Reporting of coronary artery calcification on chest CT studies in patients with interstitial lung disease

AIM

To evaluate the prevalence of coronary artery calcification (CAC) on non-contrast computed tomography (CT) of the thorax in patients with interstitial lung disease (ILD), assess consistency of CAC reporting and assess incidence of subsequent cardiac events.

MATERIALS AND METHODS

Patients with known interstitial lung disease who underwent a CT thorax over a 2-year period were retrospectively reviewed. Presence of CAC was assessed using a visual scale for CAC reporting and graded as mild, moderate, or severe by two cardiothoracic radiologists. CT reports were reviewed to determine if presence of CAC had been described. Electronic medical records were reviewed for any subsequent cardiothoracic events from the date of the CT thorax to present.

RESULTS

254 patients were included in the analysis (54.7% men; mean age 59.9 yo). 43.7% had CAC on their CT thorax; however, in 87.3% of those, reports did not comment on its presence. 8 patients had cardiac events; 7 of them had CAC on CT although only in 1 case this was reported. Global CAC and LAD CAC Patients with cardiac events had a significantly higher global CAC (p=0.016) and LAD CAC (p=0.048) when compared to patients without.

CONCLUSION

We demonstrated a high prevalence of CAC in ILD patients and its significant association with adverse cardiac events. Unfortunately, CAC on CT thorax is still largely unreported. As per recent BSCI/BSCCT and BSTI guidelines, reporting of CAC should become part of routine practice, as may prompt prevention and impact on patients outcome.

Role of pulmonary perfusion magnetic resonance imaging for the diagnosis of pulmonary hypertension: A review

Among five types of pulmonary hypertension, chronic thromboembolic pulmonary hypertension (CTEPH) is the only curable form, but prompt and accurate diagnosis can be challenging. Computed tomography and nuclear medicine-based techniques are standard imaging modalities to non-invasively diagnose CTEPH, however these are limited by radiation exposure, subjective qualitative bias, and lack of cardiac functional assessment. This review aims to assess the methodology, diagnostic accuracy of pulmonary perfusion imaging in the current literature and discuss its advantages, limitations and future research scope.

Inhaler technique knowledge and skills before and after an educational program in obstructive respiratory disease patients: A real-life pilot study

INTRODUCTION AND OBJECTIVE

Patients present poor knowledge and skills about their respiratory disease and inhaler device. We aimed to: (1) evaluate COPD and asthmatic patients... ability to manage inhaled drugs (2) identify differences among devices and (3) correlate clinical data with patient ability.

MATERIAL AND METHODS

Patients (n=134) admitted for pulmonary rehabilitation (PR) were given an ad-hoc questionnaire covering 0% as the worst and 100% the best value of global ability (indicating the sum of knowledge and skills in managing inhaled drugs) at baseline (T0) and discharge (T1). Educational program was provided during PR. Setting of rehabilitation, age, sex, diagnosis, spirometry, CIRS score, level of autonomy to use medications, if na..ve about PR, educational level, and number/type of prescribed inhaled drugs were recorded.

RESULTS

Most patients used 1 drug while 37% used 2 drugs. DPIs were the main device prescribed. At baseline, patients... mean level of knowledge and skills were 73% and 58%, respectively. There was a significant difference in level of skills (p=0.046) among device families, DPIs resulting worst and pMDIs best. Global ability, skills and knowledge improved after educational support (p<0.001) but did not reach the optimal level, 88%, 87% and 89%, respectively. Baseline global ability was positively correlated to female gender, younger age, previous PR access, outpatient status, higher education level and GOLD D class.

CONCLUSIONS

At hospital admission, global ability was not optimal. Education may improve this, irrespective of the type of device used, in particular in male, elderly, na..ve to PR, low educational level patients.

Variation in electroencephalography and neuroimaging for children receiving extracorporeal membrane oxygenation

BACKGROUND

Seizures, strokes, and intracranial hemorrhage are common and feared complications in children receiving extracorporeal membrane oxygenation (ECMO) support. Researchers and clinicians have proposed and deployed methods for monitoring and detecting neurologic injury, but best practices are unknown. We sought to characterize clinicians' approach to electroencephalography (EEG) and brain imaging modalities in children supported by ECMO.

METHODS

We performed a retrospective observational cohort study among US Children's Hospitals participating in the Pediatric Health Information System (PHIS) from 2016 to 2021. We identified hospitalizations containing ECMO support. We stratified these admissions by pediatric, neonatal, cardiac surgery, and non-cardiac surgery. We characterized the frequency of EEG, cranial ultrasound, brain computed tomography (CT), magnetic resonance imaging (MRI), and transcranial Doppler during ECMO hospitalizations. We reported key diagnoses (stroke and seizures) and the prescription of antiseizure medication. To assess hospital variation, we created multilevel logistic regression models.

RESULTS

We identified 8746 ECMO hospitalizations. Nearly all children under 1 year of age (5389/5582) received a cranial ultrasound. Sixty-two percent of the cohort received an EEG, and use increased from 2016 to 2021 (52-72% of hospitalizations). There was marked variation between hospitals in rates of EEG use. Rates of antiseizure medication use (37% of hospitalizations) and seizure diagnoses (20% of hospitalizations) were similar across hospitals, including high and low EEG utilization hospitals. Overall, 37% of the cohort received a CT and 36% received an MRI (46% of neonatal patients). Stroke diagnoses (16% of hospitalizations) were similar between high- and low-MRI utilization hospitals (15% vs 17%, respectively). Transcranial Doppler (TCD) was performed in just 8% of hospitalizations, and 77% of the patients who received a TCD were cared for at one of five centers.

CONCLUSIONS

In this cohort of children at high risk of neurologic injury, there was significant variation in the approach to EEG and neuroimaging in children on ECMO. Despite the variation in monitoring and imaging, diagnoses of seizures and strokes were similar across hospitals. Future work needs to identify a management strategy that appropriately screens and monitors this high-risk population without overuse of resource-intensive modalities.

Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT)

OBJECTIVE

Many patients presenting with suspected acute coronary syndrome (ACS) have high-sensitivity cardiac troponin (hs-cTn) concentrations between rule-in and rule-out thresholds and hence need serial testing, which is time consuming. The Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT) assessed the utility of coronary CT angiography (CCTA) in patients with suspected ACS, non-ischaemic ECG and intermediate initial hs-cTn concentration.

METHODS

Patients were randomised to CCTA-guided management versus standard of care (SOC). The primary outcome was hospital length of stay (LOS). Secondary outcomes included cost of in-hospital stay and major adverse cardiac events (MACE) at 12 months of follow-up. Data are mean (SD); for LOS harmonic means, IQRs are shown.

RESULTS

250 (aged 55 (14) years, 25% women) patients were randomised. Harmonic mean (IQR) LOS was 7.53 (6.0-9.6) hours in the CCTA arm and 8.14 (6.3-9.8) hours in the SOC arm (p=0.13). Inpatient cost was £1285 (£2216) and £1108 (£3573), respectively, p=0.68. LOS was shorter in the CCTA group in patients with <25% stenosis, compared with SOC; 6.6 (5.6-7.8) hours vs 7.5 (6.1-9.4) hours, respectively; p=0.021. More referrals for cardiology outpatient clinic review and cardiac CT-related outpatient referrals occurred in the SOC arm (p=0.01). 12-month MACE rates were similar between the two arms (7 (5.6%) in the CCTA arm and 8 (6.5%) in the SOC arm-log-rank p=0.78).

CONCLUSIONS

CCTA did not lead to reduced hospital LOS or cost, largely because these outcomes were influenced by the detection of ≥25% grade stenosis in a proportion of patients.

TRIAL REGISTRATION NUMBER

NCT03583320.

Multimodality Imaging in Valvular Structural Interventions

Structural valvular interventions have skyrocketed in the past decade with new devices becoming available and indications for patients who would previously have been deemed inoperable. Furthermore, while echocardiography is the main imaging tool and the first line for patient screening, cardiac magnetic resonance and CT are now essential tools in pre-planning and post-procedural follow-up. This review aims to address imaging modalities and their scope in aortic, mitral and tricuspid structural valvular interventions, including multimodality imaging. Pulmonary valve procedures, which are mostly carried out in patients with congenital problems, are discussed. This article presents a guide on individualised imaging approcahes on each of the available interventional procedures.

A dietary intervention study to reduce Metabolic Syndrome risks in heart-transplanted patients

Background

Since heart transplantation (HTx) has become the gold standard therapy in end-staged heart failure, many factors, including metabolic syndrome (MS), represent a burden in HTx patients. Considering key role of immunosuppressive therapy and its side effects on the appearance of MS, we focused on modifiable factors including adherence to Mediterranean Diet (MD) and improvement of dietary habits.

Methods

21 heart-transplanted patients were enrolled and randomized in a control group (CG; N 10) and an intervention group (IG; N 11). During two meetings (baseline, 6-month follow-up) were administered a validated Food Frequency Questionnaire (FFQ), to assess adherence to MD, and collected clinical and anthropometric parameters, IG were additionally requested to fill a food diary. IG received personalized advices, CG received standard recommendations. Comparison between IG and CG were analyzed, differences into the IG were also assessed.

Results

The prevalence of MS at baseline was 46% in IG and 20% in CG. During 6-month follow-up, significant lower blood pressure values were observed (median, 25th-75th: systolic 130, 120-130 IG vs 145, 130-147 CG; p = 0.004). Seven patients of IG underwent a 12-month meeting. In this group MD scores increased significantly (7 + 1.3 vs 4 + 1.5, p = 0.001). Furthermore, significant decrease of fat mass percentage (%) (23.3 + 6.3 vs 14.8 + 10.1, p = 0.014), increase of fat free mass % (76 + 6.3 vs 85.2 + 10.1, p = 0.014) and increase of body cell mass % (50.9 + 3.8 vs 53.4 + 3.4, p = 0.031) were observed. Dietary data in IG showed significant decrease of energy from saturated fatty acids % (13.0±2.1 vs 9.6±1.5, p = 0.001), sodium (mg) (2138±359 vs 1822±417, p = 0.045), and decreasing trend for cholesterol (mg) (219±82 vs 171±59, p = 0.082).

Conclusions

Dietary intervention based on MD perhaps can improve MS risks in heart-transplanted patients. Further investigations may be needed to assess the fundamental role of a structured nutritional follow-up in these patients.

Key messages

• Personalized nutritional advices based on the MD, compared to general recommendation, can significantly improve health and quality of life in heart-transplanted patients.

• A structured nutritional follow-up for heart-transplanted patients may be desirable to prevent risks of Metabolic Syndrome as a public health instrument in selected categories as these patients.

Association Between Early EEG Background and Outcomes in Infants With Mild HIE Undergoing Therapeutic Hypothermia

BACKGROUND

Hypoxic-ischemic encephalopathy (HIE) occurs in 1-4:1000 live births. Although neonates with moderate-severe HIE have been studied over several decades, newborns with mild HIE remain understudied, including seizure occurrence, electroencephalography (EEG) characteristics, and outcome.

METHODS

We conducted a retrospective cohort study of neonates ≥35 weeks of gestation with mild HIE who underwent therapeutic hypothermia to correlate the early EEG background pattern with clinical course and outcomes.

RESULTS

Of the included 29 neonates, 10 infants had a moderately to severely abnormal EEG background and 19 had either a normal or a mildly abnormal background. Those with moderately to severely abnormal background also had more multiorgan dysfunction (90% vs 42%, P = 0.02) and a higher incidence of subdural and intraventricular hemorrhages (80% vs 26%, P = 0.02). The overall seizure incidence was 20.7% and was significantly higher in newborns with more severely abnormal background compared to neonates with less abnormal background (50% vs 5%; P = 0.01; relative risk, 9.5; 95% confidence interval, 1.28-70.6). Seizure onset was between 11 and 63 hours of life. Regardless of the EEG background pattern, seizures were brief with an overall low seizure burden. None of the newborns with normal or mildly abnormal background had a new onset of seizures after 24 hours of recording or developed epilepsy during infancy.

CONCLUSIONS

In neonates with mild HIE, early moderately to severely abnormal EEG background is common and strongly associated with an increased risk for seizures.

Creation of personalised rib prostheses using a statistical shape model and 3D printing: Case report

Management of chest wall defects after oncologic resection can be challenging, depending on the size and location of the defect, as well as the method of reconstruction. This report presents the first clinical case where patient-specific rib prostheses were created using a computer program and statistical shape model of human ribs. A 64-year-old male was diagnosed with non-small-cell lung cancer originating in the right upper lobe and invading the lateral aspect of the 3rd, 4th, and 5th ribs. Prior to surgical resection, a statistical shape model of human ribs was created and used to synthesise rib models in the software MATLAB (MathWorks, Natick, MA, USA). The patient's age, weight, height, and sex, as well as the number and side of the ribs of interest, were the inputs to the program. Based on these data, the program generated digital models of the right 3rd, 4th, and 5th ribs. These models were 3D printed, and a silicone mould was created from them. The patient subsequently underwent right upper lobectomy with en bloc resection of the involved chest wall. During the operation, the silicone mould was used to produce rigid prostheses consisting of methyl methacrylate and two layers of polypropylene mesh in a “sandwich” fashion. The prosthetic patch was then implanted to cover the chest wall defect. Thirty days after the surgery, the patient has returned to his pre-disease performance and physical activities. The statistical shape model and 3D printing is an optimised 3D modelling method that can provide clinicians with a time-efficient technique to create personalised rib prostheses, without any expertise or prior software knowledge.

Development and Evaluation of a Rib Statistical Shape Model for Thoracic Surgery

Patients with advanced cancer undergoing chest wall resection may require reconstruction. Currently, rib prostheses are created by segmenting computed tomography images, which is time-consuming and labour intensive. The aim was to optimise the production of digital rib models based on a patient's age, weight, height and gender. A statistical shape model of human ribs was created and used to synthetise rib models, which were compared to the ones produced by segmentation and mirroring. The segmentation took 11.56±1.60 min compared to 0.027 ±0.009 min using the new technique. The average mesh error between the mirroring technique and segmentation was 0.58±0.25 mm (right ribs), and 0.87±0.18 mm (left ribs), compared to 1.37±0.66 mm ( ) and 1.68 ±0.77 mm ( ), respectively, for the new technique. The new technique is promising for the efficiency and ease-of-use in the clinical environment. Clinical Relevance- This is an optimised 3D modelling method providing clinicians with a time-efficient technique to create patient-specific rib prostheses, without any expertise or software knowledge required.

Two years' effect of dimethyl fumarate on focal and diffuse gray matter pathology in multiple sclerosis

BACKGROUND

Data on the effect of dimethyl fumarate (DMF) on focal and diffuse gray matter (GM) damage, a relevant pathological substrate of multiple sclerosis (MS)-related disability are lacking.

OBJECTIVE

To evaluate the DMF effect on cortical lesions (CLs) accumulation and global and regional GM atrophy in subjects with relapsing-remitting MS.

METHODS

A total of 148 patients (mean age 38.1 ± 9.7 years) treated with DMF ended a 2-year longitudinal study. All underwent regular Expanded Disability Status Scale (EDSS assessment), and at least two 3T-magnetic resonance imaging (MRI) at 3 and 24 months after DMF initiation. CLs and changes in global and regional atrophy of several brain regions were compared with 47 untreated age and sex-matched patients.

RESULTS

DMF-treated patients showed lower CLs accumulation (median 0[0-3] vs 2[0-7], p < 0.001) with respect to controls. Global cortical thickness (p < 0.001) and regional thickness and volume were lower in treated group (cerebellum, hippocampus, caudate, and putamen: p < 0.001; thalamus p = 0.03). Lower relapse rate (14% vs 40%, p < 0.001), EDSS change (0.2 ± 0.4 vs 0.4 ± 0.9, p < 0.001), and new WM lesions (median 0[0-5] vs 2[0-6], p < 0.001) were reported. No severe adverse drug reactions occurred.

CONCLUSIONS

Beyond the well-known effect on disease activity, these results provide evidence of the effect of DMF through reduced progression of focal and diffuse GM damage.

C54 METABOLIC SYNDROME IN HEART TRANSPLANTATION: AN UNDERESTIMATED RISK FACTOR?

Background and Aims

Metabolic Syndrome (MS) is a multifactorial condition that increases the risk of cardio–vascular events, it’s frequent in Heart transplant (HTx) candidates and worsens with immunosuppressive therapy.

Aim of the study was to analyse the impact of MS on long–term outcome of HTx patients in our centre.

Methods

MS was defined through the presence of at least 3 of the following factors: Triglyceride ≥150mg/dl or drug treatment for hypertriglyceridemia HDL &lt;40mg/dl for men and &lt;50mg/dl for women Blood glucose ≥100mg/dl or diabetes mellitus Arterial pressure ≥130/80 or hypertensive drug treatment BMI&gt;30. In 349 HTx patients since 2007, mortality and morbidity predictors were evaluated.

Results

MS was present in 35% of patients pre–HTx and 47% within the first year of follow–up. Five–year survival in patients with pre–HTx MS was worst (65% vs 78%, p &lt; 0.01), as well as in those with MS in the first year of follow–up (78% vs 89%, p &lt; 0.01). At the univariate analysis, risk factors for mortality were recipient age (HR 1.07, 1.04–1.09, p &lt; 0.01), pre–HTx MS (HR 1.86, 1.29–2.69, p &lt; 0.01), pre–HTx hypertension (HR 2.46, 1.70–3.55, p &lt; 0.01), pre–HTx hypertriglyceridemia (HR 1.50, 1.04–2.18, p = 0.03), chronic renal failure (HR 2.95, 2.03–4.27, p &lt; 0.01), MS and diabetes at 1–year follow–up (HR 2.00, 1.25–3.19, p &lt; 0.01; HR 2.02, 1.27–3.23, p &lt; 0.01, respectively). The last two resulted also risk factors for CAV (HR 1.86, 1.16–2.99, p = 0.01; HR 1.67, 1.03–2.69, p = 0.04, respectively). MS at 1–year follow–up determined a significant higher risk to develop CAV at 5– and 10–year follow–up, compared to patients without MS (25% vs 14% and 44% vs 25%, p &lt; 0.01).

Conclusions

MS is an important risk factor for both mortality and morbidity post–HTx, suggesting the need for a strict monitoring of metabolic disorders with a careful nutritional follow–up in HTx patients.

Cardiac and Vascular Remodeling After 6 Months of Therapy With Sacubitril/Valsartan: Mechanistic Insights From Advanced Echocardiographic Analysis

Background

Effects of Sacubitril/Valsartan (S/V) on left ventricular (LV) mechanics and ventricular-arterial coupling in patients with heart failure with reduced ejection fraction (HFrEF) are not completely understood. The aim of this study was to evaluate both cardiac and vascular remodeling in a group of HFrEF patients undergoing S/V therapy.

Methods

Fifty HFrEF patients eligible to start a therapy with S/V were enrolled. Echocardiographic evaluation was performed at baseline and after 6 months of follow-up (FU). Beside standard evaluation, including global longitudinal strain (GLS), estimated hemodynamic forces (HDFs) and non-invasive pressure-volume curves (PV loop) were assessed using dedicated softwares. HDFs were evaluated over the entire cardiac cycle, in systole and diastole, both in apex to base (A-B) and latero-septal (L-S) directions. The distribution of LV HDFs was evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio). Parameters derived from estimated PV loop curves were left ventricular end-systolic elastance (E_es), arterial elastance (E_a), and ventricular-arterial coupling (VAC).

Results

At 6 months of FU indexed left ventricular end-diastolic and end-systolic volumes decreased (EDVi: 101 ± 28 mL vs. 86 ± 30 mL, p < 0.001; ESVi: 72 ± 23 mL vs. 55 ± 24 mL, p < 0.001), ejection fraction and GLS significantly improved (EF: 29 ± 6% vs. 37 ± 7%, p < 0.001; GLS: −9 ± 3% vs. −13 ± 4%, p < 0.001). A reduction of E_a (2.11 ± 0.91 mmHg/mL vs. 1.72 ± 0.44 mmHg/mL, p = 0.008) and an improvement of E_es (1.01 ± 0.37 mmHg/mL vs. 1.35 ± 0.6 mmHg/mL, p < 0.001) and VAC (2.3 ± 1.1 vs. 1.5 ± 0.7, p < 0.001) were observed. Re-alignment of HDFs occurred, with a reduction of diastolic L-S/A-B HDFs ratio [23 (20–35)% vs. 20 (11–28) %, p < 0.001].

Conclusion

S/V therapy leads to a complex phenomenon of reverse remodeling involving increased myocardial contractility, HDFs distribution improvement, and afterload reduction.

Vascular Thrombosis in Severe COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Multicenter Study

OBJECTIVES

Coronavirus disease 2019 has been reported to be a prothrombotic condition; however, multicenter data comparing this with other viral pneumonias in those requiring extracorporeal membrane oxygenation are lacking. We conducted a multicenter study using whole-body CT to examine the prevalence, severity, and nature of vascular complications in coronavirus disease 2019 in comparison with patients with other viral pneumonias.

DESIGN

We analyzed whole-body CT scans for the presence of vascular thrombosis (defined as pulmonary artery thrombus, venous thrombus, systemic arterial thrombus, or end-organ infarct). The severity, distribution, and morphology of pulmonary artery thrombus were characterized. Competing risk cumulative incidence analysis was used to compare survival with discharge.

SETTING

Three centers of the English national extracorporeal membrane oxygenation service.

PATIENTS

Consecutive patients admitted with either coronavirus disease 2019 or noncoronavirus disease 2019 viral pneumonia admitted from January 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One-hundred thirty-six patients (45.2 ± 10.6 yr old, 39/146 [27%] female) requiring extracorporeal membrane oxygenation support underwent whole-body CT scans at admission. Of these, 86 had coronavirus disease 2019 pneumonia, and 50 had noncoronavirus disease 2019 viral pneumonia. Vascular thrombosis was seen more often in patients with coronavirus disease 2019 (odds ratio, 12.9 [95% CI 4.5-36.8]). In those with coronavirus disease 2019, 57 (73%) demonstrated pulmonary artery thrombus or pulmonary perfusion defects. Eighty-two percent of thrombus exhibited emboli-like morphology. The location of pulmonary artery thrombus and parenchymal perfusion defects was only concordant in 30% of cases. The risk of mortality was higher in those with coronavirus disease 2019 compared with noncoronavirus disease 2019 pneumonia (χ2 = 3.94; p = 0.047). Mortality was no different in coronavirus disease 2019 patients with or without vascular thrombosis (χ2 = 0.44; p = 0.51).

CONCLUSIONS

In patients who received extracorporeal membrane oxygenation, coronavirus disease 2019 is associated with a higher prevalence of vascular thrombosis compared with noncoronavirus disease viral pneumonias. The pattern of pulmonary vascular changes suggests concurrent embolic disease and small vessel disease. Despite this, vascular thrombosis was not linked to poorer short-term prognosis in those with coronavirus disease 2019.

Cardio-vascular remodelling during sacubitril/valsartan therapy in patients with heart failure and reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan (S/V) benefits in patients with heart failure and reduced ejection fraction (HFrEF) are partially related to cardiac reverse remodelling, in terms of volumes reduction and function improvement.  Effects on vascular remodeling are less investigated.

Purpose

To evaluate cardiac and vascular remodelling in a cohort of patients with HFrEF after six months of therapy with S/V.

Methods

50 patients with HFrEF eligible to start a therapy with sacubitril/valsartan were enrolled. Clinical evaluation and standard and advanced echocardiography were performed at baseline and after six months of follow up (FU). Standard left ventricular dimension and function parameters, global longitudinal strain (GLS) were calculated. Non-invasive pressure-volume curves (P-V loop) estimation was assessed with an off-line dedicated software using ST-E derived time-resolved LV volumes and brachial pressure as input. The following hemodynamic parameters were calculated based on P-V loop curves: left ventricular elastance (Ees), arterial elastance (Ea) and ventricular-arterial coupling (VAC).

Results

At six months F/U, a reduction of NYHA class in the vast majority of patients was detected (NYHA Class ≥ II, baseline vs F/U = 100% vs 50%; p&lt; 0,001). Systolic and diastolic blood pressure were lower, in comparison with baseline values (119 ± 16 vs 126  ± 11 mmHg; p = 0,002 and 71 ±  8 vs 78 ±  8 mmHg; p = 0,001, respectively). At echocardiographic evaluation, left ventricular end-diastolic and end-systolic volumes decreased (p&lt; 0.001 and p&lt; 0,001, respectively) and ejection fraction and GLS significantly improved (p&lt; 0.001 and p &lt; 0.001, respectively). Moreover, a significant reduction of Ea and a significant improvement of Ees and VAC were observed (p = 0.008, p&lt; 0,001 and p&lt; 0,001, respectively).

Conclusion

Therapy with S/V in HFrEF patients determines both cardiac and vascular remodelling reflecting the complex mechanisms behind clinical improvement. Abstract Figure.

Left ventricular forces distribution in patients with heart failure and reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Hemodynamic forces (HDFs) are the forces exchanged between the blood and the myocardium. Estimation of their magnitude and alignment could be a novel marker of cardiac dysfunction.

Purpose

To describe left ventricular (LV) HDFs values and distribution in patients with heart failure with reduced ejection fraction (HFrEF) and to compare them with those of a group of healthy controls.

Methods

A cohort of 26 non-ischemic patients with an initial diagnosis of HFrEF was enrolled. All of them underwent basal 2D echocardiography evaluation.  Off-line HDFs estimation using a dedicated software based on speckle-tracking echocardiography was conducted. HDFs were normalized for the LV volume and expressed as a percentage of the force of gravity. HDFs were assessed over the entire cardiac cycle, in systole and diastole, both in apex to base (A-B) and latero-septal (L-S) directions. The distribution of LV HDFs was evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio). HDFs of HFrEF patients were compared with those of 24 healthy volunteers.

Results

HFrEF patients showed smaller values of A-B HDFs during the entire cardiac cycle (5,2 ± 1,24% vs 12,3 ± 3,6%; p = 0,001), in systole (7,2 ± 2% vs 16,6 ± 6,3%; p = 0,001) and diastole (3,3 ± 0,8% vs 7,1 ± 3,6%; p = 0,001). Moreover, comparing HFrEF subjects with healthy volunteers , the former had lower L-S HDFs during the entire cardiac cycle (1,6 ± 0,4% vs 2 ± 0,7%; p= 0,022) and in systole (1,6 ± 0,5% vs 2,3 ± 0,8%; p = 0,003), while in diastole they showed inappropriate high values of L-S HDFs (1,7 ± 0,6% vs 1,8 ± 0,9%; p = 0,999). Consequently, HFrEF patients had higher  values of L-S/A-B ratio during the entire cardiac cycle (32 ± 6,9 vs 15 ± 7,7; p = 0,001), in systole (23,5 ± 7,4 vs 14,7± 4,2; p = 0,001), but particularly in diastole (52 ± 10,8 vs 28 ± 13,6; p = 0,001), showing an important HDFs misalignment.

Conclusion

When compared with healthy controls, HFrEF patients presented intraventricular fluid alterations characterized by lower HDFs magnitude and a significant HDFs misalignment, especially in diastole. Further studies are needed to confirm these initial results and to assess the effects of therapy on these new parameters. Abstract Figure.  Abstract Figure.

511 Cardio-vascular remodelling during sacubitril/valsartan therapy in patients with heart failure and reduced ejection fraction

Aims

Sacubitril/valsartan (S/V) benefits in patients with heart failure and reduced ejection fraction (HFrEF) are partially related to cardiac reverse remodelling, in terms of volumes reduction and function improvement. Effects on vascular remodelling are less investigated. To evaluate cardiac and vascular remodelling in a cohort of patients with HFrEF after 6 months of therapy with S/V.

Methods and results

50 patients with HFrEF eligible to start a therapy with sacubitril/valsartan were enrolled. Clinical evaluation and standard and advanced echocardiography were performed at baseline and after 6 months of follow-up (FU). Standard left ventricular dimension and function parameters and global longitudinal strain (GLS) were calculated. Non-invasive pressure-volume curves (P-V loop) estimation was assessed with an off-line dedicated software using ST-E derived time-resolved LV volumes and brachial pressure as input. The following haemodynamic parameters were calculated based on P–V loop curves: left ventricular elastance (Ees), arterial elastance (Ea), and ventricular-arterial coupling (VAC). At 6 months F/U, a reduction of NYHA class in the vast majority of patients was detected (NYHA Class ≥ II, baseline vs. F/U = 100% vs. 50%; P &lt; 0.001). Systolic and diastolic blood pressure were lower, in comparison with baseline values (119 ± 16 vs. 126 ± 11 mmHg; P = 0.002 and 71 ± 8 vs. 78 ± 8 mmHg; P = 0.001, respectively). At echocardiographic evaluation, left ventricular end-diastolic and end-systolic volumes decreased and ejection fraction and GLS significantly improved (Table). Moreover, a significant reduction of Ea and a significant improvement of Ees and VAC was observed (Table). 511 Table 1

Conclusions

Therapy with S/V in HFrEF patients determines both cardiac and vascular remodelling reflecting the complex mechanisms behind clinical improvement.

Non-invasive assessment of ventriculo-arterial coupling using aortic wave intensity analysis combining central blood pressure and phase-contrast cardiovascular magnetic resonance

BACKGROUND

Wave intensity analysis (WIA) in the aorta offers important clinical and mechanistic insight into ventriculo-arterial coupling, but is difficult to measure non-invasively. We performed WIA by combining standard cardiovascular magnetic resonance (CMR) flow-velocity and non-invasive central blood pressure (cBP) waveforms.

METHODS AND RESULTS

Two hundred and six healthy volunteers (age range 21-73 years, 47% male) underwent sequential phase contrast CMR (Siemens Aera 1.5 T, 1.97 × 1.77 mm2, 9.2 ms temporal resolution) and supra-systolic oscillometric cBP measurement (200 Hz). Velocity (U) and central pressure (P) waveforms were aligned using the waveform foot, and local wave speed was calculated both from the PU-loop (c) and the sum of squares method (cSS). These were compared with CMR transit time derived aortic arch pulse wave velocity (PWVtt). Associations were examined using multivariable regression. The peak intensity of the initial compression wave, backward compression wave, and forward decompression wave were 69.5 ± 28, -6.6 ± 4.2, and 6.2 ± 2.5 × 104 W/m2/cycle2, respectively; reflection index was 0.10 ± 0.06. PWVtt correlated with c or cSS (r = 0.60 and 0.68, respectively, P < 0.01 for both). Increasing age decade and female sex were independently associated with decreased forward compression wave (-8.6 and -20.7 W/m2/cycle2, respectively, P < 0.01) and greater wave reflection index (0.02 and 0.03, respectively, P < 0.001).

CONCLUSION

This novel non-invasive technique permits straightforward measurement of wave intensity at scale. Local wave speed showed good agreement with PWVtt, and correlation was stronger using the cSS than the PU-loop. Ageing and female sex were associated with poorer ventriculo-arterial coupling in healthy individuals.

Improving outcomes of surgery in advanced infiltrative thymic tumours: the benefits of multidisciplinary approach

Background:

For stage III or IVa thymic tumours, a multimodality approach is recommended. The role of surgery is to achieve complete resection.

Aim:

To present the outcomes of patients undergoing surgery for stage III or IVa thymoma.

Methods:

Retrospective review of patients undergoing open surgery for stage III or IVa thymoma between 2016 and 2020 at a single centre was performed. Preoperative imaging, treatment plan, surgical approach, and postoperative outcomes were analyzed.

Results:

Forty-seven patients underwent surgery for thymoma. Patients with clinical stage I/II thymoma or minimally invasive thymectomy were excluded. Thirteen patients with clinical stage III or IVa were included. Median sternotomy approach was used in four patients, of which one was redo sternotomy; a hemi-clamshell in four; and a combination of approaches in the remaining five patients. There was no postoperative mortality. Four patients had postoperative complications. Complete resection was achieved in all but two patients. At a median follow-up of 17.9 months, all patients were alive with no evidence of recurrence except one who died 4 months after surgery from coronavirus disease 2019 (COVID-19) pneumonia.

Conclusions:

Surgery for stage III and IVa thymoma is safe and can be achieved with complete macroscopic resection. To obtain adequate exposure of all structures involved in the tumour, combined surgical approaches can be used with no increased morbidity. The majority of patients, even after extrapleural pneumonectomy, did not receive adjuvant radiotherapy and had no evidence of local relapse.

Improvement of left ventricular systolic performance during sacubitril/valsartan in a cohort of patients with heart failure and reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan is a well-established therapeutic option for patients with heart failure with reduced ejection fraction (HFrEF). While it was clearly demonstrated to improve patients’ clinical conditions, its potential role in inducing left ventricle (LV) reverse remodeling is still under investigation. 

Purpose

to evaluate clinical and echocardiographic effect of sacubitril/valsartan on a cohort of patients with HFrEF after six months of therapy.

Methods

36 patients with HFrEF eligible to start a therapy with sacubitril/valsartan were enrolled. A standard and advanced echocardiographic evaluation was performed before starting the therapy and after six months of follow up (FU). Off-line analysis of left ventricle global longitudinal strain (GLS), longitudinal strain of the free wall of the right ventricle (RVFWSL) and left atrial strain (LAS) was conducted. Clinical and biochemical parameters were evaluated as well.

Results

At six months of FU NYHA class improved in the vast majority of patients (NYHA class III at baseline vs FU: 56% vs 5%, p 0.001). We observed a significant reduction in LV end-diastolic (99.62 ± 33.24 vs 91.54 ± 33.36, p 0.043) and end-systolic (69.99 ± 26.01 vs 58.68 ± 25.7, p 0.001) volumes and an improvement of LV ejection fraction (30.4 ± 5.02 vs 37.3 ± 6.4, p &lt; 0.001). After six months of therapy, GLS significantly improved (-9.71 ± 2.87 vs -13.04 ± 3.14, p &lt; 0.001). No differences in left and right atrial volumes (respectively 56.6 ± 29 vs 54 ± 30, p 0.349; 54.7 ± 23.7 vs 48.3 ± 19, p 0.157), RVFWSL (-16,5 ± 5,4 vs -16,8 ± 1,5) and LAS (14 ± 6 vs 19 ± 8, p 0.197) were found at FU. 

Conclusion

Left ventricular function evaluated with standard and advanced echocardiographic parameters improved after six months of therapy with sacubitril/valsartan in HFrEF patients. Reduction in LV volumes was found as well.

Echo Analysis Baseline Echo Analysis (n= 36) 6 Months FU Echo Analysis (n= 36) p LVEDVi, mL/m2 99, 62 ± 33,24 91,54 ± 33,36 0,043 LVESVi, mL/m2 69,99 ± 26,01 58,68 ± 25,7 0,001 LVEF, % 30,4 ± 5, 02 37,3 ± 6,4 &lt; 0,001 E/E’ average 12,16 ± 3,74 9,71 ± 1,33 0,023 LS Endo Average ,% -9,71 ± 2,87 -13,04 ± 3,14 &lt; 0,001 LVEF left ventricular ejection fraction, LVEDVi: left ventricular end diastolic volume indexed, LVESVi: left ventricular end systolic volume indexed; LS: longitudinal strain

Pulsatile and resistive systolic loads as determinants of left ventricular remodelling after physical training

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Barts Cardiovascular Biomedical Research Centre

onbehalf

The Marathon Study Consortium

Introduction

Cardiovascular function depends on the inter-relation between heart and vasculature.  The contribution of aorta and peripheral vessels to the total systolic load of the left ventricle (LV) can be represented respectively by a "pulsatile" and a "resistive" component. We sought to understand their interrelation by exploring how LV remodelling occurred with altered load associated with an external stimulus (training). Methods: 237 untrained healthy male and female subjects volunteering for their first-time marathon were recruited. At baseline and after 6 months of unsupervised training, race completers underwent 1.5T cardiac magnetic resonance, brachial and non-invasive central blood pressure assessment. For analysis, runners were divided into 4 groups according to the variation (positive versus null or negative) in Total Arterial Compliance Index (TACi), representing the pulsatile component of the LV load, and in Systemic Vascular Resistance Index (SVRI), representing the resistive component of the LV load. Results: 138runners (age 21-69 years; F: 51%) completed the race. Data are reported for each variable as Δ mean [95% Confidence Interval]. In the whole cohort, training was associated with a small increase in LV mass index (+3g/m2, [0, 6 g/m2]), indexed LV end-diastolic volume (EDVi) (+3ml/m2, [-2, 5 3ml/m2]), in LV mass/LVEDV ratio (+0.02g/ml, [0.00, 0.04 g/ml]) and in TACi (+0.02ml/m2, [0.02, 0.38 ml/m2]). SVRi mildly fell (-43dyn·s/cm2[-103, 17dyn·s/cm2]). TACi increase was associated with LVEDVi increase and no change in LV mass/EDV (eccentric remodelling). On the other hand, both TACi reduction and SVRi increase were associated with increase in LV mass/EDV and no significant change in LVEDVi (concentric remodelling). A similar increase in LV mass was observed in all groups. See Table. Conclusion: Cardiac remodelling observed after mild, medium term, unsupervised training seems to be related to the modifications of aorta and peripheral vessels. In particular, a reduction in pulsatile load seems associated with eccentric LV remodelling, while an increase in both pulsatile and resistive with concentric LV remodelling. Further research is needed to understand the interaction between TACi and SVRi.

Table 1 LV EDVi (ml/m2) LV mass index (g/m2) LV mass/EDV TACi increase (n = 75) +4 [0, 9] +3 [0, 7] 0 [-0.03, 0.03] TACi decrease (n = 62) -1 [-6, 4] +3 [0, 8] 0.04 [0.01, 0.07] SVRi increase (n = 63) 0 [-4,4] +3 [0, 7] +0.03 [0, 0.06] SVRi decrease (n = 73) +3 [-3, 7] +3 [-1, 6] +0.01 [-0.02, 0.04]

Feature tracking and mapping analysis of myocardial response to improved perfusion reserve in patients with refractory angina treated by coronary sinus Reducer implantation: a CMR study

Coronary sinus (CS) Reducer implantation improves myocardial perfusion and symptoms in patients with debilitating refractory angina. Its impact on myocardial remodeling remain uncertain. Aim of the present study was to assess possible impact of CS Reducer on myocardial systolic-diastolic deformation and microstructural remodeling, as assessed through cardiac magnetic resonance (CMR) feature tracking and mapping analysis. Twenty-eight consecutive patients with refractory angina underwent multiparametric stress CMR before and 4 months after CS Reducer implantation. Eight patients were excluded (6 for absence of inducible ischemia, 2 for artifacts). Modifications in 3D systo-diastolic myocardial deformation were evaluated using feature tracking analysis on rest cine images. Myocardial microstructural remodeling was assessed by native T1 mapping, cellular and matrix volume and extracellular volume fraction (ECV). Collaterally, the percentage of ischemic myocardium (ischemic burden %) and the myocardial perfusion reserve index (MPRI) were measured. After CS Reducer implantation, myocardial contractility improved (ejection fraction rose from 61 to 67%; p = 0.0079), along with longitudinal (from - 16 to - 19%; p = 0.0192) and circumferential strain (from - 18 to - 21%; p = 0.0017). Peak diastolic radial, circumferential and longitudinal strain rate did not change (p > 0.05), and no changes in native T1, ECV, cellular and matrix volume were observed. Myocardial perfusion improved, with a reduction of ischemic burden (13-11%; p = 0.0135), and recovery of intramural perfusion balance in segments with baseline ischemia (MPRi endocardial/epicardial ratio from 0.67 to 0.96; p = 0.0107). CS Reducer improves myocardial longitudinal and circumferential strain, without microstructural remodeling and no impact on diastolic proprieties.

Catheter-directed thrombolysis to treat acute pulmonary thrombosis in a patient with COVID-19 pneumonia

We describe a case of a patient who presented to the emergency department with severe shortness of breath and was diagnosed with mild COVID-19 pneumonia and concomitant intermediate-high risk saddle pulmonary thromboembolism. Additionally, the patient had sustained a significant head injury 2 days prior due to a syncopal episode. The patient was treated successfully with catheter-directed thrombolysis (CDT). The case highlights the importance of considering thromboembolic complications in COVID-19 infection, independent of the severity of the associated pneumonia. The case also demonstrates the potential benefit of CDT in treating COVID-19-related thromboembolism.

Pulmonary ischaemia without pulmonary arterial thrombus in COVID-19 patients receiving extracorporeal membrane oxygenation: a cohort study

AIM

To evaluate the incidence of pulmonary ischaemia in COVID-19 patients on extracorporeal membrane oxygenation (ECMO), and its correlation with pulmonary artery thrombosis.

MATERIALS AND METHODS

Computed tomography (CT) thorax of all patients receiving ECMO with proven COVID-19 pneumonitis between March and May 2020 were analysed for the presence and extension of pulmonary thromboembolic disease.

RESULTS

Fifty-one patients were reviewed. The mean (range) age of 45 (26–66) years; 38/51 (74.5%) were men. All patients had severe COVID-19 pneumonitis, and 18/51 (35.3%) had macroscopic thrombosis (15 with associated ischaemia); however, 13/51 (25.5%) patients had ischaemia without associated thrombus.

CONCLUSION

The majority of patients with COVID-19 who received ECMO had areas of ischaemia within consolidated lungs, almost half of these without subtending pulmonary artery thrombosis. Although the prognostic significance of these findings is unclear, they are highly suggestive of lung ischaemia due to isolated microvascular immune thrombosis.

•

High incidence of pulmonary artery thrombosis in COVID-19 ECMO patients.

•

Lung ischaemia seen in patients with and without visible pulmonary artery thrombus.

•

Ischaemia with no visible thrombus suggest microvascular thrombosis.

Robustness of CT radiomic features against image discretization and interpolation in characterizing pancreatic neuroendocrine neoplasms

PURPOSE

To explore the variation of the discriminative power of CT radiomic features (RF) against image discretization/interpolation in characterizing pancreatic neuro-endocrine (PanNEN) neoplasms.

MATERIALS AND METHODS

Thirty-nine PanNEN patients with pre-surgical high contrast CT available were considered. Image interpolation and discretization parameters were intentionally changed, including pixel size (0.73-2.19 mm²), slice thickness (2-5 mm) and binning (32-128 grey levels) and their combination generated 27 parameter's set. The ability of 69 RF in discriminating post-surgically assessed tumor grade (>G1), positive nodes, metastases and vascular invasion was tested: AUC changes when changing the parameters were quantified for selected RF, significantly associated to each end-point. The analysis was repeated for the corresponding images with contrast medium and in a sub-group of 29/39 patients scanned on a single scanner.

RESULTS

The median tumor volume was 1.57 cm³ (16%-84% percentiles: 0.62-34.58 cm³). RF variability against discretization/interpolation parameters was large: only 21/69 RF showed %COV < 20%. Despite this variability, AUC changes were limited for all end-points: with typical AUC values around 0.75-0.85, AUC ranges for the 27 parameter's set were on average 0.062 (1SD:0.037) for all end-points with maximum %COV equal to 5.5% (mean:2.3%). Performances significantly improved when excluding the 5 mm thickness case and fixing the binning to 64 (mean AUC range: 0.036, 1SD:0.019). Using contrast images or limiting the population to single-scanner patients had limited impact on AUC variability.

CONCLUSIONS

The discriminative power of CT RF for panNEN is relatively invariant against image interpolation/discretization within a large range of voxel sizes and binning.

Age matters: differences in exercise-induced cardiovascular remodelling in young and middle aged healthy sedentary individuals

AIMS

Remodelling of the cardiovascular system (including heart and vasculature) is a dynamic process influenced by multiple physiological and pathological factors. We sought to understand whether remodelling in response to a stimulus, exercise training, altered with healthy ageing.

METHODS

A total of 237 untrained healthy male and female subjects volunteering for their first time marathon were recruited. At baseline and after 6 months of unsupervised training, race completers underwent tests including 1.5T cardiac magnetic resonance, brachial and non-invasive central blood pressure assessment. For analysis, runners were divided by age into under or over 35 years (U35, O35).

RESULTS

Injury and completion rates were similar among the groups; 138 runners (U35: n = 71, women 49%; O35: n = 67, women 51%) completed the race. On average, U35 were faster by 37 minutes (12%). Training induced a small increase in left ventricular mass in both groups (3 g/m2, P < 0.001), but U35 also increased ventricular cavity sizes (left ventricular end-diastolic volume (EDV)i +3%; left ventricular end-systolic volume (ESV)i +8%; right ventricular end-diastolic volume (EDV)i +4%; right ventricular end-systolic volume (ESV)i +5%; P < 0.01 for all). Systemic aortic compliance fell in the whole sample by 7% (P = 0.020) and, especially in O35, also systemic vascular resistance (-4% in the whole sample, P = 0.04) and blood pressure (systolic/diastolic, whole sample: brachial -4/-3 mmHg, central -4/-2 mmHg, all P < 0.001; O35: brachial -6/-3 mmHg, central -6/-4 mmHg, all P < 0.001).

CONCLUSION

Medium-term, unsupervised physical training in healthy sedentary individuals induces measurable remodelling of both heart and vasculature. This amount is age dependent, with predominant cardiac remodelling when younger and predominantly vascular remodelling when older.

T1 mapping performance and measurement repeatability: results from the multi-national T1 mapping standardization phantom program (T1MES)

BACKGROUND

The T1 Mapping and Extracellular volume (ECV) Standardization (T1MES) program explored T1 mapping quality assurance using a purpose-developed phantom with Food and Drug Administration (FDA) and Conformité Européenne (CE) regulatory clearance. We report T1 measurement repeatability across centers describing sequence, magnet, and vendor performance.

METHODS

Phantoms batch-manufactured in August 2015 underwent 2 years of structural imaging, B0 and B1, and "reference" slow T1 testing. Temperature dependency was evaluated by the United States National Institute of Standards and Technology and by the German Physikalisch-Technische Bundesanstalt. Center-specific T1 mapping repeatability (maximum one scan per week to minimum one per quarter year) was assessed over mean 358 (maximum 1161) days on 34 1.5 T and 22 3 T magnets using multiple T1 mapping sequences. Image and temperature data were analyzed semi-automatically. Repeatability of serial T1 was evaluated in terms of coefficient of variation (CoV), and linear mixed models were constructed to study the interplay of some of the known sources of T1 variation.

RESULTS

Over 2 years, phantom gel integrity remained intact (no rips/tears), B0 and B1 homogenous, and "reference" T1 stable compared to baseline (% change at 1.5 T, 1.95 ± 1.39%; 3 T, 2.22 ± 1.44%). Per degrees Celsius, 1.5 T, T1 (MOLLI 5s(3s)3s) increased by 11.4 ms in long native blood tubes and decreased by 1.2 ms in short post-contrast myocardium tubes. Agreement of estimated T1 times with "reference" T1 was similar across Siemens and Philips CMR systems at both field strengths (adjusted R2 ranges for both field strengths, 0.99-1.00). Over 1 year, many 1.5 T and 3 T sequences/magnets were repeatable with mean CoVs < 1 and 2% respectively. Repeatability was narrower for 1.5 T over 3 T. Within T1MES repeatability for native T1 was narrow for several sequences, for example, at 1.5 T, Siemens MOLLI 5s(3s)3s prototype number 448B (mean CoV = 0.27%) and Philips modified Look-Locker inversion recovery (MOLLI) 3s(3s)5s (CoV 0.54%), and at 3 T, Philips MOLLI 3b(3s)5b (CoV 0.33%) and Siemens shortened MOLLI (ShMOLLI) prototype 780C (CoV 0.69%). After adjusting for temperature and field strength, it was found that the T1 mapping sequence and scanner software version (both P < 0.001 at 1.5 T and 3 T), and to a lesser extent the scanner model (P = 0.011, 1.5 T only), had the greatest influence on T1 across multiple centers.

CONCLUSION

The T1MES CE/FDA approved phantom is a robust quality assurance device. In a multi-center setting, T1 mapping had performance differences between field strengths, sequences, scanner software versions, and manufacturers. However, several specific combinations of field strength, sequence, and scanner are highly repeatable, and thus, have potential to provide standardized assessment of T1 times for clinical use, although temperature correction is required for native T1 tubes at least.

Early T1 Myocardial MRI Mapping: Value in Detecting Myocardial Hyperemia in Acute Myocarditis

Background Hyperemia is a key component of acute myocarditis (AM). Early gadolinium uptake because of myocardial hyperemia may be quantified by using T1 mapping. Purpose To evaluate the value of early enhanced T1 shortening for the diagnosis of acute myocarditis. Materials and Methods Study participants suspected of having AM and healthy control (HC) participants were prospectively enrolled from September 2016 to May 2019. Participants underwent 1.5-T cardiac MRI including Lake Louise criteria, T2 mapping, native T1, and extracellular volume, with the addition of early enhanced T1 mapping (2 minutes after intravenous administration of 0.15 mmol/kg gadobutrol). Color-coded maps of the percentage of T1 shortening from precontrast to early postcontrast were generated. Optimal early T1 shortening cut-off value and its diagnostic performance in the identification of acute myocarditis were calculated. Results Forty-five study participants with AM (median age, 40 years; interquartile range [IQR], 20-46 years; 22 women) diagnosed according to multidisciplinary clinical evaluation, electrocardiography, laboratory test, echocardiography, cardiac MRI, and coronary CT and/or invasive angiography. Findings were confirmed by endomyocardial biopsy in 64% (29 of 45) of participants. MRI parameters were compared with 19 HC participants (median age, 39 years; IQR, 28-46 years; seven women). Median early T1 shortening was 75% (IQR, 72%-78%) in participants with AM versus 65% (IQR, 61%-66%) in HC participants (P < .001). Early T1 shortening showed high diagnostic performance (area under the receiver operating characteristic curve [AUC], 0.97; 95% confidence interval [CI]: 0.94, 1.00) and excellent interobserver reproducibility (intraclass correlation coefficient: 0.98; 95% CI: 0.96, 1.00). Early T1 shortening of 70% or greater identified acute myocarditis with 93% sensitivity, 100% specificity, and 95% diagnostic accuracy. Early T1 shortening had better diagnostic performance than late percentage T1 shortening (AUC, 0.97 vs 0.90, respectively; P = .03) and extracellular volume (AUC, 0.97 vs 0.88, respectively; P = .046), and similar to native T1 (AUC, 0.97 vs 0.93, respectively; P = .63) and T2 mapping (AUC, 0.97 vs 0.97, respectively; P > .99). Conclusion In this proof-of-concept study, percentage of T1 shortening at early enhanced T1 mapping showed high accuracy for the diagnosis of acute myocarditis. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by De Cecco and Monti in this issue.

Short-course treatment outcomes and adverse events in adults and children-adolescents with MDR-TB in Niger

<sec id="st1"> <title>SETTING</title> Niger National Tuberculosis Programme. </sec> <sec id="st2"> <title>OBJECTIVE</title> To describe the outcomes and adverse events (AEs) in a cohort of adults, children and adolescents with multidrug-resistant tuberculosis (MDR-TB) who were treated with the 'short-course regimen'. </sec> <sec id="st3"> <title>DESIGN</title> The regimen comprised an intensive phase of 4-6 months with kanamycin, medium-high dose of isoniazid and prothionamide, and high doses of gatifloxacin, clofazimine, ethambutol and pyrazinamide throughout. Sixty-five patients were treated with a regimen of 12-14 months and 55 patients with a regimen of 9-11 months. </sec> <sec id="st4"> <title>RESULTS</title> Of the 120 patients evaluated, 110 (92%) were adults (median age 31 years) and 10 (8%) were children or adolescents (median age 17 years). The treatment success rate was respectively 88% and 83% with the 9-month regimen, and 90% and 75% with the 12-month regimen in adults and children/adolescents. Initial resistance to ethambutol and prothionamide did not affect treatment success rates but resistance to fluoroquinolones did, although this was not statistically significant. Vomiting was the most frequently encountered AE, followed by ototoxicity and hepatotoxicity. AEs experienced were mild or moderate in severity in most patients, and did not lead to treatment interruption. </sec> <sec id="st5"> <title>CONCLUSION</title> These results confirm the programmatic effectiveness and tolerability of the shorter regimen in second-line drug-naïve patients. </sec>.

Mid-term repair durability after MitraClip implantation in patients with functional mitral regurgitation

BACKGROUND

The aim of this study was to identify variables that are associated with the durability of percutaneous repair of secondary mitral regurgitation at 6-month follow-up.

METHODS AND RESULTS

Thirty-five consecutive patients with functional mitral regurgitation scheduled for MitraClip implant were enrolled. Left ventricular (LV) volumes and function and mitral valve characteristics were assessed before and immediately after MitraClip implantation using three-dimensional transesophageal echocardiography. Five patients with an unsuccessful procedure were excluded. The other patients were subdivided according to repair durability: group 1 with a durable repair (19 patients, 65%) and group 2 with significant mitral regurgitation recurrence (11 patients, 35%). At baseline, group 1 patients had smaller and more elliptical mitral valve annulus (1055 ± 241 vs. 1273 ± 359 mm, P = 0.02 and 125 ± 11 vs. 117 ± 16%, P = 0.02), a smaller left atrial volume (54.1 ± 26 vs. 71.5 ± 20 ml, P = 0.005) and lower systolic pulmonary artery pressure (38 ± 11 vs. 49 ± 12 mmHg, P = 0.03). Baseline LV end systolic volume had a linear correlation with the 3D annulus area (P = 0.048) and an inverse correlation with annulus ellipticity (P = 0.021). Group 1 patients showed an increase in annulus ellipticity after MitraClip (125 ± 17 vs. 141 ± 23%, P = 0.014).

CONCLUSION

Percutaneous mitral valve repair leads to a significant and stable mitral regurgitation reduction in a large number of patients. Annulus dimensions and remodeling as well as left atrial area and pulmonary hypertension seem to be associated with durability of the procedure.

1634 3D transoesofageal echocardiography in detection of anterior leaflet laceration during mitraclip implantation

Background

MitraClip is a percutaneous way of treatment of mitral regurgitation. Recent trials demonstrate its value in modifying prognosis of patients with functional mitral regurgitation. During MitraClip implant imaging with 3D TEE is mandatory to guide the procedure and monitoring the results. Unfortunately, laceration of mitral leaflets is a well-described complication of Percutaneous Mitral valve repair by implantation of MitraClip. 3D TEE can be useful even to detect complication of the procedure and in particular leaflets lacerations. Here we describe a case where 3D TEE was capable to recognize and visualize a laceration in the anterior leaflet (AL) and we assume some mechanisms leading to this complication.

Methods

An 83 years old man with post-ischemic severe functional mitral regurgitation underwent to MitraClip implantation. The mitral valve shows a severe tenting and annulus was deformed and dilated.

The procedure was performed under fluoroscopic and 3D TEE guidance (Philips iE33). Due to the large central regurgitation and large coaptation gap, we decide to implant MitraClip XTR, this is the larger device 5 mm longer.

Results

A single MitraClip XTR was implanted in the central scallop (A2-P2) in the region of the larger jet, after device positioning a further jet was detected in the region of implant and the original jet was unchanged.

Using 3D color complete volume and X-plane reconstructions we recognize that the jet originates between the clip and the basal aspects of AL. Without color Doppler in 3D zoom and X plane reconstruction, a continuum solution was suspected in the body of AL but the shadow of the delivery system partially masked the region. After removal of the device, perforation of AL was clearly depicted also with 3D zoom without color Doppler. The patient was surgically treated and inspection confirmed the laceration and shows a worn thin AL. The laceration of AL can be caused by the tension on a thinned tissue carried out by the large device. The severe tethering and annular dilatation with a marked distance between anterior and posterior leaflet at the tip of the device may have been a determinant factor in the tear occurrence.

Conclusion

3D TEE can clearly depict lacerations of leaflets during MitraClip implantation. Preoperative extensive analysis of valve geometry and inspection of leaflets searching for a thinned region can avoid intraoperative complications. The distance between leaflets at the expected tips of the MitraClip can be a predictive parameter of tension applied on the leaflets and of the risk of tearing.

Abstract 1634 Figure. Image 1

1177Insights on mitochondrial energetics in obstructive hypertrophic cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy, heterogeneous in phenotype and clinical course. The genotype-phenotype relationship and associated molecular mechanisms are still incompletely understood. In the HCM milieu, increased energy cost of force production, impairing performance and mitochondrial function, may be associated to patients' genotype and/or phenotype.

Purpose

To determine abnormalities in mitochondrial energetics in HCM and their possible relationship with genotype and clinical phenotype of patients.

Methods

Septal myectomies from characterized patients with obstructive HCM (HOCM, n=18) and donor hearts discarded from transplantation (CTRL, n=8) have been compared. HOCM patients were screened and demographic, clinical and instrumental data (routine ECG, echocardiography and cardiac magnetic resonance-CMR) were collected.

Genetic analysis was performed on total DNA extracted from myectomies by NGS on MiSeq platform using the TruSight Cardio Sequencing kit and testing a panel of 26 genes.

Activity and amount of mitochondrial enzymes generating/scavenging reactive oxygen species were investigated.

Results

Within the HOCM cohort 30% of patients was bearing mutations in sarcomeric genes associated with HCM.

The amount and/or activity of mitochondrial Complex I NADH dehydrogenase, of SOD2 and (m)-aconitase were upregulated in HOCM vs. CTRL. NADH dehydrogenase level was inversely correlated with the degree of mitral valve regurgitation and mitral valve backward volume by CMR (Spearman R=−0.5 and −0.8, respectively).

The Complex V enzyme ATP synthase activity decreased, whilst its amount was comparable in HOCM vs. CTRL. Analogously the SOD1 activity was similar in HOCM and CTRL.

No difference in mitochondrial DNA (mtDNA) copy number was found.

Results were unrelated to HCM-associated mutations.

Conclusions

HOCM hearts are characterized by mitochondrial hyperactivity aimed at quenching reactive oxygen species, but decreased ATP synthase activity. Overall, these data suggest an abnormal mitochondrial activity in the myocardium of HOCM patients independent of the presence of HCM-associated mutations. Moreover, our results underpin the markedly abnormal cellular energetics of HOCM, identifying potential therapeutic targets.

Acknowledgement/Funding

NET-2011-02347173, Italian Minister of Health

P4571PFA-100, a test of platelet adhesion/aggregation, predicts cardiovascular events after an acute coronary syndrome and can help in the decision-making for dual antiplatelet extension

Background

The dual antiplatelet therapy (DAPT) duration is a matter of great interest among cardiologists. Because of the conflicting evidences and the necessity to balance the reduction in major cardiac events (MACE) occurrence and the risk of major bleedings after an acute coronary syndrome (ACS), there is a general consensus on prolonging DAPT on an individual basis. There is less consensus on which parameters are to be evaluated. Nowadays tests of platelet reactivity are not included in the decision-making. Few data are available on the prognostic value of aspirin response tests that are sensitive to other mediators of platelet adhesion and aggregation in vivo under flow conditions.

Purpose

To demonstrate the role of the Platelet Function Analyzer (PFA-100) Collagen/Epinephrine (CEPI) cartridge, which is very sensitive to von Willebrand factor (VWF) levels, an emerging vascular risk factor, in risk stratification in ACS patients undergoing percutaneous coronary intervention (PCI).

Methods

We measured platelet reactivity by PFA-100 CEPI cartridges in a prospective cohort of 928 patients admitted for ACS between January 2006 to December 2009 and urgently treated by PCI at day 6±1 after admission. All the patients were treated with aspirin and clopidogrel according to current standard of that time.

Results

High platelet reactivity (HPR) defined as PFA-100 values <190”was found in 307 (33%) patients. No significant differences were found in demographic, angiographic and biochemical characteristics of both populations (PFA-100 <190” and PFA-100>190”). At a mean follow up of 5±1 years patients with HPR had a significant increase in cardiac death: 12.3% vs 2.6% (hazard ratio 6.05; 95% confidence interval: 3.34–10.95; p<0.0001) and recurrence of myocardial infarction (MI): 49% vs 17% (hazard ratio 4,29; 95% confidence interval: 3,27–5,64; p<0.0001). The trend in events incidence in our cohort of patients, in line with recent evidences, was maintained beyond the first year of follow-up

Conclusions

Using a multivariable Cox-proportional hazard model, HPR was found to be an independent predictor of MACE. These results indicate that PFA-100 CEPI cartridge, which correlates well with VWF levels, may be a useful point-of-care test to stratify the cardiovascular risk after an ACS. This also underlines the additional value of this test in the decision-making about the correct extension of DAPT.

Identifying exceptional malaria occurrences in the absence of historical data in South Sudan: a method validation

Background

Detecting unusual malaria events that may require an operational intervention is challenging, especially in endemic contexts with continuous transmission such as South Sudan. Médecins Sans Frontières (MSF) utilises the classic average plus standard deviation (AV+SD) method for malaria surveillance. This and other available approaches, however, rely on antecedent data, which are often missing.

Objective

To investigate whether a method using linear regression (LR) over only 8 weeks of retrospective data could be an alternative to AV+SD.

Design

In the absence of complete historical malaria data from South Sudan, data from weekly influenza reports from 19 Norwegian counties (2006-2015) were used as a testing data set to compare the performance of the LR and the AV+SD methods. The moving epidemic method was used as the gold standard. Subsequently, the LR method was applied in a case study on malaria occurrence in MSF facilities in South Sudan (2010-2016) to identify malaria events that required a MSF response.

Results

For the Norwegian influenza data, LR and AV+SD methods did not perform differently (P > 0.05). For the South Sudanese malaria data, the LR method identified historical periods when an operational response was mounted.

Conclusion

The LR method seems a plausible alternative to the AV+SD method in situations where retrospective data are missing.

Persistence on apixaban in atrial fibrillation patients: a retrospective multicentre study

AIMS

Real-world data on treatment persistence, safety and effectiveness of non-Vitamin K antagonist oral anticoagulants (NOACs) play an important role in the assessment of risks and benefits of these drugs. Our aim was to evaluate persistence on treatment, incidence of major bleeding and incidence of a composite endpoint of major events, including all-cause death, myocardial infarction, stroke and systemic thromboembolism, during treatment with apixaban in a cohort of patients with nonvalvular atrial fibrillation (NVAF).

METHODS

In this multicentre retrospective observational study, we retrieved data from medical records of five Italian hospitals on patients with a diagnosis of NVAF who initiated apixaban between 1 January 2014 and 31 March 2016 and had a first subsequent visit at the same hospital.

RESULTS

We studied 766 patients with mean age of 74.2 (standard deviation 11.1) years and median CHADS2 and CHA2DS2VASc scores of 2.0 and 4.0, respectively. Over a median follow-up period of 339 days, persistence on treatment was 83.5% [95% confidence interval (95% CI) 75.5-89.1%]. The rate of major bleeding (per 100 person-years) was 1.15 (95% CI 0.39-1.90 per 100 person-years), while the cumulative incidence was 4.4% (95% CI 1.6-12.0). The rate of major events was 1.97 (95% CI 1.08-2.86) per 100 patient-years, with a cumulative incidence over the entire follow-up period of 7.7% (95% CI 4.6-12.8).

CONCLUSION

In real-life conditions, NVAF patients treated with apixaban show rates of treatment discontinuation and major bleedings, which are comparable to those found in the ARISTOTLE pivotal study, thus supporting its external validity.

Two-dimensional and three-dimensional cardiac magnetic resonance feature-tracking myocardial strain analysis in acute myocarditis patients with preserved ejection fraction

To explore the potential role of two- (2D) and three-dimensional (3D) cardiac magnetic resonance (CMR) feature tracking (FT) myocardial strain analysis in identifying sub-clinical myocardial systolic and diastolic dysfunction in acute myocarditis patients with preserved ejection fraction (EF). Prospective two centre study-control study. Thirty patients (9 female, 37.2 ± 11.8 years.) with a CMR diagnosis of acute myocarditis according to the Lake Louise Criteria and preserved EF (≥ 55%) were included in the analysis. CMR data from 24 healthy volunteers (11 female, 36.2 ± 12.5 years.) served as control. 2D and 3D LV tissue tracking analysis were performed in a random fashion by two double-blinded operators. Variables were checked for normality and analysed with parametric test. The baseline characteristics of myocarditis patients with preserved EF and the healthy volunteers were perfectly comparable, except for the LV mass index and T1 and T2 mapping values (p < 0.001). The results of the interobserver variability in the 2D and 3D LV CMR FT myocardial strain analysis were p > 0.42, ICC > 0.80 and η² > 0.98. There was no statistical difference in 2D and 3D global radial, circumferential and longitudinal strain peak (%) and both systolic and diastolic strain rate (1/s) between acute myocarditis with preserved EF and healthy volunteers (all p = ns). There were no difference in 2D and 3D global radial, circumferential and longitudinal strain peak and both systolic and diastolic strain rate of the LV between acute myocarditis patients with preserved ejection fraction and healthy volunteers.

Ct radiomic features of pancreatic neuroendocrine neoplasms (panNEN) are robust against delineation uncertainty

PURPOSE

The aim of this study was to quantify the impact of CT delineation uncertainty of pancreatic neuroendocrine neoplasms (panNEN) on Radiomic features (RF).

METHODS

Thirty-one previously operated patients were considered. Three expert radiologists contoured panNEN lesions on pre-surgical high-resolution contrast-enhanced CT images and contours were transferred onto pre-contrast CT. Volume agreement was quantified by the DICE index. After images resampling and re-binning, 69 RF were extracted and the impact of inter-observer variability was assessed by Intra-Class Correlation (ICC): ICC > 0.80 was considered as a threshold for "very high" inter-observer agreement.

RESULTS

The median volume was 1.3 cc (range: 0.2-110 cc); a satisfactory inter-observer volume agreement was found (mean DICE = 0.78). Only 4 RF showed ICC < 0.80 (0.48-0.73), including asphericity and three RFs (of five) of the neighborhood intensity difference matrix (NID).

CONCLUSIONS

The impact of inter-observer variability in delineating panNEN on RF was minimum, with the exception of the NID family and asphericity, showing a moderate agreement. These results support the feasibility of studies aiming to assess CT radiomic biomarkers for panNEN.