Predictors of adverse cardiac events of coronary myocardial bridging diagnosed with computed tomography angiography

AIMS

Myocardial bridging (MB) is a frequent congenital anomaly of the epicardial coronary arteries commonly considered a benign condition. However, in some cases a complex interplay between anatomical, clinical and physiology factors may lead to adverse events, including sudden cardiac death. Coronary CT angiography (CCTA) emerged as the gold standard noninvasive imaging technique for the evaluation of MB. Aim of the study was to evaluate MB prevalence and anatomical features in a large population of patients who underwent CCTA for suspected CAD and to identify potential anatomical and clinical predictors of adverse cardiac events at long-term follow-up.

METHODS AND RESULTS

Two-hundred and six patients (mean age 60.3 ± 11.8 years, 128 male) with MB diagnosed at CCTA were considered. A long MB was defined as ≥25 mm of overlying myocardium, whereas a deep MB as ≥2 mm of overlying myocardium. The study endpoint was the sum of the following adverse events: cardiac death, bridge-related acute coronary syndrome, hospitalization for angina or bridge-related ventricular arrhythmias and MB surgical treatment. Of the 206 patients enrolled in the study, 9 were lost to follow-up, whereas 197 (95.6%) had complete follow-up (mean 7.01 ± 3.0 years) and formed the analytic population. Nineteen bridge-related events occurred in 18 patients (acute coronary syndrome in 7, MB surgical treatment in 2 and hospitalization for bridge-related events in 10). Typical angina at the time of diagnosis and long MB resulted as significant independent predictors of adverse outcome.

CONCLUSIONS

Typical angina and MB length ≥ 25 mm were independent predictors of cardiac events.

Post-cardiac injury syndrome and pericardial effusion recurrence after pericardial effusion drainage in chronic idiopathic pericardial effusion

INTRODUCTION

The management of even large pericardial effusions in asymptomatic patients is still a matter of debate. Aim of the present study is to explore, in a multicenter setting, the rate of post-cardiac injury syndromes (PCIS) and pericardial effusion recurrence after pericardial effusion drainage procedure.

MATERIAL AND METHODS

This is a multicenter international retrospective study including a consecutive cohort of patients diagnosed with large, chronic and idiopathic pericardial effusions, prospectively evaluated from January 2003 to December 2021 who underwent a clinically indicated pericardial drainage procedure. Two separate end-points were recorded: 1) recurrence of pericardial effusion after drainage without any sign of pericardial inflammation 2) occurrence of PCIS, defined as the new onset of pericarditis 1 to 6 weeks after pericardial intervention.

RESULTS

124 patients were enrolled (50 % female, mean age 64 years old). A mean follow-up of 29.6 ± 25.6 months was obtained in 110 patients (88 %). 110 patients were treated with pericardiocentesis (89 %), 25 with pleuro-pericardial windows (20 %), and 1 with pericardiectomy (1 %). PCIS occurred in 21 out of 124 patients followed for at least 6 weeks (16.9%). Recurrence of pericardial effusion after drainage without any sign of pericardial inflammation occurred in 68 out of 110 patients at a longer follow-up (61.8 %). At multivariate analysis only inflammatory cells in pericardial fluid was associated with PCIS and pericardiocentesis with pericardial effusion recurrency.

CONCLUSION

Our data support the need of caution with the use of pericardiocentesis in asymptomatic patients with large pericardial effusion as it is often associated with pericardial effusion recurrence. Of interest the presence of inflammatory cells in the pericardial fluid is associated with PCIS after pericardial drainage procedures.

Contemporary Echocardiographic Evaluation of Mitral Regurgitation and Guidance for Percutaneous Mitral Valve Repair

Mitral valve regurgitation (MR) is a multifaceted valvular heart disease. Echocardiography plays a central role in etiology assessment, severity quantification, treatment candidacy, outcome evaluation, and patient follow-up. In this review, we describe the comprehensive echocardiographic assessment of MR, including transthoracic (TTE) and transesophageal (TEE) approaches, 2D and 3D modalities, strain imaging, stress echocardiography, and artificial intelligence (AI) applications. Transcatheter edge-to-edge mitral valve repair (TEER) has been established as a key therapy for patients with severe, symptomatic MR and high surgical risk. TEER is performed under TEE guidance. We outline a practical overview of echocardiographic guidance on TEER.

635 AMYLOIDOSIS AND THE ILE68LEU MUTATION OF THE TTR GENE: A RARE DISEASE YOU CAN TREAT

Case presentation

During the last year, a 66-year-old man was repetitively hospitalized for anasarcatic heart failure in an infiltrative heart disease with an impaired left ventricular function.

In March 2022 the patient first presented to our emergency department with clinical signs of decompensated heart failure. An accurate diagnosis was made during the inpatient care.

The electrocardiogram documented sinus bradycardia, degree I atrioventricular block, and right bundle branch block. Echocardiography showed a slight reduction in biventricular function, concentric hypertrophy and a significant reduction in longitudinal systolic function (GLS -11.8%) with an apical-sparing pattern. At the same time, the presence of mild to moderate circumferential pericardial effusion was documented. According to the clinical suspicion, a cardiac MRI was performed, revealing consistent amyloid infiltrative disease. A 99-mTc-HDP myocardial scintigraphy confirmed pathological accumulation of trans-thyretine with a Perugini Score 2. Serum and urinary immunofixation were negative. A genetic test was subsequently performed whereby a heterozygous Ile68Leu (p.Ile88Leu) pathogenic mutation in the TTR gene was documented. Follow-up neurologic evaluation ruled out the indication to start Patisiran therapy due to the absence of significant neurologic involvement. In the meantime, the patient was put on Torasemide therapy with moderate clinical benefit. Few months ago, shortly after the diagnosis, the patient was hospitalized again for anasarcatic heart failure complicated by a severe ascites, underwent a paracentesis. During this hospitalization, therapy with Tafamidis was started. The patient is currently in good cardiovascular clinical compensation.

Discussion

This clinical case offers the chance to investigate the characteristics and phenotype of cardiac amyloidosis caused by the Ile68Leu mutation.

The typical Ile68Leu ATTRm patient is caucasian, tipically a 70 years’man (slightly younger than ATTRwt fenotipe), seeks medical attention with heart failure symptoms, and receives the correct diagnosis of cardiac amyloidosis almost 1 year after the onset of these symptoms.

Usually, the mutation leads to predominantly cardiac manifestations, instead of a combined form (cardiac and/or neurological manifestations). The Ile68Leu TTR mutation is a cause of cardiac amyloidosis that leads to a phenotype similar to ATTRwt.

The electrocardiogram and echocardiogram features described in the clinical case are typical and often indistinguishable from that of ATTRwt. The age at diagnosis and advanced heart failure symptoms at presentation were the only factors independently associated with mortality.

The subject patient is younger than the average affected ones and suffers from an aggressive form of the disease. The take home message could be that we should definitely learn and remember the importance of etiologic screening in infiltrative diseases, especially in young people, now that there are effective therapies capable to reduce mortality and improve quality of life.

Early GLS changes detection after chemoradiation in locally advanced non-small cell lung cancer (NSCLC)

PURPOSE

Chemoradiation is the standard treatment in patients with locally advanced non-small-cell lung cancer (LA-NSCLC), and thanks to the recent combination with immunotherapy, median survival has unexpectedly improved. This study aims to evaluate early changes in cardiac function after chemoradiotherapy (CRT) in LA-NSCLC by multimodal use of advanced imaging techniques.

MATERIALS AND METHODS

This is a prospective, observational cohort study. At the beginning of combined treatment, screening tests including blood samples, electrocardiogram (ECG), echocardiographic examination (TTE), and cardiac magnetic resonance were performed in all patients with LA-NSCLC. ECG and cardiac marker assays were performed weekly during treatment. ECG and TTE were performed at month 1 (M1) and month 3 (M3) after the end of CRT.

RESULTS

This preliminary analysis included thirty-four patients with a mean age of 69.5 years. The median follow-up was 27.8 months. 62% of patients were in stage IIIA. Radiation therapy was delivered with a median total dose of 60 Gy with conventional fractionation. All patients were treated with concurrent CRT, and 65% of cases were platinum-based therapy. Global longitudinal strain (GLS) and ejection fraction (EF) progressively decreased from baseline to M1 and M3. There was a strong correlation between GLS and EF reduction (at M1: p = 0.034; at M3: p = 0.018). Cardiac arrhythmias occurred in eight patients (23.5%) at a mean follow-up of 15.8 months after CRT.

CONCLUSIONS

Reduction in GLS is an early sign occurring after the end of CRT for LA-NSCLC. Future studies are needed to identify variables that can increase the risk of cardiac events in this patient population to implement adequate damage prevention strategies.