how it works is uncertain. Recent data suggest that much, or perhaps most, of the benefits of CRT are not delivered by re-coordinating left ventricular dyssynchrony. Atrio-ventricular resynchronization, reduction in mitral regurgitation and prevention of bradycardia are other potential mechanisms of benefit that will vary from one patient to the next and over time. Because there is no single therapeutic target, it is unlikely that any single measure will accurately predict benefit. The only clinical characteristic that appears to be a useful predictor of the benefits of CRT is a QRS duration of >140 ms. Many new approaches are being developed to try to improve the effectiveness of and extend the indications for CRT. These include smart pacing algorithms, better pacing-site targeting, new sensors, multipoint pacing, remote device monitoring and leadless endocardial pacing. Whether CRT is effective in patients with atrial fibrillation or whether adding a defibrillator function to CRT improves prognosis awaits further evidence.
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Nchimi A, Davin L, Georgiopoulos A, Lancellotti P. Value of cardiac MRI to evaluate ischemia-related ventricular arrhythmia substrates. Expert Rev Cardiovasc Ther 2015; 13:565-76. [DOI: 10.1586/14779072.2015.1030394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mehta NK, Abraham WT, Maytin M. ICD and CRT use in ischemic heart disease in women. Curr Atheroscler Rep 2015; 17:512. [PMID: 25921310 DOI: 10.1007/s11883-015-0512-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although the role of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) in improving outcomes in ischemic cardiomyopathy (ICM) has been described, the data regarding gender-based survival outcomes are limited. There is a higher preponderance of non-ischemic cardiomyopathy (NICM) in women, and most of the ICM literature is derived from sub-study analysis. This review summarizes the current body of literature on prognosis, pathophysiology, and the present clinical practice for device implantation in women with ICM.
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Affiliation(s)
- Nishaki Kiran Mehta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43220, USA,
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Pozo E, Sanz J. Técnicas de imagen en la evaluación de la función y cicatriz tras el infarto. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pozo E, Sanz J. Imaging techniques in the evaluation of post-infarction function and scar. ACTA ACUST UNITED AC 2014; 67:754-64. [PMID: 25172072 DOI: 10.1016/j.rec.2014.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
Imaging techniques are essential in the clinical evaluation of patients with a myocardial infarction. They are of value for both initial assessment of the ischemic injury and for detection of the subgroup of patients at higher risk of developing cardiovascular events during follow-up. Echocardiography remains the technique of choice for the initial evaluation, owing to its bedside capability to determine strong predictors, such as ventricular volumes, global and regional systolic function, and valvular regurgitation. New techniques for evaluating ventricular mechanics, mainly assessment of ventricular deformation, are revealing important aspects of post-infarction ventricular adaptation. The main alternative to echocardiography is cardiac magnetic resonance imaging. This technique is highly accurate for determining ventricular volumes and ventricular function and has the additional advantage of being able to characterize the myocardium and demonstrate changes associated with the ischemic insult such as necrosis/fibrosis, edema, microvascular obstruction, and intramyocardial hemorrhage. These features not only allow detection and quantification of the infarct size, but also reveal additional characteristics of the scar tissue with prognostic value.
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Affiliation(s)
- Eduardo Pozo
- The Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine, New York, United States; Servicio de Cardiología, Hospital Universitario de La Princesa, Madrid, Spain
| | - Javier Sanz
- The Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health; Icahn School of Medicine, New York, United States.
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Kwon DH, Asamoto L, Popovic ZB, Kusunose K, Robinson M, Desai M, Marwick TH, Flamm SD. Infarct characterization and quantification by delayed enhancement cardiac magnetic resonance imaging is a powerful independent and incremental predictor of mortality in patients with advanced ischemic cardiomyopathy. Circ Cardiovasc Imaging 2014; 7:796-804. [PMID: 25085923 DOI: 10.1161/circimaging.114.002077] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infarct heterogeneity has been shown to be independently associated with adverse outcomes in previous smaller studies. However, it is unknown whether infarct characterization is an independent predictor of all-cause mortality in patients with advanced ischemic cardiomyopathy, after adjusting for clinical risk factors, severity of ischemic mitral regurgitation, incomplete revascularization, and device therapy. METHODS AND RESULTS A total of 362 patients with ischemic cardiomyopathy (left ventricular dysfunction with >70% stenosis in ≥1 epicardial coronary artery) underwent delayed hyperenhancement-magnetic resonance imaging and coronary angiography between 2002 and 2006. Total myocardial scar and peri-infarct (PI) area were measured using various threshold techniques. Multivariate survival analysis (primary end point of all-cause mortality) was conducted. One hundred fifty-seven deaths occurred during a mean 5.4-year follow-up (mean left ventricular ejection fraction, 23±9%; mean end-systolic volume index, 113±48 mL; mean total myocardial scar %, 25.5±16.0%; mean PI%, 5.7±2.9%). PI% (β=2.07; P<0.001) was an independent predictor of survival, independent of age, end-systolic volume, sex, mitral regurgitation, diabetes mellitus, dyslipidemia, coronary artery disease severity, implantable cardioverter defibrillator, and incomplete revascularization. PI% using 2 to 3 SD technique yielded the highest incremental prognostic power (χ(2) score 149). CONCLUSIONS In advanced ischemic cardiomyopathy, PI% is a powerful independent and incremental predictor of all-cause mortality. Infarct heterogeneity offers substantial further risk stratification when compared with quantification of total myocardial scar % alone even after adjusting for clinical risk factors, end-systolic volume index, mitral regurgitation, incomplete revascularization, and implantable cardioverter defibrillator implantation.
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Affiliation(s)
- Deborah H Kwon
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.).
| | - Lisa Asamoto
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.)
| | - Zoran B Popovic
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.)
| | - Kenya Kusunose
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.)
| | - Monique Robinson
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.)
| | - Milind Desai
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.)
| | - Thomas H Marwick
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.)
| | - Scott D Flamm
- From the Heart and Vascular Institute (D.H.K., Z.B.P., K.K., M.R., M.D., S.D.F.) and Imaging Institute (D.H.K., Z.B.P., M.D., S.D.F.), Cleveland Clinic, OH; Department of Family Medicine, University of Colorado, Denver, CO (L.A.); and Menzies Research Institute of Tasmania, Hobart, Australia (T.H.M.)
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