Right Ventricular Postsystolic Strain Curve Morphology before and after Vasodilator Treatment in Idiopathic Pulmonary Arterial Hypertension

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RV function is an important prognostic factor in pulmonary arterial hypertension.

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Several echocardiographic parameters are needed for a complete RV function assessment.

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RV postsystolic strain patterns have a prognostic impact in IPAH.

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RV postsystolic strain patterns may help in evaluating treatment response.

Coronary computed tomography angiography improves coronary risk prediction in general population

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Carlos III Health Institute and the European Regional Development FundAgency for Management of University and Research Grants

Introduction

In the next decades, it is expected an increasing incidence of acute coronary syndrome in the Spanish population. Identify high-risk patients could be the most cost-effective way to reduce its incidence and morbi-mortality burden. We studied the effect of adding coronary artery calcification (CAC) and the extent of atherosclerotic disease (SIS score) to classical cardiovascular (CV) risk factors in coronary risk prediction.

Methods

This was a prospective cohort study of 325 asymptomatic patients recruited between 2013-2017. Demographic characteristics and CV risk factors were obtained and all participants underwent a coronary computed tomography angiography exam in which CAC and SIS were determined. The cohort was followed-up (median= 4 years) for a composite endpoint that included CV death, myocardial infarction, coronary angiography and/or revascularization. Improvement in discrimination and in reclassification by the inclusion of CAC/SIS in the Framingham-REGICOR function were examined with the Sommer's D index and with the Net reclassification index (NRI) (categorical and continuous), respectively.

Results

Nine of the 251 individuals included in the study had an event in the follow-up. Of the included participants, 94 had a CAC = 0 and 85 a SIS = 0. These participants had no events. The addition of SIS or of SIS and CAC scores to the Framigham-REGICOR risk function increased significantly the discrimination capacity from 0.71 to 0.88 (Table 1). Reclassification measured by the continuous NRI also improved significantly from 69.5 to 112.4/115.5 when SIS or both scores were included (Table 2).

Conclusions

CAC and SIS scores were associated to 4-year CV event incidence, independently of coronary risk estimation. Discrimination and reclassification of the Framigham-REGICOR coronary function were significantly improved by both indexes, but SIS overrode the effect of CAC.

Sex-related differences of fatty acid-binding protein 4 and leptin levels in atrial fibrillation

AIMS

Adiposity plays a key role in the pathogenesis of atrial fibrillation (AF). Our aim was to study the sex differences in adipokines levels according to AF burden.

METHODS AND RESULTS

Two independent cohorts of patients were studied: (i) consecutive patients with AF undergoing catheter ablation (n = 217) and (ii) a control group (n = 105). (i) Adipokines, oxidative stress, indirect autonomic markers, and leucocytes mRNA levels were analysed; (ii) correlation between biomarkers was explored with heatmaps and Kendall correlation coefficients; and (iii) logistic regression and random forest model were used to determine predictors of AF recurrence after ablation. Our results showed that: (i) fatty acid-binding protein 4 (FABP4) and leptin levels were higher in women than in men in both cohorts (P < 0.01). In women, FABP4 levels were higher on AF cohort (20 ± 14 control, 29 ± 18 paroxysmal AF and 31 ± 17 ng/mL persistent AF; P < 0.01). In men, leptin levels were lower on AF cohort (22 ± 15 control, 13 ± 16 paroxysmal AF and 13 ± 11 ng/mL persistent AF; P < 0.01). (ii) In female with paroxysmal AF, there was a lower acetylcholinesterase and higher carbonic anhydrase levels with respect to men (P < 0.05). (iii) Adipokines have an important role on discriminate AF recurrence after ablation. In persistent AF, FABP4 was the best predictor of recurrence after ablation (1.067, 95% confidence interval 1-1.14; P = 0.046).

CONCLUSION

The major finding of the present study is the sex-based differences of FABP4 and leptin levels according to AF burden. These adipokines are associated with oxidative stress, inflammatory and autonomic indirect markers, indicating that they may play a role in AF perpetuation.

Impact of coronary atherosclerotic plaque metrics and CT reader skills on inter-observer variation of repeated on-site CT-FFR

Funding Acknowledgements

Type of funding sources: None.

Background and Purpose

 

Little is known about the on-site CT-FFR inter-reader reproducibility and its variability in different atherosclerotic plaque scenarios. The aim of this study was to determine the variation of repeated CT-FFR analyses between two CCTA readers with different training skills across different atherosclerotic features. 

Methods

 

Patients referred for invasive coronary angiography who accepted to undergo a CCTA/CT-FFR study were prospectively included. Patients with contraindications for CCTA, atrial fibrillation, chronic total occlusions or previous coronary revascularization were excluded. Quantification of atherosclerotic plaque metrics and CT-FFR was performed for each coronary vessel by two different CT readers, one Level I and one Level III. Inter-reader agreement for CT-FFR was assessed using kappa index, Bland-Altman and Lin’s concordance correlation agreement (LCCA). The impact of each atherosclerotic feature was assessed by dividing the dataset based on the corresponding median and assessing inter-reader variability for both the lower and upper half.

Results

47 patients (137 vessels) were included. Mean age was 66 ± 10 years, 89% were males, 63% had hypertension, 76% dyslipidemia and 38% diabetes. Degree of stenosis was moderate (50-69%) in 29% and severe (≥70%) in 28% of vessels with a positive CT-FFR (≤0.80) in 39%. CT-FFR showed good correlation between the two readers based on a kappa index of 0.77 with a mean CT-FFR difference of -0.017 ± 0.12. The inter-reader agreement was good in the main epicardial vessels (LCCA of 0.70 for LAD, 0.74 for LCX and 0.76 for RCA, p &lt; 0.001 for all) and better in proximal than in distal segments (LCCA of 0.83 vs 0.63, p &lt; 0.001). Likewise, in different atherosclerotic plaque scenarios, the agreement was better in those vessels with lower plaque volume, less calcified and longer lesions (see table 1). 

Conclusions

 

In our cohort, on-site CT-FFR showed good inter-reader agreement without relevant impact by reader experience level and atherosclerotic plaque features.

Table 1 Mean difference Bland-Altman Lin’s concordance correlation coefficient p value Plaque volume &lt; median (556 mm3) -0.01 ± 0.12 0.85 &lt;0.001 Plaque volume &gt; median (556 mm3) -0.035 ± 0.13 0.64 &lt;0.001 Calcified plaque burden &lt; median (34%) -0.03 ± 0.11 0.82 &lt;0.001 Calcified plaque burden &gt; median (34%) -0.02 ± 0.14 0.75 &lt;0.001 Lesion length &lt; median (55 mm) -0.005 ± 0.12 0.68 &lt;0.001 Lesion length &gt; median (55 mm) -0.031 ± 0.12 0.83 &lt;0.001 *p values indicate inter-reader agreement by two independent observers for each category

Gender-dependent regulation of FABP4 and leptin according to atrial fibrillation burden

Aims

Adiposity plays a key role in the pathogenesis of atrial fibrillation (AF). Its associated proteins are differentially released between male and female. FABP4 and leptin are mediators in adipose tissue-inflammatory effects. Our aim was to study their gender differential behavior on mechanisms associated with AF progression.

Methods and results

Two independent cohorts were analyzed: A) patients referred for AF catheter ablation (n=217) and patients with suspected coronary artery disease referred for a CT scan (without previous history of AF) (n=105). Protein levels were determined by multiplex fluorometric immunoassay. Gene mRNA expression was analyzed by real time polymerase chain reaction. Correlation between biomarkers was explored with heatmaps and Kendall correlation coefficients. Logistic regression and random forest model determined the best predictors of AF recurrence after catheter ablation. Our results showed: 1) a distinctive profile according to gender, with an increment of FABP4 levels in women (20±14, 29±18 and 31±17 ng/mL; p=0.007) and a decrease of leptin levels in men (22±15, 13±16 and 13±11 ng/mL; p=0.001) among control, paroxysmal and persistent AF groups, respectively; 2) sex differences regarding inflammatory profile, oxidative stress and autonomic indirect markers in AF; 3) a prominent role of adipokines to discriminate AF recurrence after ablation. In persistent AF, FABP4 was the best predictor (LR coefficient 1.067, 95% CI 1–1.14, p=0.046).

Conclusion

The major finding of the present study is the sex differences of FABP4 and leptin according to AF burden. The relationship of these adipokines with oxidative stress, inflammatory and autonomic indirect markers might explain part of the mechanisms underlying the AF perpetuation.

Adipokines regarding Gender & AF burden

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Institute of Health Carlos III

P6174On-site CT-derived FFR predicts the need for revascularization

Background and purpose

Coronary computed tomography angiography (CTA) in combination with CT-derived fractional flow reserve (CT-FFR) is a solid tool for assessing both the anatomical and functional impact of coronary atherosclerotic disease (CAD) in a single study. The development of new software for on-site CT-FFR quantification may reduce costs and increase availability. The aim of this study was to analyze the incremental value of CT-FFR over CTA alone and its ability to predict the need for revascularization.

Methods

Patients referred for invasive coronary angiography (ICA) who accepted to undergo a CTA/CT-FFR study were prospectively included. Patients with any contraindication for CT, atrial fibrillation, chronic total occlusions, severe ventricular hypertrophy or previous coronary revascularization were excluded. On-site CT-FFR was calculated for each coronary vessel. Invasive FFR was quantified during ICA, considering ≤0.8 as a surrogate for the need for revascularization.

Results

33 patients (90 vessels) were included. Mean age was 65±10 years, 88% were males, 60% had hypertension, 77% dyslipidaemia and 40% diabetes. The average analysis time of CT-FFR was 16±4 minutes. There was a good correlation between CT-FFR and FFR in all three main epicardial vessels as well as in proximal segments or in moderate to severe stenosis (see Table). 83% of vessels with FFR≤0.8 were predicted by CT-FFR study (89% of LAD lesions, 86% of LCX and 66% of RCA). CT-FFR added incremental diagnostic value over CTA alone to predict FFR≤0.8 (ΔAUC 0.0336 with a net reclassification index 1.4±0.23; p<0.001) (see Image).

n Mean difference from Bland-Altman Pearson's r coefficient p value All-vessels 90 0.037±0.1 0.8 <0.001 Lesions in LAD 40 0.005±0.11 0.81 <0.001 Lesions in LCX 32 0.061±0.094 0.85 <0.001 Lesions in RCA 18 0.06±0.11 0.83 <0.001 Moderate lesions (50–69% QCA stenosis) 24 0.02±0.06 0.88 <0.001 Severe lesions (70–99% QCA stenosis) 25 0.034±0.18 0.4 <0.001 Proximal lesions 42 0.012±0.11 0.84 <0.001 Non-proximal lesions 48 0.061±0.1 0.78 <0.001

Conclusions

On-site CT-FFR is a good predictor of the need for revascularization in all three main coronary vessels and adds incremental diagnostic value over CTA alone. There is higher dispersion of the values in severe stenosis, lesions in LCX or RCA although this do not result in misclassification.

P6185Impact of coronary atherosclerotic plaque metrics on the correlation between on-site CT-FFR and invasive FFR

Background

Developed in the last years, coronary computed tomography-derived fractional flow reserve (CT-FFR) has shown good correlation with invasive fractional flow reserve (FFR). However, little is known about the interaction of coronary atherosclerotic plaque characteristics in the correlation between CT-FFR and FFR.

Purpose

This study sought to determine the effect of main coronary atherosclerotic plaque metrics (APM) on the correlation between on-site CT-FFR and invasive FFR.

Methods

Patients referred for invasive coronary angiography (ICA) who accepted to undergo a CT-FFR study were prospectively included. We excluded patients with atrial fibrillation, chronic total occlusions, severe ventricular hypertrophy or previous coronary revascularization, and those with any contraindication for CT. On-site CT-FFR and APM were calculated for each coronary vessel. Continuous variables of APM were dichotomized as above and below the median and their interaction on the correlation between on-site CT-FFR and invasive FFR was assessed by multiple linear regression model.

Results

33 patients (90 vessels) were included. Mean age was 65±10 years, 88% were males, 60% had hypertension, 77% dyslipidaemia and 40% diabetes. The mean delay time between CTA and ICA of 21 days. The average analysis time of CT-FFR was 16±4 minutes. Overall, correlation between FFR and CT-FFR showed a Pearson's r coefficient of 0.77±0.06 and a standardized beta coefficient of 0.8 (p<0.001). The beta coefficients between CT-FFR and FFR did not change significantly after the interaction with different APM (p>0.05 for all) (see Table).

Standardized Beta coefficients for on-site CT-FFR with invasive FFR as a gold standard Below the median Above the median p value for interaction Total atheroma volume (TAV) (mm3) 0.66 0.93 0.071 Percent atheroma volume (PAV) (%) 1.00 0.69 0.063 Calcified atheroma plaque volume (%) 0.89 0.68 0.175 Remodeling index 0.94 0.71 0.129 Lesion length (LL) (mm) 0.67 0.89 0.158 Minimal lumen area (mm2) 0.73 0.71 0.955

Conclusions

There is a good correlation between on-site CT-FFR and invasive FFR, which is not affected by main atherosclerotic plaque characteristics.

Identification of new biophysical markers for pathological ventricular remodelling in tachycardia-induced dilated cardiomyopathy

Our aim was to identify biophysical biomarkers of ventricular remodelling in tachycardia-induced dilated cardiomyopathy (DCM). Our study includes healthy controls (N = 7) and DCM pigs (N = 10). Molecular analysis showed global myocardial metabolic abnormalities, some of them related to myocardial hibernation in failing hearts, supporting the translationality of our model to study cardiac remodelling in dilated cardiomyopathy. Histological analysis showed unorganized and agglomerated collagen accumulation in the dilated ventricles and a higher percentage of fibrosis in the right (RV) than in the left (LV) ventricle (P = .016). The Fourier Transform Infrared Spectroscopy (FTIR) 1st and 2nd indicators, which are markers of the myofiber/collagen ratio, were reduced in dilated hearts, with the 1st indicator reduced by 45% and 53% in the RV and LV, respectively, and the 2nd indicator reduced by 25% in the RV. The 3rd FTIR indicator, a marker of the carbohydrate/lipid ratio, was up-regulated in the right and left dilated ventricles but to a greater extent in the RV (2.60-fold vs 1.61-fold, P = .049). Differential scanning calorimetry (DSC) showed a depression of the freezable water melting point in DCM ventricles - indicating structural changes in the tissue architecture - and lower protein stability. Our results suggest that the 1st, 2nd and 3rd FTIR indicators are useful markers of cardiac remodelling. Moreover, the 2nd and 3rd FITR indicators, which are altered to a greater extent in the right ventricle, are associated with greater fibrosis.

Cystatin-C and epicardial adipose tissue as noninvasive predictors of cardiovascular risk in acromegaly

BACKGROUND

Acromegaly (ACRO) is associated with elevated cardiovascular risk, although the prevalence of coronary artery disease (CAD) is unclear. Increased epicardial adipose tissue (EAT) and elevated cystatin-C (Cys-C) levels are cardiovascular risk factors, also related to the progression of CAD in several populations.

AIMS

To measure the severity and extent of CAD in patients with ACRO and to determine whether either EAT or Cys-C reflect higher cardiovascular risk in patients with ACRO than in healthy controls.

SUBJECTS AND METHODS

Case-control study, of 35 patients with ACRO (19 males, 17 with active disease) and 35 age-, gender- and body mass index (BMI)-matched healthy controls; mean age was 48·1 ± 8·1 years and mean BMI was 27·6 ± 4·8 kg/m² . Cys-C was measured by an immunoturbidimetric assay. The 10-year risk of developing a coronary event was calculated using the Framingham Risk Score (FRS). EAT index (volume indexed to body surface area), and severity and extent of CAD were measured using a 256-slice multidetector computed tomography scanner (iCT-256 Philips Healthcare, Amsterdam).

RESULTS

Coronary artery disease lesions, EAT index and severity/extent of CAD were similar between patients with ACRO and controls. Forty-four per cent of patients with ACRO had mild coronary lesions associated with greater EAT index (ß = 0·022, P = 0·036). Cys-C levels correlated with both EAT index (ρ = 0·386, P = 0·031) and FRS (ρ = 0·477, P = 0·004) in patients with ACRO only, despite similar prevalence of traditional cardiovascular risk factors. In a multiple linear regression model, both Cys-C levels (ß = 0·369, P = 0·007) and EAT index (ß = 0·29, P = 0·025) predicted FRS (R² = 0·613).

CONCLUSIONS

In patients with ACRO, both Cys-C and EAT index might be used as noninvasive predictors of cardiovascular risk.

Chest CT examinations in patients presenting with acute chest pain: a pictorial review

Acute chest pain (ACP) is one of the most common presenting symptoms at the emergency department. The differential diagnosis is vast. To exclude life-threatening causes, radiologists encounter an increasing amount of thoracic computed tomography (CT) examinations including CT angiography of the heart and great vessels. The dual- and triple-rule CT examinations are currently implemented in clinical practice. We retrospectively identified chest CT examinations in the setting of acute chest pain in our hospitals and collected a variety of common and uncommon cases. In this pictorial essay, we present the most educative cases from patients who presented with acute chest pain in the emergency department of our hospitals and for whom a thoracic CT was ordered. When aortic emergencies, acute coronary syndrome, and pulmonary embolism are excluded, these cases may help the radiologist to suggest alternative diagnoses in the diagnostic challenge of acute chest pain.

Teaching Points

• The number of chest CT examinations for ACP is increasing.

• Chest CT examinations may help suggesting alternative diagnosis in ACP.

• Radiologists should be aware of the differential diagnosis of ACP.

Left ventricular torsion and longitudinal shortening: two fundamental components of myocardial mechanics assessed by tagged cine-MRI in normal subjects

Cardiac magnetic resonance imaging (Cardiac MRI) has become a gold standard diagnostic technique for the assessment of cardiac mechanics, allowing the non-invasive calculation of left ventricular long axis longitudinal shortening (LVLS) and absolute myocardial torsion (AMT) between basal and apical left ventricular slices, a movement directly related to the helicoidal anatomic disposition of the myocardial fibers. The aim of this study is to determine AMT and LVLS behaviour and normal values from a group of healthy subjects. A group of 21 healthy volunteers (15 males) (age: 23-55 y.o., mean: 30.7 ± 7.5) were prospectively included in an observational study by cardiac MRI. Left ventricular rotation (degrees) was calculated by custom-made software (Harmonic Phase Flow) in consecutive LV short axis planes tagged cine-MRI sequences. AMT was determined from the difference between basal and apical planes LV rotations. LVLS (%) was determined from the LV longitudinal and horizontal axis cine-MRI images. All the 21 cases studied were interpretable, although in three cases the value of the LV apical rotation could not be determined. The mean rotation of the basal and apical planes at end-systole were -3.71° ± 0.84° and 6.73° ± 1.69° (n:18) respectively, resulting in a LV mean AMT of 10.48° ± 1.63° (n:18). End-systolic mean LVLS was 19.07 ± 2.71%. Cardiac MRI allows for the calculation of AMT and LVLS, fundamental functional components of the ventricular twist mechanics conditioned, in turn, by the anatomical helical layout of the myocardial fibers. These values provide complementary information about systolic ventricular function in relation to the traditional parameters used in daily practice.

[Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease]

OBJECTIVE

To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs).

DESIGN

Compare standard reference (Doppler-echocardiography) with contrast.

LOCATION

Echocardiography department.

PATIENTS

Ambulatory chronic obstructive patient disease (COPD).

INTERVENTION

Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10 mm Hg to the transtricuspid gradient, calculated from the TR peak velocity.

RESULTS

PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10 mm Hg vs. 56±15 mm Hg (p<0.01).

CONCLUSION

The use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value.

Idiopathic dilated cardiomyopathy exhibits defective vascularization and vessel formation

BACKGROUND

Ultrastructural findings of idiopathic dilated cardiomyopathy (IDCM) include myocyte atrophy and myofilament loss, yet little is known about the vascular abnormalities present in IDCM.

METHODS AND RESULTS

Patients with IDCM and controls underwent multi-slice CT to examine length and diameter of epicardial vasculature. The levels of mobilizing cytokines and circulating EPCs were assessed by endothelial colony formation assay and flow cytometry. Immunohistochemistry and Western blot were used to examine microvessel density and expression of HIF-1alpha and beta-catenin. Main epicardial coronary arteries were shorter and smaller, and microvascular density was reduced in the epicardium in IDCM. Epicardial vessel paucity was associated with increased numbers of HIF-1alpha(+) cells (46.8+/-13.1% vs. 19.4+/-9.4%, p=0.006) indicating local epicardial hypoxia and elevation of circulating VEGF-A (394 pg/mL vs. 22 pg/mL, p=0.001). The number of mobilized progenitors CD133(+)/VEGF-R2(+) was 21-fold higher in IDCM compared with controls (6.5+/-3.3% vs. 0.3+/-0.2%; p<0.001). Moreover, this defective vascularization was associated with reduced myocardial expression of vascular beta-catenin, an important angiogenic regulator.

CONCLUSIONS

This study shows defective vascularization and impaired vasculogenesis (the de novo vascular organization of mobilized endothelial progenitors) and angiogenesis (by which new blood vessels are formed from pre-existing mature endothelial cells) in human IDCM.

[Transthoracic echocardiography in stroke performed by neurologist: pilot study]

INTRODUCTION

The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke.

METHODS

We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement.

RESULTS

The 27 patients studied had a mean age of 68,7 +/- 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001).

CONCLUSION

Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists.

Utility of Contrast-Enhanced Cardiovascular Magnetic Resonance (CE-CMR) to Assess How Likely is an Infarct to Produce a Typical ECG Pattern

OBJECTIVES

For over 50 years, Q-wave myocardial infarction (MI) location has been based on pathologic ECG studies. Although contrast-enhanced magnetic resonance (CE-CMR) is currently the "gold standard" technique for location and quantification of necrotic areas, we found no large study in the literature devoted to establish which ECG patterns corresponds to different MI location detected by CE-CMR. We hypothesized that CE-CMR would be very accurate for evaluating different ECG patterns and its sensitivity (SE) and specificity (SP) for locating MI in different LV areas.

METHODS AND RESULTS

CE-CMR/ECG correlation was studied in 48 patients who presented a first MI due to acute coronary syndrome (ACS) with ST-segment elevation and in whom CE-CMR was performed in chronic phase. We evaluated the ECG patterns that best correlated with the 7 prespecified necrotic areas assessed by CE-CMR, 4 in anteroseptal zone (septal, apical/anteroseptal, extensive anterior, and limited anterolateral) and 3 in inferolateral zone (inferior, lateral and inferolateral). The global concordance between CE-CRM and ECG was of 75% and 7 ECG patterns were stablished.

CONCLUSION

The capacity of CE-CMR to detect ECG patterns for necrotic area location presents highly acceptable concordance. Thanks to CE-CMR, we defined 7 ECG patterns for MI detection according to the 7 areas of the LV studied. The areas that present more cases with normal ECG are limited anterolateral and the areas of the inferolateral zone.

Morphological and functional evidences of the helical heart from non-invasive cardiac imaging☆

The non-invasive study of cardiac mechanics has been improved after the recent introduction of advanced magnetic resonance and echocardiographic imaging techniques. Tagged and diffusion-sensitive cardiac magnetic resonance allows the study of myocardial torsion dynamics as well as the anatomical disposition of myocardial fibers. Local myocardial strain and synchronicity of myocardial contraction can also be determined with Doppler tissue imaging (DTI) echocardiography. Published results with these techniques demonstrate a mechanical behavior that is a consequence of a myocardial helical fiber orientation and strongly support the evidence of the double-loop single muscular band model described by Torrent-Guasp.

Transient biventricular dysfunction following pericardiocentesis

We report the case of a 41-year-old woman admitted to the hospital due to cardiac tamponade as the first manifestation of a pulmonary neoplasm. The patient developed an early biventricular dysfunction and pulmonary edema after removal of the pericardial effusion, with complete recovery within ten days. Since transient ventricular dysfunction after pericardiocentesis is a very unusual complication, we present a review of the different mechanisms suggested in the literature to explain the pathophysiology of this rare phenomenon.

Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality

AIMS

To investigate the clinical features, echocardiographic characteristics, management, and prognostic factors of mortality of aorto-cavitary fistulization (ACF) in infective endocarditis (IE). Extension of infection in aortic valve IE beyond valvular structures may result in peri-annular complications with resulting necrosis and rupture, and subsequent development of ACF. Aorto-cavitary communications create intra-cardiac shunts, which may result in further clinical deterioration and haemodynamic instability.

METHODS AND RESULTS

In a retrospective multi-centre study over 4681 episodes of IE, a total of 76 patients with ACF [1.6%, confidence interval (CI) 95%: 1.2-2.0%] diagnosed by echocardiography or during surgery were identified. Fistulae were found in 1.8% of cases of native valve IE and in 3.5% of cases of prosthetic valve IE from the general population and in 0.4% of drug abusers. PVE was present in 31 (41%) cases of ACF. Transthoracic and transoesophageal echocardiography detected the fistulous tracts in 53 and 97% of cases, respectively. Peri-annular abscesses were detected in 78% of cases, fistulae originated in similar rates from the three sinuses of Valsalva, and the four cardiac chambers were equally involved in the fistulous tracts. Heart failure (HF) developed in 62% of cases and surgery was performed in 66 (87% CI 95% 77-93%) patients with a mortality of 41% (95% CI 30-53%) in the overall population. Multivariate analysis identified HF (OR 3.4, CI 95% 1.0-11.5), prosthetic IE (OR 4.6, CI 95% 1.4-15.4) and urgent or emergency surgical treatment (OR 4.3, CI 95% 1.3-16.6) as variables significantly associated with an increased risk of death. Major complications during follow-up (death, re-operation, or re-admission for HF) among the five operative survivors with residual fistulae occurred in 20 and 100% of patients at 1 and 2 years, respectively.

CONCLUSION

Aorto-cavitary fistulous tract formation is an uncommon but extremely serious complication of IE. In-hospital mortality was exceptionally high despite aggressive management with surgical intervention in the majority of patients. Prosthetic IE, urgent surgery, and the development of HF identify the subgroup of patients with IE and ACF that have significantly increased risk of in-hospital death.

Astrocytes in multiple sclerosis lack beta-2 adrenergic receptors

BACKGROUND

In MS, T cells reactive to myelin proteins can cross the blood-brain barrier and release proinflammatory cytokines, such as interferon gamma. These can induce glial cells to express class II major histocompatibility complex (MHC) molecules, which are required to present myelin antigens to the T cells in order to mount a proper autoimmune response. Both microglia and astrocytes can function as antigen-presenting cells. In contrast to microglia, endogenous suppressors, including norepinephrine, regulate astrocytic class II MHC expression. The effects of norepinephrine are mediated through activation of P2 adrenergic receptors.

OBJECTIVE

To investigate P, adrenergic receptors in astrocytes in MS.

METHODS

Immunocytochemical techniques were applied in postmortem brain tissue from 10 patients with MS, three patients with a cerebral infarction, and six controls, and in spinal cord from three patients with ALS.

RESULTS

beta2 adrenergic receptors were visualized on astrocytes in white matter of controls, and they were prominently expressed in reactive astrocytes at the boundary of cerebral infarctions and in the lateral corticospinal tract in ALS. In MS, beta2 adrenergic receptors could neither be visualized on astrocytes in normal-appearing white matter nor in reactive astrocytes in chronic active and inactive plaques, whereas they were normally present on neurons. MHC class II-positive astrocytes were only visualized in chronic active plaques.

CONCLUSIONS

Because astrocytic beta2 adrenergic receptors are involved in suppressing inducibility of MHC class II molecules, we suggest that their lack of expression may play an important role in the induction or perpetuation of autoimmune reactions in MS.