Cardiac Magnetic Resonance to Predict Cardiac Mass Malignancy: The CMR Mass Score

BACKGROUND

Multimodality imaging is currently suggested for the noninvasive diagnosis of cardiac masses. The identification of cardiac masses' malignant nature is essential to guide proper treatment. We aimed to develop a cardiac magnetic resonance (CMR)-derived model including mass localization, morphology, and tissue characterization to predict malignancy (with histology as gold standard), to compare its accuracy versus the diagnostic echocardiographic mass score, and to evaluate its prognostic ability.

METHODS

Observational cohort study of 167 consecutive patients undergoing comprehensive echocardiogram and CMR within 1-month time interval for suspected cardiac mass. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, by histology or radiological resolution after adequate anticoagulation treatment. Logistic regression was performed to assess CMR-derived independent predictors of malignancy, which were included in a predictive model to derive the CMR mass score. Kaplan-Meier curves and Cox regression were used to investigate the prognostic ability of predictors.

RESULTS

In CMR, mass morphological features (non-left localization, sessile, polylobate, inhomogeneity, infiltration, and pericardial effusion) and mass tissue characterization features (first-pass perfusion and heterogeneity enhancement) were independent predictors of malignancy. The CMR mass score (range, 0-8 and cutoff, ≥5), including sessile appearance, polylobate shape, infiltration, pericardial effusion, first-pass contrast perfusion, and heterogeneity enhancement, showed excellent accuracy in predicting malignancy (areas under the curve, 0.976 [95% CI, 0.96-0.99]), significantly higher than diagnostic echocardiographic mass score (areas under the curve, 0.932; P=0.040). The agreement between the diagnostic echocardiographic mass and CMR mass scores was good (κ=0.66). A CMR mass score of ≥5 predicted a higher risk of all-cause death (P<0.001; hazard ratio, 5.70) at follow-up.

CONCLUSIONS

A CMR-derived model, including mass morphology and tissue characterization, showed excellent accuracy, superior to echocardiography, in predicting cardiac masses malignancy, with prognostic implications.

Predictive value of Killip classification in MINOCA patients

BACKGROUND

Killip classification is a practical clinical tool for risk stratification in patients with acute myocardial infarction (AMI). However, its prognostic role in myocardial infarction with non-obstructive coronary artery (MINOCA) is still poorly explored. Our purpose was to evaluate the prognostic role of high Killip class in the specific setting of MINOCA and compare the results with a cohort of patients with obstructive coronary arteries myocardial infarction (MIOCA).

METHODS

This study included 2455 AMI patients of whom 255 were MINOCA. We compared the Killip classes of MINOCA with those of MIOCA and evaluated the prognostic impact of a high Killip class, defined if greater than I, on both populations' outcome. Short-term outcomes included in-hospital death, re-AMI and arrhythmias. Long-term outcomes were all-cause mortality, re-AMI, stroke, heart failure (HF) hospitalization and the composite endpoint of MACE.

RESULTS

Killip class >1 occurred in 25 (9.8%) MINOCA patients compared to 327 (14.9%) MIOCA cases. In MINOCA subjects, a high Killip class was associated with a greater in-hospital mortality (p = 0.002) and, at long term follow-up, with a three-fold increased mortality (p = 0.001) and a four-fold risk of HF hospitalization (p = 0.003). Among MINOCA, a high Killip class was identified as a strong independent predictor of MACE occurrence [HR 2.66, 95% CI (1.25-5.64), p = 0.01] together with older age and worse kidney function while in MIOCA population also left ventricular ejection fraction and troponin value predicted MACE.

CONCLUSIONS

Killip classification confirmed its prognostic impact on short- and long-term outcomes also in a selected MINOCA population, which still craves for a baseline risk stratification.

[Periprocedural myocardial injury and infarction after myocardial revascularization: incidence, clinical features and prognosis]

Myocardial revascularization, either percutaneous or surgical, is the cornerstone of chronic and acute ischemic coronary artery disease therapy. Periprocedural myocardial injury and infarction are possible complications of these procedures. Several pathogenetic mechanisms have been proposed in the setting of percutaneous (distal embolism, vasospasm, obstruction of a minor vessel) or surgical revascularization (prolonged ischemic time, early graft failure, arrhythmia or severe hypotension during the procedure). High-sensitivity cardiac troponins have emerged as the recommended biomarkers due to their important prognostic implications. However, data regarding diagnostic criteria, management and prognostic implications of these complications are lacking. The present review aims to provide an overview regarding the possible diagnostic criteria, management and prognostic role of periprocedural myocardial injury and infarction.

Sex- and age-related differences in outcomes of patients with acute myocardial infarction: MINOCA vs. MIOCA

AIMS

The aim of the study is to evaluate the impact of sex on acute myocardial infarction (AMI) patients' clinical presentation and outcomes, comparing those with non-obstructive and obstructive coronary arteries (MINOCA vs. MIOCA).

METHODS AND RESULTS

We enrolled 2455 patients with AMI undergoing coronary angiography from January 2017 to September 2021. Patients were divided according to the type of AMI and sex: male (n = 1593) and female (n = 607) in MIOCA and male (n = 87) and female (n = 168) in MINOCA. Each cohort was further stratified based on age (≤/> 70 years). The primary endpoint (MAE) was a composite of all-cause death, recurrent AMI, and hospitalization for heart failure (HF) at follow-up. Secondary outcomes included all-cause and cardiovascular death, recurrent AMI, HF re-hospitalization, and stroke. MINOCA patients were more likely to be females compared with MIOCA ones (P < 0.001). The median follow-up was 28 (15-41) months. The unadjusted incidence of MAE was significantly higher in females compared with males, both in MINOCA [45 (26.8%) vs. 12 (13.8%); P = 0.018] and MIOCA cohorts [203 (33.4%) vs. 428 (26.9%); P = 0.002]. Age was an independent predictor of MAE in both cohorts. Among MINOCA patients, females ≤70 years old had a higher incidence of MAE [18 (23.7%) vs. 4 (5.9%); P = 0.003] compared with male peers, mainly driven by a higher rate of re-hospitalization for HF (P = 0.045) and recurrence of AMI (P = 0.006). Only in this sub-group of MINOCA patients, female sex was an independent predictor of MAE (hazard ratio = 3.09; 95% confidence interval: 1.02-9.59; P = 0.040). MINOCA females ≤70 years old had worse outcomes than MIOCA female peers.

CONCLUSION

MINOCA females ≤70 years old had a significantly higher incidence of MAE, compared with males and MIOCA female peers, likely due to the different pathophysiology of the ischaemic event.

TRIAL REGISTRATION

Data were part of the ongoing observational study 'AMIPE: Acute Myocardial Infarction, Prognostic and Therapeutic Evaluation' (ClinicalTrials.gov Identifier: NCT03883711).

Performance of Prognostic Scoring Systems in MINOCA: A Comparison among GRACE, TIMI, HEART, and ACEF Scores

Background: the prognosis of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is not benign; thus, prompting the need to validate prognostic scoring systems for this population. Aim: to evaluate and compare the prognostic performance of GRACE, TIMI, HEART, and ACEF scores in MINOCA patients. Methods: A total of 250 MINOCA patients from January 2017 to September 2021 were included. For each patient, the four scores at admission were retrospectively calculated. The primary outcome was a composite of all-cause death and acute myocardial infarction (AMI) at 1-year follow-up. The ability to predict 1-year all-cause death was also tested. Results: Overall, the tested scores presented a sub-optimal performance in predicting the composite major adverse event in MINOCA patients, showing an AUC ranging between 0.7 and 0.8. Among them, the GRACE score appeared to be the best in predicting all-cause death, reaching high specificity with low sensitivity. The best cut-off identified for the GRACE score was 171, higher compared to the cut-off of 140 generally applied to identify high-risk patients with obstructive AMI. When the scores were tested for prediction of 1-year all-cause death, the GRACE and the ACEF score showed very good accuracy (AUC = 0.932 and 0.828, respectively). Conclusion: the prognostic scoring tools, validated in AMI cohorts, could be useful even in MINOCA patients, although their performance appeared sub-optimal, prompting the need for risk assessment tools specific to MINOCA patients.

Myocardial infarction with nonobstructive coronary arteries: from pathophysiology to therapeutic strategies

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a heterogeneous group of clinical entities characterized by clinical evidence of acute myocardial infarction (AMI) with normal or near-normal coronary arteries on coronary angiography (stenosis < 50%) and without an over the alternative diagnosis for the acute presentation. Its prevalence ranges from 6% to 11% among all patients with AMI, with a predominance of young, nonwhite females with fewer traditional risks than those with an obstructive coronary artery disease (MI-CAD). MINOCA can be due to either epicardial causes such as rupture or fissuring of unstable nonobstructive atherosclerotic plaque, coronary artery spasm, spontaneous coronary dissection and cardioembolism in-situ or microvascular causes. Besides, also type-2 AMI due to supply-demand mismatch and Takotsubo syndrome must be considered as a possible MINOCA cause. Because of the complex etiology and a limited amount of evidence, there is still some confusion around the management and treatment of these patients. Therefore, the key focus of this condition is to identify the underlying individual mechanisms to achieve patient-specific treatments. Clinical history, electrocardiogram, echocardiography, and coronary angiography represent the first-level diagnostic investigations, but coronary imaging with intravascular ultrasound and optical coherent tomography, coronary physiology testing, and cardiac magnetic resonance imaging offer additional information to understand the underlying cause of MINOCA. Although the prognosis is slightly better compared with MI-CAD patients, MINOCA is not always benign and depends on the etiopathology. This review analyzes all possible pathophysiological mechanisms that could lead to MINOCA and provides the most specific and appropriate therapeutic approach in each scenario.

Sex-Related Disparities in Cardiac Masses: Clinical Features and Outcomes

BACKGROUND

Cardiac masses (CM) represent a heterogeneous clinical scenario, and sex-related differences of these patients remain to be established.

PURPOSE

To evaluate sex-related disparities in CMs regarding clinical presentation and outcomes.

MATERIAL AND METHODS

The study cohort included 321 consecutive patients with CM enrolled in our Centre between 2004 and 2022. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, with radiological evidence of thrombus resolution after anticoagulant treatment. All-cause mortality at follow-up was evaluated. Multivariable regression analysis assessed the potential prognostic disparities between men and women.

RESULTS

Out of 321 patients with CM, 172 (54%) were female. Women were more frequently younger (p = 0.02) than men. Regarding CM histotypes, females were affected by benign masses more frequently (with cardiac myxoma above all), while metastatic tumours were more common in men (p < 0.001). At presentation, peripheral embolism occurred predominantly in women (p = 0.03). Echocardiographic features such as greater dimension, irregular margin, infiltration, sessile mass and immobility were far more common in men. Despite a better overall survival in women, no sex-related differences were observed in the prognosis of benign or malignant masses. In fact, in multivariate analyses, sex was not independently associated with all-cause death. Conversely, age, smoking habit, malignant tumours and peripheral embolism were independent predictors of mortality.

CONCLUSIONS

In a large cohort of cardiac masses, a significant sex-related difference in histotype prevalence was found: Benign CMs affected female patients more frequently, while malignant tumours affected predominantly men. Despite better overall survival in women, sex did not influence prognosis in benign and malignant masses.

Echocardiographic Markers in the Diagnosis of Cardiac Masses

BACKGROUND

The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown. The aim of this study was to identify and integrate the echocardiographic features of CMs that can accurately predict malignancy.

METHODS

An observational cohort study was conducted among 286 consecutive patients who underwent standard echocardiographic assessment for suspected CM at Bologna University Hospital between 2004 and 2022. A definitive diagnosis was achieved by histologic examination or, in the case of cardiac thrombi, with radiologic evidence of thrombus resolution after appropriate anticoagulant treatment. Logistic and multivariable regression analysis was performed to confirm the ability of six echocardiographic parameters to discriminate malignant from benign masses. The unweighted count of these parameters was used as a numeric score, ranging from 0 to 6, with a cutoff of ≥3 balancing sensitivity and specificity with respect to the histologic diagnosis of malignancy. Classification tree analysis was used to determine the ability of echocardiographic parameters to discriminate subgroups of patients with differential risk for malignancy.

RESULTS

Benign masses were more frequently pedunculated, mobile, and adherent to the interatrial septum (P < .001). Malignant masses showed a greater diameter and exhibited a higher frequency of irregular margins, an inhomogeneous appearance, sessile implantation, polylobate shape, and pericardial effusion (P < .001). Infiltration, moderate to severe pericardial effusion, nonleft localization, sessile implantation, polylobate shape, and inhomogeneity were confirmed to be independent predictors of malignancy in both univariate and multivariable models. The predictive ability of the unweighted score of ≥3 was very high (>0.90) and similar to that of the previously published weighted score. Classification tree analysis generated an algorithm in which infiltration was the best discriminator of malignancy, followed by nonleft localization and sessile implantation. The percentage correctly classified by classification tree analysis as malignant was 87.5%. Agreement between observer readings and CM histology ranged between 85.1% and 91.5%. The presence of at least three echocardiographic parameters was associated with lower survival.

CONCLUSIONS

In the approach to CMs, some echocardiographic parameters can serve as markers to accurately predict malignancy, thereby informing the need for second-level investigations and minimizing the diagnostic delay in such a complex clinical scenario.

948 MULTIMODALITY IMAGING IN CARDIAC MASSES

Background

Cardiac masses (CM) are an extremely heterogeneous clinical scenario, including benign and malignant neoformations. After a first echocardiographic assessment, Cardiac Computed Tomography (CCT) together with Cardiac Magnetic Resonance (CMR) and 18-Fluorodeoxyglucose Positron Emission Tomography (18-FDG-PET) represent second-line and third-line imaging techniques to determine the nature of the mass. However, data regarding their diagnostic performance and a standardized imaging algorithm are lacking.

Purpose

To evaluate the different roles of CCT, CMR, and PET in defining the nature of CMs and to propose an evidence-based, stepwise, diagnostic approach.

Materials and methods

Out of 312 patients with suspected mass from January 2000 and August 2022, we enrolled 87 patients who underwent CCT, CMR and 18-FDG-PET within a month from the initial evaluation. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. For each imaging technique, we identified a model with the strongest predictors of malignancy at multivariate analysis and evaluated their ability to discriminate between benign and malignant neoformations. A multiple model with forwarding selection was performed to identify the strongest predictors of malignancy at CCT, CMR and 18-FDG-PET.

Results

CCT model included 4 variables (irregular margins, mass dimension, invasiveness and not-hypodense lesion) with an Area Under the Curve (AUC) of 0.972, 95% Confidence Interval (CI) 0.94-1.0; CMR model included 3 parameters (invasiveness, pericardial effusion and irregular margins, AUC 0.976 with 95% CI 0.95-1.0); PET model included only cardiac maximum Standardized Uptake Value (SUVmax), with an AUC 0.87 (95% IC 0.74-0.971). When implemented with SUVmax, CCT and CMR models showed only a slight improvement in their discrimination ability (AUC 0.975 and 0.986, respectively). No statistical difference was observed between CCT and CMR models regarding their discrimination ability (AUC 0.972 vs 0.976, p=0.26). However, on a multiple model with forwarding selection evaluating CCT, CMR and PET variables, only the 3 MR parameters remained significant predictors of malignancy.

Conclusion

After a first echocardiographic assessment, the application of the CMR model may be the most accurate second-level investigation to discriminate between benign and malignant lesions. When CMR is not available, or the patient has contraindications to CMR, the CCT model performs similarly, and 18-FDG-PET provides a negligible advantage.

855 PREDICTORS OF LATE GADOLINIUM ENHANCEMENT DEVELOPMENT AND EXTENSION IN MYOCARDIAL INFARCTION WITH NON-OBSTRUCTIVE CORONARY ARTERIES

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity and in its complex diagnostic approach cardiovascular magnetic resonance (CMR) plays a pivotal role.

Purpose

To characterize the differences of MINOCA patients with and without late gadolinium enhancement (LGE) at CMR and to identify the predictors for ischemic LGE development and extension.

Methods

We assessed 461 MINOCA cases from January 2016 to June 2021. MINOCA were defined according to the current European guidelines criteria. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR imaging findings, our cohort was divided into two CMR phenotypes based on regional myocardial necrosis detected throughout LGE (“LGE-positive MINOCA”) or regional ischemic injury without LGE (“LGE-negative MINOCA”). Extended LGE was considered as the presence of &gt;2 segments with transmural LGE. Multivariate logistic regression analysis was used to determine the predictors of LGE and extended LGE.

Results

The final cohort included 175 MINOCA: 121 (69.1%) constituted the LGE-positive group. The mean time delay between acute clinical presentation and CMR was 6 ± 2.9 days. At admission, MINOCA LGE-patients more frequently presented angina and ST segment elevation (24% vs 7.4%, p = 0.01), compared to the LGE negative ones. Furthermore, the LGE positive group had a significantly greater infarct size, measured by peak hs-Troponin I values and left ventricular function. The only predictor of LGE was the peak troponin value (OR 1.64, 95% CI 1.18–2.28, p = 0.003), while predictors of extended LGE were ST-segment elevation at admission (OR 7.44, 95% CI 1.57–35.22, p = 0.01), peak troponin values (OR 1.07, 95% CI 1.02–1.13, p = 0.01) and the presence of non-obstructive coronary artery disease at coronary angiography (OR 5.49, 95% CI 1.20–25.09, p = 0.028).

Conclusion

The presence and extension of LGE at early CMR evaluation is an important feature in the setting of MINOCA. In addition, simple baseline characteristics (such as ST elevation, peak troponin value and LVEF) may aid the identification of a greater ischemic necrosis burden at CMR and therefore these high-risk MINOCA subjects could be benefit from a stricter management effort.

996 INCIDENCE AND PREDICTORS OF HEART FAILURE DEVELOPMENT IN A COHORT OF PATIENTS WITH MYOCARDIAL INFARCTION WITH NON-OBSTRUCTIVE CORONARY ARTERIES

Background

A higher risk of death and major cardiovascular events, including Heart Failure (HF), after a Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) has been described. In particular, HF has a negative impact not only on survival but also on quality of life. In this context, strategies to identify subjects with a greater risk of developing HF are needed.

Aims

To assess the incidence and predictors of HF developing subsequently a MINOCA.

Methods

461 subjects with suspected MINOCA from 2016 to 2021 were assessed. Acute myocarditis, Takotsubo syndromes, cardiomyopathies and patients with incomplete data were excluded. The final cohort consisted of 188 patients with a confirmed MINOCA diagnosis. After a mean follow-up of 36±14.8 months, 20 patients (10.6%) had hospital readmission for HF. Demographic, clinical, laboratory, and instrumental data were collected and analyzed.

Results

None among demographic characteristics, cardiovascular risk factors or comorbidities showed correlation with HF occurrences. Paroxysmal or permanent atrial fibrillation was more frequent among patients who developed HF (p .005), such as ST-elevation at onset (p .001). Higher glycemia at admission correlated with HF (p .012). In this regard, hyperglycemia could act as a direct toxic agent or as an indirect marker of a greater stress response. Cardiac troponin I (cTnI) at peak, but not first cTnI measurement, was significantly higher in patients who developed HF (p&lt;.001), confirming the prognostic value of troponin, even in this context. Concerning echocardiography, HF incidence was higher in patients with any wall motion abnormalities (p .037), lower ejection fraction (EF; p .046), especially if EF≤40% (p&lt;.001), higher atrial maximum diameter (p .005), end-diastolic diameter (p. 001) or normalized end-diastolic volume (p&lt;.001). Among cardiac magnetic resonance findings, HF occurred more often (p&lt;.001) in patients with a transmural pattern of late gadolinium enhancement (LGE), which resulted as an independent risk factor for HF developing at the multivariate analysis (HR 15.32, 95% CI 5.13-45.75, p&lt;.001). Finally, 32 patients (17%) were affected by non-obstructive coronary arteries stenosis (i.e., &lt;50%). This finding, but not re-infarction, was also associated with HF development (p .004). Notably, only 2 out of the 68 patients dismissed with DAPT developed HF (p .010). In our study beta-blockers, RAS inhibitors and statins at dismission had not reduced the risk of HF. Nevertheless, the low sample size forbids inferring conclusions about the therapy.

Conclusion

In our cohort of patients with MINOCA, several clinical, laboratory and echocardiographic characteristics correlated with a higher frequency of HF occurrences. Moreover, a broader extent of cardiac damage, as testified by cTnI, wall motion abnormalities, reduced EF and transmural LGE, could predict HF development. Further studies to establish adequate follow-up programs and therapy to prevent HF progression in these patients are needed.

1016 CARDIAC MAGNETIC RESONANCE IMAGING IN DIFFERENTIAL DIAGNOSIS OF CARDIAC MASSES

Background

Differential diagnosis of cardiac masses represents a challenging issue with important implications for therapeutic management and patient's prognosis. Cardiac Magnetic Resonance (CMR) is a non-invasive imaging technique used to characterize morphologic and functional features of masses. Integration of these information can lead to an accurate diagnosis.

Purpose

To evaluate the diagnostic role of CMR in defining the nature of cardiac masses.

Methods

One hundred-fourteen patients with cardiac masses evaluated with CMR were enrolled. All masses had histological certainty. CMR sequences allowed a qualitative morphologic description as well as tissue characterization. Evaluation of masses morphology included localization, size and borders assessment, detection of potential multiple lesions and pericardial effusion. Tissue characterization resulted from an estimation of contrast enhancement - early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE) sequences - and tissue homogeneity in T1 and T2 weighted acquisitions. The descriptive analysis was carried out by comparing benign vs malignant lesions as well as dividing patients into 4 subgroups: primitive benign tumours, primitive malignant tumours, metastatic tumours and pseudotumours.

Results

The descriptive analysis of morphologic features showed that diameter &gt; 50 mm, invasion of surrounding planes, irregular margins and presence of pericardial effusion were able to predict malignancy (p &lt; 0.001). As for tissue characteristics, heterogeneous signal intensity - independently from T1 and T2 weighted acquisitions - and EGE were more common in malignant lesions (p &lt;0.001). When analysing the four subgroups, CMR features did not discriminate between primitive malignant masses and metastasis. Conversely, hyperintensity signal in T2 w-TSE, EGE and heterogeneity after gadolinium enhancement were more common in benign primitive lesions compared to pseudotumours.

Furthermore, using classification and regression tree (CART) analysis, we developed an algorithm to differentiate masses: invasion of surrounding planes was a common characteristic of malignancy and identifies itself malignant tumours. In the absence of invasive features, gadolinium enhancement was evaluated: the lack of contrast uptake was able to increase the probability of a pseudotumour. Last step of decision algorithm included ejection fraction assessment to discriminate between benign tumours: a reduced ejection fraction increased the probability of pseudotumour diagnosis and reduced the probability of primary benign tumour diagnosis.

Conclusions

Cardiac magnetic resonance is a very powerful diagnostic tool for differential diagnosis of cardiac masses as it correctly addresses malignancy. Furthermore, an accurate evaluation of the several CMR features may discriminate primary benign masses and pseudotumours.

1031 IMPACT OF PRE-TREATMENT WITH A P2Y12 RECEPTOR INHIBITOR ON PERIPROCEDURAL MYOCARDIAL INFARCTION AND MYOCARDIAL INJURY IN NSTEMI

Background

Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor is the standard of care in patients with acute coronary syndromes. The optimal timing of the administration of oral P2Y12 inhibitors has been largely debated, particularly among patients with non-ST-segment elevation myocardial infarction (NSTEMI). The latest European Society of Cardiology guidelines, based on recent scientific evidence, do not recommend routine pre-treatment with a P2Y12 inhibitor before coronary angiography. However, the impact of pre-treatment on the incidence of peri-procedural myocardial infarction (MI) and myocardial injury has never been explored.

Purpose

To evaluate the impact of pre-treatment with a P2Y12 receptor inhibitor on periprocedural myocardial infarction and injury in NSTEMI patients undergoing invasive treatment.

Methods

We evaluated all consecutive patients admitted to our coronary care unit from 2016 to 2021 affected by NSTEMI undergoing invasive management with percutaneous coronary intervention (PCI). We enrolled only patients with stable (≤ 20% variation) or falling pre-procedure baseline cardiac troponin (cTn) values. The entire population was divided into two groups: patients pre-treated with dual antiplatelet therapy (an oral P2Y12 inhibitor in adjunct to aspirin) before performing coronary angiography (upstream group) and patients who started an oral P2Y12 inhibitor only after PCI (downstream group). All patients received aspirin and anticoagulant therapy before coronary angiography. The primary endpoint was the incidence rate of periprocedural MI and myocardial injury according to the fourth universal definition of myocardial infarction. Finally, a safety endpoint of major and minor bleeding according to Thrombolysis in Myocardial Infarction (TIMI) criteria was evaluated for all bleeding episodes during hospitalization.

Results

A total of 878 patients with NSTEMI undergoing PCI and with pre-procedure stable cTn levels were analyzed: 615 (70%) constituted the upstream group. The mean age of the study population was 70.1±12.5 years and 71.3% were males. There were no significant differences regarding traditional cardiovascular risk factors, comorbidities, cTn and hemoglobin levels between the two groups.

After PCI, the rate of periprocedural myocardial injury and MI did not significantly differ between the upstream and downstream groups (19.5% vs 24.7%, p=0.08 and 17.6% vs 19.4%, p=0.5, respectively). A trend of lower periprocedural myocardial injury and MI cumulative incidence was observed in the upstream group (37.1% vs 44.1%, p=0.051). Notably, major and minor bleedings during hospitalization occurred more frequently in the upstream group compared to the downstream one (5.2% vs 1.9%, p=0.02).

Conclusions

Among NSTEMI patients undergoing invasive management and with stable pre-procedure cTn levels, pretreatment with an oral P2Y12 inhibitor did not reduce the rate of periprocedural MI and myocardial injury but was associated with an increase in major and minor bleeding complications during hospitalization.

1018 DIAGNOSTIC AGREEMENT BETWEEN ECHOCARDIOGRAPHY AND SECOND-LEVEL IMAGING TECHNIQUES IN PATIENTS WITH CARDIAC MASSES

Background

Cardiac masses (CMs) are a diagnostic dilemma in clinical practice and require multimodality imaging to assess malignancy, which is essential to guide the proper treatment.

Aim

To define diagnostic accuracy and agreement between echocardiographic features and second-level imaging techniques (cardiac computed tomography – CCT or cardiac magnetic resonance – CMR) in patients with CMs.

Methods

All consecutive patients with histologically confirmed cardiac masses from January 2004 to December 2020, undergoing CCT and/or CMR after echocardiographic assessment were enrolled. Six echocardiographic variables, namely infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization, were used to predict malignancy. Patients with more than 3 of these features were considered at higher risk of malignancy. For the patients before 2017, the choice of which second-level imaging to perform was up to the clinical cardiologist. Since 2017, the indication has been the result of a multidisciplinary discussion by the Heart Team. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. The echo-vs-CCT agreement and echo-vs-CMR agreement were evaluated. Accuracy indicators (sensitivity, specificity, PPV, NPV, Cohen's Kappa coefficient) were calculated by standard formulas.

Results

Out of 249 patients with histologically confirmed CM, 138 underwent a CCT and 112 a CMR, after the standard echocardiographic assessment. A complete agreement between the echocardiographic assignment (using the cut-off of 3 parameters as a marker for malignancy) and CCT was reached in 104 out of 138 cases (75.4%), ranging from 85.1 to 70.3% for benign and malignant cardiac masses, respectively. On the other side, the agreement between the echocardiographic assignment and CMR report was in 93 out of 112 cases (83%), ranging from 88.7 to 82% for benign and malignant cardiac masses. The agreement between these imaging techniques expressed as Cohen's κ was higher for echocardiography versus CMR (k=0.73), compared to echocardiography versus CCT (k=0.61). These results were also confirmed by the higher diagnostic accuracy of echocardiography versus CMR compared to echocardiography versus CCT (87% vs 80%), with best values of sensitivity, and specificity, denoting good reliability between the first 2 techniques.

Conclusions

A multimodal imaging approach is mandatory in the diagnostic work-up of CMs. The CMR, after a standard echocardiographic assessment, turned out to be the most accurate second-level investigation to discriminate between benign and malignant masses. However, when CMR is not available or the patient has a contraindication, the CCT could still be reliable.

1024 PROGNOSTIC VALUE OF CI-AKI AND HIS RELATIONSHIP WITH PERIPROCEDURAL MYOCARDIAL DAMAGE IN NSTEMI

Background

Periprocedural myocardial damage and contrast-induced acute kidney injury (CI-AKI) are frequent complications of percutaneous coronary intervention (PCI) and impact prognosis. The possible associations and the prognostic role of these peri-procedural complications are still not well understood.

Purpose

To evaluate predictors and prognostic role of CI-AKI in patients with NSTEMI and the relationship between CI-AKI and periprocedural myocardial damage.

Methods

Patients with NSTEMI undergoing coronary angiography within 72 hours were enrolled from January 2016 to September 2021. To detect post-PCI acute myocardial damage in this setting of NSTEMI patients, we included only those with stable (≤ 20% variation) or falling pre-procedure baseline cardiac troponin (cTn) values. Serum cTnI were measured at baseline and at 3-6-12 hours after PCI in all patients. Periprocedural myocardial damage was evaluated according to postprocedural hsTnI criteria provided by most recent consensus documents. Renal injury was documented when absolute serume creatinine increased of ≥ 0.3 mg/dL or ≥ 50% within 72 hours or urine output reduced to ≤ 0.5 mL/Kg/hour for at least 6 hours.

Results

We enrolled 878 patients with NSTEMI undergoing PCI and with pre procedure stable cTn levels. 53 patients suffered from AKI post contrast and among these 8 patients exhibited myocardial periprocedural injury and 20 patients had periprocedural myocardial infarction according to European Society of Cardiology guidelines. Myocardial periprocedural damage occurred more frequently in the CI- AKI group compared to non-CI-AKI group (52% vs 38%, p = 0.01). Patients who experienced CI-AKI were significantly older (mean age 86 ± 4) and had more frequently cardiovascular risk factors such as diabetes (p &lt; 0.001) and hypertension (p = 0.006), compared to non-CI-AKI group. Moreover NSTEMI patients with CI-AKI were more often on beta-blockers (p= 0.001) and statins (p &lt; 0.001) and exhibited more frequently at admission ST-T segment (p &lt; 0.000) and wall motion alterations at echocardiography evaluation (p = 0.004).Regarding intra-hospital outcomes, CI-AKI population experienced more frequently reinfarction (p = 0.02) and arrhythmias (p &lt; 0.000) compared to others . Surprisingly, the multivariate logistic regression showed that the stronger predictor of CI-AKI was periprocedural myocardial infarction (p &lt; 0.001). Finally, at 3 years of follow-up, in patients with CI-AKI there was more incidence of all-cause mortality (p = 0.001) and the composite of all-cause death, re-acute myocardial infarction and hospitalization for heart failure (p = 0.05) compared to non-CI-AKI group.

Conclusion

In NSTEMI patients, contrast-induced acute kidney injury was associated with majors adverse events, both intra-hospital and at long-term follow-up. Subjects who experienced acute kidney injury were older, had more comorbidities and had a worse clinical and instrumental profile at admission. CI-AKI was also associated with peri-procedural acute myocardial injury and infarction. More studies are needed to understand the patophysiological relations between these to post-PCI complications to improve their management.

1025 PROGNOSTIC IMPACT OF STATINS AND DUAL ANTIPLATELET THERAPY ON LONG-TERM PROGNOSIS IN MINOCA PATIENTS

Background

Myocardial Infarction with Non-Obstructive Coronary Artery disease (MINOCA) is a heterogeneous entity with relevant long-term major adverse cardiovascular events (MACE). There is solid evidence that secondary prevention strategies improve prognosis of patients with obstructive myocardial infarction. However, evidence-based treatments for MINOCA are lacking as no published randomized clinical trials have ever exclusively enrolled this population. In fact, treatment recommendations in current guidelines are mainly based on expert opinions and MINOCA patients are frequently discharged with statins and dual antiplatelet therapy (DAPT).

Purpose

To evaluate the effects of statins and DAPT as secondary prevention treatments on long-term outcomes in MINOCA patients.

Methods

We enrolled all consecutive MINOCA patients admitted to our Centre from 2016 to 2021. The diagnosis of MINOCA was made according to the current European Society of Cardiology diagnostic criteria (angiographic conventional cut-off of &lt; 50% coronary stenosis without a clinically apparent alternative diagnosis). Second-level diagnostic work-up including cardiac magnetic resonance was performed to exclude non-ischemic troponin elevation cause.

All-cause mortality and MACE (a composite of all-cause mortality, hospitalization for heart failure, myocardial re-infarction and stroke) were collected during follow-up. The prognostic impact of statins and DAPT at discharge was assessed. The relationship between treatments and outcomes was evaluated by using Kaplan-Meier survival analysis.

Results

278 MINOCA patients were enrolled, of whom 203 (73%) were discharged on statins and 123 (44.2%) on DAPT. After a median follow-up of 36 ± 14.8 months, the overall all-cause mortality was 11.8% and the composite endpoint (MACE) was achieved in 28.4% of the entire population. Kaplan-Meier curves showed that patients treated with statins had a significantly lower rate of all-cause mortality (9.3% vs 18.2%, p=0.04) and MACE (24.6% vs 39.2%, p=0.02). On the other hand, rates of death (9.8% vs 13.2%, p=0.4) and MACE (23.6% vs 31.6%, p=0.1) were similar in MINOCA patients treated with DAPT or single antiplatelet therapy.

Conclusions

Among MINOCA patients, DAPT at discharge neither reduced long-term all-cause mortality nor MACE. In contrast, statin treatment provided beneficial effects on long-term outcomes. These results should be considered preliminary and require confirmation from randomized clinical trials.

857 DEVELOPMENT AND VALIDATION OF A DIAGNOSTIC ECHOCARDIOGRAPHIC MASS (DEM) SCORE IN THE COMPLEX APPROACH TO CARDIAC MASSES

Background

Cardiac masses (CM) are an extremely heterogeneous clinical entity, including benign and malignant neoformations. 2D Echocardiography is, nowadays, the first-line approach to define nature and management of CM.

Purpose

The purpose of our study was to identify the echocardiographic predictors of malignancy and create a multiparametric score to further increase the diagnostic yield and accurately suggest the nature of CM.

Materials and methods

249 consecutive patients undergoing a complete echocardiographic assessment for suspected cardiac mass in our center were enrolled from January 2004 to December 2020. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. Logistic regression was performed to evaluate the ability of echocardiography to discriminate benign versus malignant masses.

Results

A scoring system was developed in a derivation cohort of 178 (70%) and validated in 71 (30%) patients. A weighted score [Diagnostic Echocardiographic Mass (DEM) Score] ranging from 0 to 9 was obtained from 6 variables: infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization. The AUC for the score was 0.965 (95% CI 0.938-0.993). In a logistic regression analysis using the DEM score as a predictor, the likelihood of malignancy increased more than 4 times for a 1-unit increase of the score (OR=4.468; 95% CI 2.733-7.304). The prognostic validity of the score was confirmed by its ability to predict survival during follow-up (median time of 31 months).

Conclusions

The application of a multiparametric echocardiographic score in the approach to CM accurately predicts mass malignancy, thereby reducing the need for second-level investigations, and minimizing the diagnostic delay in such a complex clinical scenario.

225 PROGNOSTIC ROLE OF EARLY CARDIAC MAGNETIC RESONANCE IN MYOCARDIAL INFARCTION WITH NON-OBSTRUCTIVE CORONARY ARTERIES (MINOCA)

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a significant proportion of acute myocardial infarction (AMI) population. MINOCA is a working diagnosis and an accurate investigation of the underlying causes should always be performed. In this setting, cardiac magnetic resonance (CMR) imaging plays a pivotal diagnostic role. However, a prognostic stratification based on the CMR findings in ischemic MINOCA is still unavailable.

Purpose

To evaluate the potential prognostic impact of specific CMR findings - especially ischemic late gadolinium enhancement (LGE) patterns - in order to look for measurable parameters that may guide the management of this still troubled clinical entity.

Methods

We assessed 461 MINOCA from January 2016 to June 2021. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR findings, MINOCA were classified in two phenotypes: LGE-positive (an ischemic subendocardial or transmural LGE pattern) or LGE-negative (cases without LGE but exhibiting regional myocardial injury defined by myocardial edema in a coronary territory with a typically ischemic "wave-front" and/or regional wall motion abnormality consistent with coronary distribution).

All-cause mortality, re-infarction, stroke, heart failure (HF) and the composite endpoint (MACE) were evaluated. Extended LGE was considered as the presence of &gt;2 segments with transmural LGE. The mean follow-up was 36.1 ± 15.2 months and CMR was performed at a mean of 6 ± 2.9 days from the acute presentation.

Results

The final cohort included 175 MINOCA with a likely-ischemic etiology: 121 (69.1%) constituted the LGE-positive group. The mean age of the study population was 62.3 ± 12.9 years and more than 61% were females. During follow-up, HF (15.7% vs 1.9%, p=0.008) and MACE (20.7% vs 7.4%, p=0.029) occurred more frequently in MINOCA "LGE-positive" compared to the "LGE-negative" ones. Extended LGE was significantly more prevalent in patients with versus without subsequent HF. On multivariable Cox regression, extended LGE was an independent predictor of HF occurrence (HR 18.49, 95%CI 4.65–73.61, p &lt; 0.001) and MACE (HR 14.64, 95%CI 3.91–54.86, p &lt; 0.001).

Conclusions

Our data suggest that in MINOCA patients the detection of LGE is correlated with the incidence of major cardiovascular events and heart failure during long-term follow-up. In fact, LGE extension was identified as the strongest predictor of cardiac adverse events. The early execution of CMR is useful in the prognostic stratification of MINOCA and this could guide the subsequent clinical and therapeutic management.

1054 GENDER DIFFERENCES IN MINOCA POPULATION

Background

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is a clinical condition that includes acute myocardial infarction (AMI) occurring with non-obstructive coronary disease. This entity accounts above 6% (from 1% to 14%) of all patients presenting with AMI and it's known to be more prevalent in females. However, differences in terms of clinical features and prognosis in MINOCA patients according to gender have been poorly understood.

Purpose

To evaluate differences in clinical characteristics at admission and during follow-up between males and females with MINOCA.

Methods

We included all consecutive patients with AMI undergoing coronary angiogram between 2016 and 2020 at our center. According to 2016 ESC Position Paper criteria, we considered as MINOCA all patients with AMI and coronary stenosis &lt;50% at coronary angiography without clinically apparent alternative diagnoses such as Takotsubo syndrome and myocarditis. Then, we analyzed the baseline clinical characteristics of MINOCA patients by dividing the population into two groups according to gender. Variables with a statistical significance lower than p&lt;0.05 in univariable analysis were included in a logistic regression analysis to determine independent predictors of MINOCA. The predictive value of both groups was evaluated using Kaplan-Meier survival curves. Our aim was to evaluate composite endpoint of death, re IMA, stroke and heart failure in a follow up time mean of 36 ± 14.8 months.

Results

Among 289 patients affected by MINOCA according to the 2016 ESC criteria, 98 were male (34%) and 191 were female (66%). Females were older than males (68.9 ± 13.1 vs 58.4 ± 14.5 years, p =0.0001). About the traditional cardiovascular risk factors males were more frequently smokers (56.1% vs 33.9%, p=0.001) while there were no significant differences in others risk factors. Females were more frequently on beta-blockers (39% vs 20%, p=0.002) and statins (33% vs 19%, p=0.015) compared to males. No differences were found between the two groups regarding clinical characteristics and instrumental findings (EKG and echocardiography). At coronary angiography, males had more frequently severe coronary stenosis than females (15.5 ± 26.4 VS 9.1 ± 21.5, p =0.019). During follow up we did not find any differences in terms of death, reinfarction, stroke and heart failure while females had more MACEs than males (33% vs 19.4%, p=0.015); and this data was confirmed at Kaplan Meier curves (p = 0.014). Finally, the multivariate analysis showed that age is an independent predictor of MINOCA (HR 1.04, CI 1.01-2.07, p=0.006), rather than sex, diabetes, and hypertension.

Conclusions

In our MINOCA population we found that females were older than males, more frequently on statins and beta blockers at admission and they showed a lower degree of atherosclerotic disease. Nevertheless, after 36 ± 14.8 months of follow-up, we found a higher incidence of MACE in females than in males. We hypothesize that these findings could reflect the different pathogenesis of myocardial damage in our subgroups. Actually, statins and estrogens have a well-known protective role towards the progression of atherosclerosis, but they have no impact on other mechanisms of myocardial infarction which are more frequent in females, such as spontaneous coronary artery dissections, epicardial spasms or microvascular dysfunction.

Prognostic role of acute myocardial infarction diagnostic criteria in patients presenting with non-ST segment elevation myocardial infarction

Background

The Fourth Universal Definition of Myocardial Infarction (UDMI) defines acute myocardial infarction (AMI) as an acute myocardial injury associated with clinical evidence of acute myocardial ischemia. However, the prognostic role of each single diagnostic criteria has never been explored.

Purpose

To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in patients with non-ST-segment elevation myocardial infarction.

Methods

We enrolled all consecutive patients with NSTEMI undergoing coronary angiography at our Centre. The admission diagnosis was performed according to the current guidelines criteria, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischemia, ECG changes (new ST depression or negative T-waves), echocardiographic evidence of new regional wall motion abnormality. Patients with very high-risk NSTEMI were excluded. Patients were then divided into different subgroups according to the combination of diagnostic criteria presented at admission. A composite endpoint of all-cause mortality, re-hospitalization for myocardial reinfarction or heart failure was collected. The predictive value of AMI diagnostic criteria alone and their combination were evaluated using Kaplan-Meier survival curves and subsequent Cox-regression analysis to find independent predictors of major adverse events.

Results

Our study population consisted of 2791 patients. The mean age was 68.3±13.4 and 31.5% were female. The mean follow-up time was 23.3±14.5 months. Depending on the AMI diagnostic criteria and their combination, patients were divided into three subgroups: 196 patients fulfilling only clinical criteria (group A), 187 with clinical and ECG-graphic criteria (group B) and 829 patients with clinical, ECG-graphic and echo-graphic criteria (group C). Baseline characteristics of the three groups were similar. At two-year follow-up, patients with clinical criteria alone exhibited the best outcome, whereas those with all three criteria fulfilled showed the worse prognosis (14.8% for group A vs 23.6% for group B vs 28.0% for group C; p-value &lt;0.001). In multivariable Cox-regression model, the presence of clinical criteria alone was the independent predictor of better prognosis compared to the other diagnostic criteria combination (HR=0.48; CI 95% 0.31–0.74; p&lt;0.001).

Conclusions

In non-very high-risk NSTEMI, not all diagnostic criteria have the same prognostic value. In fact, prognosis is significantly more favorable in patients exhibiting only the clinical criteria at admission. We hypothesize that the absence of ECG-graphic and echocardiographic alterations may indirectly indicate smaller infarct sizes that contribute to patients' outcomes. These findings could enhance the current risk stratification in patients admitted with NSTEMI.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role and predictors of high Killip class in myocardial infarction with non-obstructive coronary artery

Background

Killip classification is a simple clinical tool for risk stratification in patients with acute myocardial infarction (AMI). However, predictors of high Killip class at admission and its prognostic role in myocardial infarction with non-obstructive coronary artery (MINOCA) are still poorly explored.

Purpose

To identify clinical predictors of high Killip class and its potential prognostic role in patients with MINOCA compared to patients with myocardial infarction with obstructive coronary artery (MIOCA).

Methods

We included patients with AMI undergoing coronary angiogram from January 2016 to June 2021. MINOCA were defined according to the current European guidelines criteria. We compared the Killip classes of MINOCA with those of MIOCA and defined a high Killip class if greater than 1. Kaplan-Meier (KM) curves were developed for the comparison of all-cause mortality among MIOCA and MINOCA with high Killip class (&gt;1) compared to the others. Multivariate logistic regression analysis was used to determine the predictors of high Killip class.

Results

Among 3261 AMI, 261 were MINOCA. The median follow-up time was 36.1±15.2 months. Killip class &gt;1 occurred in 24 (8.8%) MINOCA patients compared to 518 (17.3%) MIOCA cases (p=0.001). During long-term follow-up, a high Killip class was associated with a 3-fold increased mortality both in MIOCA and MINOCA populations (p&lt;0.001 and p=0.001). Furthermore, in both groups, the KM survival curves were significantly worse for patients with high Killip class compared to lower classes (p&lt;0.001). Within MIOCA multivariate logistic regression showed that predictors of a high Killip class at admission were older age [OR 1.04, 95% CI (1.03–1.06), p&lt;0.001], diabetes [OR 1.60, 95% CI (1.24–2.07), p&lt;0.001], ST-segment-elevation [OR 1.53, 95% CI (1.12–2.10), p=0.008], left ventricular ejection fraction (LVEF) [OR 0.95, 95% CI (0.94–0.96), p&lt;0.001] and elevated cardiac troponin [OR 1.01, 95% CI (1.00–1.01), p=0.01]. Instead, in MINOCA only older age [OR 1.08, 95% CI (1.03–1.14), p=0.003], ST-segment-elevation [OR 7.40, 95% CI (1.08–50.65), p=0.04] and diabetes [OR 3.60, 95% CI (1.09–11.96), p=0.04] were predictors of a high Killip class whereas LVEF (p=0.3) and elevated cardiac troponin (p=0.6) exhibited a neutral impact in these patients.

Conclusions

High Killip class at admission is a high-risk marker of adverse cardiovascular events even in patients with MINOCA. Simple baseline characteristics (such as older age, diabetes, ST-segment-elevation) predict a high Killip class in MINOCA subjects and can help to identify a high-risk population who might benefit from a stricter management. Furthermore, LVEF and elevated cardiac troponin were identified as predictors of a high Killip class in MIOCA but they did not show a similar impact in the setting of MINOCA. This may reflect the different pathogenesis and myocardial damage extent in MINOCA compared to MIOCA.

Funding Acknowledgement

Type of funding sources: None.

Development and validation of a diagnostic echocardiographic mass (DEM) score in the complex approach to cardiac masses

Background

Cardiac masses (CM) are an extremely heterogeneous clinical entity, including benign and malignant neoformations. 2D Echocardiography is nowadays the first-line approach to define nature and management of CM.

Purpose

The purpose of our study was to identify the echocardiographic predictors of malignancy and create a multiparametric score to further increase the diagnostic yield and accurately suggest the nature of CM.

Material and methods

249 consecutive patients undergoing a complete echocardiographic assessment for suspected cardiac mass were enrolled from January 2004 to December 2020. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. Logistic regression was performed to evaluate the ability of echocardiography to discriminate benign versus malignant masses.

Results

A scoring system was developed in a derivation cohort of 178 (70%) and validated in 71 (30%) patients. A weighted score [Diagnostic Echocardiographic Mass (DEM) Score] ranging from 0 to 9 was obtained from 6 variables: infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization. The AUC for the score was 0.965 (95% CI 0.938–0.993). In a logistic regression analysis using the DEM score as a predictor, the likelihood of malignancy increased more than 4 times for a 1-unit increase of the score (OR=4.468; 95% CI 2.733–7.304). The prognostic validity of the score was confirmed by its ability to predict survival during follow-up (median time of 31 months).

Conclusions

The application of a multiparametric echocardiographic score in the approach to CM accurately predicts mass malignancy thereby reducing the need for second-level investigations, and minimizing the diagnostic delay in such a complex clinical scenario.

Funding Acknowledgement

Type of funding sources: None.

[Cardiac masses: classification, clinical features and diagnostic approach]

The term cardiac mass refers to benign or malignant cardiac tumors and cardiac metastases but also to pseudotumors, which is a heterogeneous group consisting of thrombi, vegetations and normal variant structures. While primitive cardiac tumors are rare, metastases and pseudotumors are relatively common. The non-invasive diagnostic approach has not been well established in the literature yet. The first-line non-invasive approach consists of echocardiography, which provides good diagnostic accuracy for masses like thrombi, vegetations and some tumors (mainly myxoma and fibroelastoma). In contrast, for other masses, it does not provide information about the potential malignancy because of poor tissue characterization. Second-line (cardiac computed tomography and cardiac magnetic resonance) or third-line (positron emission tomography-computed tomography) evaluations have been validated in the diagnostic approach to cardiac masses by many studies. In fact, a comprehensive diagnostic approach may establish the diagnosis of malignancy without histological report, which is pivotal for the subsequent therapeutic strategy.The aim of this narrative review is to describe the commonly available non-invasive diagnostic techniques for cardiac masses, their potential and limitations and to suggest a diagnostic pathway for common practice.

Impact on beef cattle productivity of infection with anthelmintic-resistant nematodes

ABSTRACTAims: The main goal of the current study was to evaluate, on a commercial beef cattle farm, the impact of infection with gastrointestinal nematodes resistant to both ivermectin (IVM) and moxidectin (MXD) on the productivity of calves.Methods: Male Aberdeen Angus calves, aged 9-11 months, with faecal nematode egg counts (FEC) ≥200 epg and body weight ≥190 kg, were allocated to two herds. Herd A (n = 90) grazed a maize-winter forage crop rotation and Herd B (n = 90) grazed a 2-year-old Agropyrum pasture. On Day 0 in each herd, calves were randomly allocated into five groups (n = 18), which were treated with 0.2 mg/kg IVM; 0.2 mg/kg MXD; 3.75 mg/kg ricobendazole (RBZ), both IVM and RBZ, or remained untreated. Faecal samples collected on Days -1 and 19 were used to determine the percentage reduction in FEC, and genera of the nematodes were determined by the identification of the third-stage larvae recovered from faecal cultures. Total weight gain was determined from body weights recorded on Days -1 and 91.Results: Overall mean reduction in FEC was 42% for IVM, 67% for MXD, 97% for RBZ and 99% for IVM + RBZ. The reduction in FEC for Cooperia spp. was ≤78% for IVM and MXD, and for Haemonchus spp. was 0 and 36% for IVM and MXD, respectively, confirming the presence of parasites resistant to both anthelmintics. Only IVM + RBZ treatment resulted in 100% efficacy against Haemonchus spp. The overall estimated mean total weight gain for calves treated with IVM was 15.7 (95% CI = 11.9-19.7) kg and for calves treated with IVM + RBZ was 28.8 (95% CI = 25-32.5) kg (p < 0.001). Mean total weight gain for calves treated with MXD was 23.5 (95% CI = 19.7-27.2) kg.Conclusions and clinical relevance: In calves naturally infected with resistant nematodes, under the production system assessed here, weight gains were lower in calves treated with anthelmintics that were moderately or highly ineffective compared to those treated with highly effective anthelmintics. These results demonstrate to farmers and veterinarians the importance of a sustainable and effective nematode control under field conditions.

Structure of Meson-Baryon interaction vertices

We present a microscopic derivation of the form factors of strong-interaction piNN and piNDelta vertices within a relativistic constituent quark model. The results are compared with form factors from phenomenological meson-baryon models and recent lattice QCD calculations. We give an analytical representation of the vertex form factors suitable for applications in further studies of hadron reactions.

Coupled-channel evaluations of cross sections for scattering involving particle-unstable resonances

How does the scattering cross section change when the colliding bound-state fragments are allowed particle-emitting resonances? This question is explored in the framework of a multichannel algebraic scattering method of determining nucleon-nucleus cross sections at low energies. Two cases are examined, the first being a gedanken investigation in which n + 12C scattering is studied with the target states assigned artificial widths. The second is a study of neutron scattering from 8Be, a nucleus that is particle unstable. Resonance character of the target states markedly varies evaluated cross sections from those obtained assuming stability in the target spectrum.

Predicting narrow states in the spectrum of a nucleus beyond the proton drip line

Properties of particle-unstable nuclei lying beyond the proton drip line can be ascertained by considering the (usually known) properties of its mirror neutron-rich system. We have used a multichannel algebraic scattering theory to map the known properties of the neutron-14C system to those of the proton-14O one from which we deduce that the particle-unstable 15F will have a spectrum of two low-lying broad resonances of positive parity and, at higher excitation, three narrow negative-parity ones. A key feature is to use coupling to Pauli-hindered states in the target.

Role of the Pauli principle in collective-model coupled-channel calculations

A multichannel algebraic scattering theory, to find solutions of coupled-channel scattering problems with interactions determined by collective models, has been structured to ensure that the Pauli principle is not violated. By tracking the results in the zero coupling limit, a correct interpretation of the subthreshold and resonant spectra of the compound system can be made. As an example, the neutron-12C system is studied defining properties of 13C to 10 MeV excitation. Accounting for the Pauli principle in collective coupled-channels models is crucial to the outcome.

Endoscopic perforator vein division with ablation of superficial reflux improves venous hemodynamics

PURPOSE

Hemodynamic consequences of incompetent perforator vein interruption have not been well documented. The effects of perforator interruption, with or without ablation of superficial venous reflux, on venous function in patients with advanced chronic venous insufficiency was studied.

METHODS

Calf muscle pump function, venous incompetence, and outflow obstruction were assessed by means of strain-gauge plethysmography (SGP) before and within 6 months after subfascial endoscopic perforator surgery (SEPS). SEPS was performed with laparoscopic instrumentation and CO2 insufflation. Concomitant high ligation or saphenous vein stripping was performed in 24 limbs (77%).

RESULTS

Twenty-six patients, 18 women and 8 men, with a mean age of 50 years (range, 20 to 77 years) underwent SEPS. Preoperative evaluation confirmed superficial reflux in 65% of limbs, deep venous reflux in 77% of limbs, and perforator incompetence in 97% of limbs. All limbs had advanced venous dysfunction (C3, C4, C5, C6). All active ulcers (C6, n = 12) healed after surgery (mean, 32 +/- 3 days), and only 1 recurred during a mean follow-up period of 11 months (range, 1 to 43 months). Clinical score improved from 6.58 +/- 0.50 to 2.19 +/- 0.25 (P <.0001). Improved calf muscle pump function was demonstrated by means of postoperative SGP and was indicated by increased refill volume (RV: 0.27 +/- 0.06 vs 0.64 +/- 0.10 mL/100 mL tissue, P <.01). Venous incompetence also improved, as evidenced by prolonged duration to refill after exercise (T90: 7. 71 +/- 1.20 vs 16.71 +/- 1.98 seconds, P <.001) and a decrease in RV after passive drainage (3.23 +/- 0.19 vs 2.63 +/- 0.15 mL/100 mL tissue, P <.01). Improved refill rate (RR) correlated with improvements in clinical scores (P <.01, r = 0.77).

CONCLUSION

SEPS with ablation of superficial reflux improved calf muscle pump function, reduced venous incompetence, and produced excellent midterm clinical results. However, functional improvement directly related to SEPS requires further investigation. This study supports adding SEPS to ablation of superficial reflux in patients with advanced chronic venous insufficiency.