Diagnosis and treatment of transthyretin amyloidosis cardiomyopathy: A position statement of the Polish Cardiac Society

Considering the rare incidence of transthyretin amyloidosis cardiomyopathy (ATTR-CM) in Poland, patients encounter difficulties at the stages of diagnosis and treatment. For successful diagnosis, it is vital to raise the suspicion of ATTR-CM, that is, to identify typical clinical scenarios such as heart failure with preserved ejection fraction or the red flags of amyloidosis. In most cases, it is possible to establish the diagnosis on the basis of noninvasive tests. This article presents the recommended diagnostic algorithms including laboratory workup, imaging tests (in particular, isotope scanning), and genetic tests. Since ATTR-CM should be differentiated from light chain amyloidosis, we also discuss aspects related to hematological manifestations and invasive diagnosis. We describe neurological signs and symptoms in patients with amyloidosis and present therapeutic options, including the causative treatment of ATTR-CM with the only currently approved drug, tafamidis. We also discuss drugs that are being assessed in ongoing clinical trials. We outline differences in the symptomatic treatment of heart failure in ATTR-CM and recommendations for nonpharmacological treatment and monitoring of the disease. Finally, we underline the need for providing access to the causative treatment with tafamidis as part of a drug program, as in other rare diseases, so that patients with ATTR-CM can be treated according to the European Society of Cardiology guidelines on heart failure and cardiomyopathy.

Advances in Molecular Imaging in Infective Endocarditis

Infective endocarditis (IE) is a growing epidemiological challenge. Appropriate diagnosis remains difficult due to heterogenous etiopathogenesis and clinical presentation. The disease may be followed by increased mortality and numerous diverse complications. Developing molecular imaging modalities may provide additional insights into ongoing infection and support an accurate diagnosis. We present the current evidence for the diagnostic performance and indications for utilization in current guidelines of the hybrid modalities: single photon emission tomography with technetium99m-hexamethylpropyleneamine oxime-labeled autologous leukocytes (^99mTc-HMPAO-SPECT/CT) along with positron emission tomography with fluorodeoxyglucose (¹⁸F-FDG PET/CT). The role of molecular imaging in IE diagnostic work-up has been constantly growing due to technical improvements and the increasing evidence supporting its added diagnostic and prognostic value. The various underlying molecular processes of ^99mTc-HMPAO-SPECT/CT as well as ¹⁸F-FDG PET/CT translate to different imaging properties, which should be considered in clinical practice. Both techniques provide additional diagnostic value in the assessment of patients at risk of IE. Nuclear imaging should be considered in the IE diagnostic algorithm, not only for the insights gained into ongoing infection at a molecular level, but also for the determination of the optimal clinical therapeutic strategies.

To what extent does prior antimicrobial therapy affect the diagnostic performance of radiolabeled leukocyte scintigraphy in infective endocarditis?

AIMS

This prospective, single-center study sought to assess to what extent there is interference between the hybrid technique of single-photon emission tomography-computed tomography with technetium99m-hexamethylpropyleneamine oxime-labeled leukocytes (99mTc-HMPAO-SPECT/CT) and antimicrobial therapy in patients with infective endocarditis (IE).

METHODS AND RESULTS

During the years 2015-2019, we enrolled 205 consecutive adults with suspected IE, all underwent 99mTc-HMPAO-SPECT/CT. The study population was divided into those who had received antimicrobial therapy up to 30 days prior to 99mTc-HMPAO-SPECT/CT (group 1, n = 96) and those who had not (group 2, n = 109). Patients were prospectively observed for 12 ± 10 months. Group 1 presented higher positive predictive values (91.89% vs. 60.00%, = 0.001), and decreased negative predictive values (77.97% vs. 90.54%, P = 0.04). Patients treated with antimicrobial therapy displayed false-negative 99mTc-HMPAO-SPECT/CT results more often [odds ratio (OR), 4.63; 95% confidence interval (CI), 1.41-15.23, P = .01], particularly when intravenous (OR 5.37; 95% CI 1.73-16.62, P = .004), definite (OR 9.43; 95% CI 2.65-33.51, P = .001), and combination antibiotic regimens (OR 8.1; 95% CI 2.57-25.64, P = .001) had been administered.

CONCLUSION

Prior antibiotic therapy affects 99mTc-HMPAO-SPECT/CT diagnostic properties. Patients treated with antimicrobial therapy display false-negative 99mTc-HMPAO-SPECT/CT results more often, especially if intravenous, definite, or combination regimens are administered.

Mechanical extraction of implantable cardioverter-defibrillator leads with a dwell time of more than 10 years: insights from a single high-volume centre

AIMS

To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads with a dwell time of >10 years (Group A) vs. younger leads (Group B) using mechanical extraction systems.

METHODS AND RESULTS

Between October 2011 and July 2022, we performed TLE in 318 patients. Forty-six (14.4%) extracted ICD leads in 46 (14.5%) patients that had been implanted for >10 years. The median dwell time of all extracted ICD leads was 5.9 years. Cardiovascular implantable electronic device-related infection was an indication for TLE in 31.8% of patients. Complete ICD leads removal and complete procedural success in both groups were similar (95.7% in Group A vs. 99.6% in Group B, P = 0.056% and 95.6% in Group A vs. 99.6% in Group B, P = 0.056, respectively). We did not find a significant difference between major and minor complication rates in both groups (6.5% in Group A vs. 1.5% in Group B and 2.2% in Group A vs. 1.8% in Group B, P = 0.082, respectively). One death associated with the TLE procedure was recorded in Group B.

CONCLUSION

The TLE procedures involving the extraction of old ICD leads were effective and safe. The outcomes of ICD lead removal with a dwell time of >10 years did not differ significantly compared with younger ICD leads. However, extraction of older ICD leads required more frequent necessity for utilizing multiple extraction tools, more experience and versatility of the operator, and increased surgery costs.

Spectrum of transthyretin gene mutations and clinical characteristics of Polish patients with cardiac transthyretin amyloidosis

BACKGROUND

Transthyretin amyloidosis (ATTR) is a rare, life-threatening systemic disorder. We present first findings on the cardiac hereditary ATTR in Poland.

METHODS

Sixty-eight consecutive patients with suspected or known cardiac amyloidosis were evaluated, including blood tests, standard 12-lead electrocardiography (ECG) and transthoracic echocardiography. ATTR was confirmed histologically or non-invasively using 99mTc-DPD scintigraphy. Transthyretin (TTR) gene sequencing was performed.

RESULTS

In 2017-2019, 10 unrelated male patients were diagnosed with hereditary ATTR. All patients had very uncommon TTR gene mutations: 7 patients had p.Phe53Leu mutation, 2 patients had p.Glu109Lys mutation and 1 patient had p.Ala101Val mutation. The age of onset ranged from 49 to 67 years (mean [SD] age, 58.7 [6.4] years). On ECG, most patients (70%) had pseudoinfarct pattern and/or low QRS voltage. The maximal wall thickness (MWT) on echocardiography varied considerably among the patients from moderate (16 mm) to massively increased (30 mm). Most patients (90%) had decreased left ventricular ejection fraction (mean [SD], 43 [11] %). On follow-up, we observed progressive heart failure in almost all cases. The first patient with p.Phe53Leu mutation died of heart failure, the second died suddenly, the third successfully underwent combined heart and liver transplant with 15 months survival from the surgery. The patient with p.Ala101Val mutation died of stroke.

CONCLUSIONS

According to available data, this is the first time that the types of TTR mutations and the clinical characteristics of Polish patients with cardiac hereditary ATTR have been described. Previous literature data about Polish background in families with p.Phe53Leu mutation and the present results, suggest that this TTR mutation might be endemic in the Polish population.

The scintigraphic diagnosis of cardiac amyloidosis. An expert opinion endorsed by the Section of Nuclear Medicine of the Polish Cardiac Society and the Polish Nuclear Medicine Society

Amyloid transthyretin cardiomyopathy is a progressive disease that confers significant mortality. While it is relatively rare, the frequency of diagnoses has risen with the increased contribution of novel diagnostic approach over the last decade. Traditionally tissue biopsy was considered to be a gold standard for amyloidosis diagnosis. However, there are significant limitations in the wide application of this approach. A noninvasive imaging-based diagnostic algorithm has been substantially developed in recent years. Establishing radionuclide imaging standards may translate into a further enhancement of disease detection and improving prognosis in the group of patients. Therefore we present in the following document current evidence on the scintigraphic diagnosis of cardiac transthyretin amyloidosis. Moreover, we present standardized protocol for the acquisition and interpretation criteria in the scintigraphic evaluation of cardiac amyloidosis.

Genotoxicity Associated with 131I and 99mTc Exposure in Nuclear Medicine Staff: A Physical and Biological Monitoring Study

Nuclear medicine staff are constantly exposed to low doses of ionizing radiation. This study investigated the level of genotoxic effects in hospital employees exposed to routinely used ¹³¹I and ^99mTc in comparison with a control group. The study compared the results of physical and biological monitoring in peripheral blood lymphocytes. The effects of confounding factors, such as smoking status and physical activity, were also considered. Physical dosimetry monitoring revealed differences in the individual annual effective dose as measured by finger ring dosimeter and whole-body dosimeter between the ¹³¹I- and ^99mTc-exposed groups. The DNA damage studies revealed differences between the groups in terms of excess premature chromosome condensation (PCC) fragments and tail DNA. Physical activity and smoking status differentiated the investigated groups. When assessed by the level of physical activity, the highest mean values of tail DNA were observed for the ^99mTc group. When assessed by work-related physical effort, excess PCC fragments were significantly higher in the ¹³¹I group than in the control group. In the investigated groups, the tail DNA values were significantly different between non-smokers and past or current smokers, but excess PCC fragments did not significantly differ by smoking status. It is important to measure exposure to low doses of ionizing radiation and assess the potential risk from this exposure. Such investigations support the need to continue epidemiological and experimental studies to improve our understanding of the mechanisms of the health effects of radionuclides and to develop predictive models of the behavior of these complex systems in response to low-dose radiation.

The Relationship between Cardiac Magnetic Resonance-Assessed Replacement and Interstitial Fibrosis and Ventricular Arrhythmias in Hypertrophic Cardiomyopathy

Non-sustained ventricular tachycardia (nsVT) creates the electrical basis for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). We aimed to evaluate the relationship between interstitial fibrosis on cardiac magnetic resonance (CMR) and nsVT in HCM. A total of 50 HCM patients underwent CMR with a 3 T scanner to determine the presence of replacement fibrosis expressed by late gadolinium enhancement (LGE), and interstitial fibrosis expressed by native T₁, post-contrast T₁, and extracellular volume (ECV). The incidence of nsVT was assessed by Holter monitoring. We detected nsVT in 14 (28%) out of 50 HCM patients. Replacement fibrosis expressed by LGE was present in 37 (74%) patients and only showed a trend towards a differentiation between the groups with and without nsVT (p = 0.07). However, the extent of LGE was clearly higher in the nsVT group (3.8 ± 4.9% vs. 7.94 ± 4.5%, p = 0.002) and was an independent predictor of nsVT in a multivariable regression analysis (OR 1.2; 95%CI 1.02–1.4; p = 0.02). No relationship was observed between interstitial fibrosis and nsVT. To conclude, it was found that it is not the mere presence but the actual extent of LGE that determines the occurrence of nsVT in HCM patients; the role of interstitial fibrosis remains unclear.

Updates for the diagnosis and management of cardiac amyloidosis

A substantial increase in the interest in transthyretin cardiac amyloidosis (ATTR-CA) is a result of the constantly growing number of patients, the use of clear diagnostic protocols and the availability of the first selective drug for these patients. This has also raised the awareness of the disease among physicians of all specialties. The topic is particularly relevant to cardiologists, who use non-invasive multimodal imaging in their daily practice. The differential diagnosis of the causes of myocardial hypertrophy includes arterial hypertension, hypertrophic cardiomyopathy, aortic stenosis (AS), athletic heart syndrome, Fabry disease, and cardiac amyloidosis (CA). It turns out that in patients with myocardial hypertrophy >15 mm, amyloidosis is the most common cause of left ventricular (LV) hypertrophy. In parallel, CA is one of the most common infiltrative diseases leading to a clinical picture that may mimic heart failure with preserved ejection fraction (HFpEF). The accumulation of amyloid in the extracellular space impairs the diastolic function of the myocardium, which is observed as the restrictive cardiomyopathy phenotype. In advanced cases, the LV systolic function is also impaired. Moreover, protein deposits contribute to the disturbances of calcium metabolism and cell metabolism as well as to cardiotoxicity, leading to edema and damage to cardiomyocytes.

Relationship between left ventricular global longitudinal strain, infarct size and left ventricular function in patients with acute myocardial infarction in a stem cell therapy study

Introduction

It is critically important to determine the accuracy, and relationships between, non-invasive imaging modalities, such as two-dimensional echocardiography (TTE), gated single-photon emission computed tomography (SPECT) and cardiac magnetic resonance imaging (cMRI) in patients with recent acute myocardial infarction (AMI) because these are used as clinical trial endpoints. Modest improvements in the left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and infarct zone size (IS) have been reported in AMI stem cells therapy trials (SCT).

Purpose

The aim of the study was to evaluate left-ventricular global longitudinal strain (GLS) in patients with AMI enrolled to SCT and assess its relation with infarct zone, LVEF and LVEDV using multimodality imaging including TTE, cMRI and SPECT.

Methods

Twenty-eight patients (21 male, 7 female, mean age 60.0±8.7 years) with first AMI, 2–5 days after left anterior descending percutaneous coronary intervention (PCI) and IS ≥10% were enrolled. GLS was evaluated with two-dimensional speckle tracking echocardiography (aCMQ, Philips Epiq 7). Infarct zone was measured using SPECT (E.CAM, Siemens) and gadolinium-enhanced cMRI (Siemens Magnetom Sonata 1.5T). LVEF and LVEDV were assessed with TTE (Auto-ROI, Philips), SPECT (GSQUAN, Siemens) and cMRI (MASS Medis). Measurements were obtained independently by blinded analysts.

Results

Mean GLS was −11.0±2.5% and showed a positive correlation with infarct zone by SPECT and MRI, negative with TTE-LVEF and cMRI-LVEF (Figure 1) and borderline with SPECT-LVEF (r=−0.35, p=0.08). There was no correlation between GLS and TTE-LVEDV (r=−0.25, p=0.25); SPECT-LVEDV (r=−0.38, p=0.077) and MRI-LVEDV (r=−0.20, p=0.365).

Patients in the third and fourth GLS quartile had a smaller IS measured by MRI and a trend toward a smaller infarct zone by SPECT (table 1). Patients in the GLS fourth quartile had higher TTE-LVEF and a trend toward higher cMRI-LVEF compared with other quartiles.

LVEF measured with TTE and cMRI was higher compared with SPECT-LVEF (+2.6±6.8%, p=0.006 and +4.2±7.8%, p=0.030, respectively) with no difference between TTE-LVEF and MRI-LVEF (p=0.823) (Table 1).

LVEDV evaluated by SPECT and MRI was higher compared with TTE-LVEDV (+48.3±24.9 ml, +47.7±29.5 ml, both p<0.001) with no difference between SPECT-LVEDV and MRI-LVEDV (p=0.984)

Conclusions

In patients with anterior wall AMI, 2–5 days after PCI, GLS showed a good correlation with infarct zone quantified by SPECT and MRI and with LVEF measured with TTE and cMRI. GLS might thus be a valuable tool in the evaluation of myocardial injury in SCT.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland/ZDS/00564 Jagiellonian University Medical College Table 1Figure 1

Prevalence of cardiac amyloidosis in patients with unexplained left ventricle hypertrophy

Background

Amyloid cardiomyopathy (CA) it is more frequently diagnosed due to rapidly developing imaging modalities. Misfolding of transthyretin (TTR) is the source of two distinct forms of amyloidosis (ATTR): acquired wild-type (ATTRwt) and hereditary (ATTRm). Types of TTR gene variants display genetic and ethnic variability. The aim of this prospective study was to assess the prevalence and types of pathogenic genetic variants associated with ATTRm amyloidosis in patients with unexplained left ventricle (LV) hypertrophy.

Methods

We evaluated prospectively 101 consecutive patients (37 (37%) females, age: 69.7±13.6 y.o.) in years 2016–2021. Analysis included clinical data, free light chain blood immunoglobulins and urine immunofixation, transthoracic echocardiography (TTE), single-photon emission computed tomography (SPECT) with 3,3-disphono-1,2-propanodicarboxylic acid (DPD), and in selected cases cardiac or soft tissue biopsy. Patients with DPD cardiac uptake in SPECT or positive histopathology or family history of ATTR were subjected to genetic testing by an amplicon-based next-generation TTR sequencing approach.

Results

Enrolled patients presented with marked LV hypertrophy with maximum wall thickness of 18.9±4 mm. Based on performed tests 34 patients (33.7%) were diagnosed with amyloidosis, including 17 cases of light-chain amyloidosis (AL), 16 of ATTR, and 1 case of other type of amyloidosis. Overall, patients with CA presented with mean 2.6±0.9 NYHA class. In TTE there was LV maximum wall thickness of 19.5±4 mm and LV mass value index value of 182±48 g/m2, decreased global longitudinal strain value (GLS, −14.1±5%) and advanced diastolic dysfunction (EA 2.2±1.1, E/E' 22±9). Overall, there were 8 cases of ATTRwt and eight patients were diagnosed ATTRm. There were detected following types of TTR variants - c.302C>T p.(Ala101Val) in a single male patient, c.325G>A p.(Glu109Lys) in a single male patient and c.157T>C p.(Phe53Leu) in six patients. Overall, 10 patients with ATTR presented with polyneuropathy, additionally six had diagnosed carpal tunnel syndrome. All patients with ATTRm had positive family history for CA.

Conclusions

In patients with unexpected LV hypertrophy evaluated in a cardiology referral center a high number of patients may suffer from underlying CA. Types of detected TTR gene variants associated with CA included most often Phe53Leu, and rare variants Ala101Val, Glu109Lys.

Funding Acknowledgement

Type of funding sources: None.

The Diagnostic Value of 99mTc-HMPAO-Labelled White Blood Cell Scintigraphy and 18F-FDG PET/CT in Cardiac Device-Related Infective Endocarditis-A Systematic Review

(1) Background: Treatment of cardiac arrhythmias and conduction disorders with the implantation of a cardiac implantable electronic device (CIED) may lead to complications. Cardiac device-related infective endocarditis (CDRIE) stands out as being one of the most challenging in terms of its diagnosis and management. Developing molecular imaging modalities may provide additional insights into CDRIE diagnosis. (2) Methods: We performed a systematic literature review to critically appraise the evidence for the diagnostic performance of the following hybrid techniques: single photon emission tomography with technetium99m-hexamethylpropyleneamine oxime–labeled autologous leukocytes (99mTc-HMPAO-SPECT/CT) and positron emission tomography with fluorodeoxyglucose (18F-FDG PET/CT). An analysis was performed in accordance with PRISMA and GRADE criteria and included articles from PubMed, Embase and Cochrane databases. (3) Results: Initially, there were 2131 records identified which had been published between 1971–2021. Finally, 18 studies were included presenting original data on the diagnostic value of 99mTc-HMPAO-SPECT/CT or 18F-FDG PET/CT in CDRIE. Analysis showed that these molecular imaging modalities provide high diagnostic accuracy and their inclusion in diagnostic criteria improves CDRIE work-up. (4) Conclusions: 99mTc-HMPAO-SPECT/CT and 18F-FDG PET/CT provide high diagnostic value in the identification of patients at risk of CDRIE and should be considered for inclusion in the CDRIE diagnostic process.

Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Scintigraphic and echocardiographic evaluation of patients with cardiac transthyretin amyloidosis and first-degree relatives

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Pfizer Research Grant (ID#57165999)

Background

Misfolding of transthyretin (TTR) is the source of two distinct forms of amyloidosis (ATTR): acquired or wild-type (ATTRwt) and hereditary (ATTRm), which is transmitted in an autosomal dominant inheritance with a variable penetrance.  Types of transthyretin (TTR) gene mutations display genetic and ethnic variability.

Purpose

The aim of this prospective study was to assess the TTR gene variants, echocardiographic parameters and regional left ventricle 99mTc-DPD uptake among patients with ATTR and first-degree relatives.

Methods

We present data based on evaluation of first 25 patients (13 (52%) females), including 10 (40%) index patients with ATTR (age 66.4 ± 13 years) and 15 (60%) first-degree relatives who were studied between June 2020 and February 2021. Analysis included clinical data, free light chain blood immunoglobulins and urine immunofixation, transthoracic echocardiography (TTE) with global longitudinal strain (GLS) analysis, single-photon emission computed tomography (SPECT) with 3,3-disphono-1,2-propanodicarboxylic acid (DPD), genetic testing by an amplicon-based next-generation TTR sequencing approach, and in selected cases cardiac or soft tissue biopsy.

Results

Overall, 6 index patients were diagnosed with ATTRm and 4 with ATTRwt presenting mixed, cardiac or neuropathic phenotype. There were detected following types of TTR variants - Phe53Leu, Ala101Val, Glu112Lys, Glu109Lys. Nine out of 10 index patients were diagnosed with amyloid cardiomyopathy (CA) with grade 2-3 tracer uptake in SPECT and symptomatic heart failure (NYHA 2.2 ± 1.1; NT-proBNP value 2224 ± 2799 pg/ml). In both ATTRm and ATTRwt there were patients presenting with either focal or diffuse tracer pattern evaluated by SPECT technique. In TTE there was marked left ventricle (LV) hypertrophy with maximum wall thickness of 22 ± 5 mm and LV mass value index value of 382 ± 111 g/m2. All patients with CA had abnormal global longitudinal strain (GLS, -14.5 ± 5%) and diastolic dysfunction (EA 1.56 ± 0.76, E/E’ 16 ± 11). None of relatives expressed tracer uptake in scintigraphy. Overall, 5 first-degree relatives were diagnosed with Phe53Leu variant, among them two patients presented with decreased GLS value.

Conclusions

Patients with ATTR presented in TTE with LV hypertrophy, decreased GLS value, diastolic dysfunction and grade 2-3 in scintigraphy with either focal or diffuse tracer uptake in SPECT technique. None of first-degree relatives expressed increased tracer uptake in scintigraphy. However, some of relatives who were diagnosed with pathogenic TTR variant presented with decreased GLS value.

99mTc internal contaminations measurements among nuclear medicine medical personnel during ventilation - perfusion SPECT lung scans

This paper presents results of measurements of ^99mTc activity concentration in air and nuclear medical personnel blood during ventilation-perfusion SPECT lung scans. ^99mTc activity measurements were conducted at the Nuclear Medicine Department, John Paul II Hospital, Krakow. Technicians and nurses who perform examinations were equipped with personal aspirators enabling air sampling to determine the radiation exposure at their workplaces. Measurements allowed to evaluate the concentration of ^99mTc in 14 air samples and it ranged from 7800 ± 600 to 10,000 ± 1000 Bq m^-3 for air samples collected by technicians and from 390 ± 30 to 600 ± 40 Bq m^-3 for air samples collected by nurses. In addition ^99mTc concentrations in blood of medical personnel were determined in 24 samples. For technicians the maximum ^99mTc blood concentration levels reached 920 ± 70 Bq L^-1 and 1300 ± 100 Bq L^-1. In the case of nurses, the maximum estimated activity concentrations were about ten times lower, namely 71 ± 7 Bq L^-1 and 39 ± 3 Bq L^-1. Although the intakes appear to be relatively high, the resulting annual effective doses are about 34 µSv for technicians and only 2 µSv for nurses.

Evolution of left ventricular function after Wharton's jelly mesenchymal stem cells transcoronary administration: 5-year follow up in a pilot cohort of CIRCULATE-AMI Randomized Trial

Introduction

CIRCULATE-Acute Myocardial Infarction is a double-blind controlled trial randomizing (RCT) in 105 consecutive patients with their first, large AMI (cMRI-LVEF ≤45% and/or cMRI-infarct size ≥10% of LV) with successful infarct-related artery (IRA) primary percutaneous coronary intervention (pPCI) to transcoronary administration of Wharton's Jelly Mesenchymal Stem Cells (WJMSCs) vs. placebo (2:1). The pilot study cohort (PSC) preceded the RCT.

Aim

To evaluate WJMSCs long-term safety, and evolution of left-ventricular (LV) function in CIRCULATE-AMI PSC.

Material and methods

30 000 000 WJMSCs (50% labelled with 99mTc-exametazime) were administered via IRA in a ten-patient PCS (age 32–65 years, peak hs-Troponin T 17.3±9.1ng/mL and peak CK-MB 533±89U/L, cMRI-LVEF 40.3±2.7% and infarct size 20.1±2.8%) at ≈5–7 days after AMI using a cell delivery-dedicated, coronary-non-occlusive method. Other treatments were per guidelines.

WJMSCs showed an unprecedented high myocardial uptake (30.2±5.3%; 95% CI 26.9–33.5%), corresponding to ≈9×10 000 000 cells retention in the infarct zone – in absence of epicardial flow or myocardial perfusion impairment (TIMI-3 in all; cTFC 45±8 vs. 44±9, p=0.51) or any hs-Troponin T elevation. Five-year follow up included cardiac Magnetic Resonance Imaging (cMRI) (at baseline, 1 year and 3 years) and detailed echocardiography (echo) at baseline, 1 year, 3 years and 5 years.

Results

By 5 years, one patient died from a new, non-index territory AMI. There were no other cardiovascular events and MACCE that might be related to WJMSCs transplantation.

On echo (Fig), there was an increase in left ventricular ejection fraction (LVEF) between WJMSCs administration point and 1 year (37.7±2.9% vs. 48.3±2.5%, p=0.002) that was sustained at 3 years (47.2±2.6%, p=0.005 vs. baseline) and at 5 years: (44.7±3.2%, p=0.039 vs. baseline). LVEF reached a peak at 1 year after the AMI and WJMSCs transfer (Fig). cMRI data (obtained up to 3 years; 1 year 41.9±2.6% vs. 51.0±3.3%, p<0.01; 3 years 52.2±4.0%, p<0.01 vs. baseline) were consistent with the echo LVEF assessment.

Conclusions

5-year follow up in CIRCULATE-AMI PSC indicates that WJMSC transcoronary application is safe and may be associated with an LVEF improvement. The magnitude of LV increase appears to peak at 1 year, suggesting a potential role for repeated WJMSCs administration(s). Currently running double-blind RCT will provide placebo-controlled insights into the WJMSCs effect(s) on changes in LV function, remodelling, scar reduction and clinical outcomes.

Echo-LVEF evolution

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland/ZDS/00564 Jagiellonian University Medical College

The burden of atrial fibrillation and its prognostic value in patients with dilated cardiomyopathy

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia in patients with dilated cardiomyopathy (DCM). However, the epidemiology as well as clinical and prognostic significance of AF in DCM are poorly defined.

AIMS

We aimed to assess the impact and prognostic value of AF in DCM as well as to investigate the concept of AF‑induced DCM.

METHODS

Hospital records of 285 patients with DCM from 2012 to 2018 with follow-up were analyzed.

RESULTS

Atrial fibrillation was present in 89 patients (31%). They were older, more frequently male, hadhigher body mass index, New York Heart Association class, heart rate (HR), creatinine levels, and larger atria (all P < 0.05) than patients without AF. During follow‑up (mean [SD], 35 [24] months), death occurred in 20 of the 82 available patients with AF and 22 of the 188 patients without AF (24% and 12%, respectively; P = 0.007). Atrial fibrillation was independently associated with a worse outcome (hazard ratio, 2.4; 95% CI, 1.3-4.3) and was found to be the major cause of DCM in 21 patients (24%). The diagnostic accuracy of the most optimal predictive model for AF‑induced DCM was 0.935 (95% CI, 0.903-0.967). Despite numerical differences, survival was similar in DCM patients with and without AF (P = 0.15).

CONCLUSIONS

Almost one‑third of patients with DCM had AF. Most of the parameters analyzed differed between patients with and without AF, and AF was found to be an independent prognostic factor of DCM. One‑fourth of patients with DCM and AF met the diagnostic criteria for AF‑induced DCM.

P1294 Distribution of infective lesions detected with radiolabeled leucocyte scintigraphy in carriers of various types of cardiac implantable electronic devices

Funding Acknowledgements

Grant from the Jagiellonian University Medical College (K/DSC/004383)

Background

The rate of cardiac device-related infective endocarditis (CDRIE) is increasing disproportionately to the rising rate of device implantations. Hybrid technique of single photon emission tomography and computed tomography with technetium99m-hexamethylpropyleneamine oxime–labeled autologous leukocytes (99mTc-HMPAO-SPECT/CT) is a developing technique in patients with suspected endocarditis.

Purpose

The aim of this study was to evaluate distribution of both intracardiac and extracardiac inflammatory lesions detected with 99mTc-HMPAO-SPECT/CT in patients with suspected CDRIE depending on the type of carried cardiac implantable electronic device (CIED).

Methods

During years 2015-2018, we prospectively enrolled 103 consecutive patients with suspected CDRIE (70 males, 61 ± 18 y.o.). Patients undergone evaluation according to current ESC guidelines and subsequently 99mTc-HMPAO-SPECT/CT. Scans were classified as positive in the presence of abnormal tracer uptake involving cardiac or/and intravascular sections of device electrodes. Patients were divided to group 1 with implanted pacemakers (61 patients) and group 2 including 42 carriers of either an implantable cardioverter-defibrillator (ICD) or a cardiac resynchronization therapy device (CRT).

Results

Overall, in group 2 there was a higher prevalence of diabetes mellitus, coronary artery disease and heart failure (p &lt; 0.05). Moreover, group 2 had worse functional status with higher NYHA class (2.8 ± 0.9 vs. 1.7 ± 1, p = 0.001), NT-proBNP levels (5027 ± 5813 vs. 2320 ± 4279, p = 0.0004) and lower left ventricle ejection fraction (29 ± 12 vs. 54 ± 13, p = 0.0001). Both groups had comparable values of C-reactive protein, procalcitonin and white blood cells (p &gt; 0.05). The mean time since device implantation was 3.4 ± 3.8 years and on average patients had 1.9 implanted electrodes. Patients from group 2 presented more often with 99mTc-HMPAO-SPECT/CT positive for CDRIE (45% vs. 26%, p = 0.045). Frequency of lesions consistent with infection localized within the intravascular section of the electrode and the CIED lodge did not differ between groups (p &gt; 0.05). However, inflammatory foci in the vicinity of the intracardiac portion of the electrode were detected more often in group 2 (43% vs. 21%, p = 0.019). Overall, extracardiac inflammatory foci were found in 34% of patients, with most common localization in the gastrointestinal tract (13%) and musculoskeletal system (8%). Both prevalence and localization of extracardiac foci did not differ between groups (39% vs. 24%, p = 0.16).

Conclusions

Prevalence and localization of intracardiac inflammatory foci typical for CDRIE detected with 99mTc-HMPAO-SPECT/CT is different in patients with various types of CIEDs. Patients with implanted ICD or CRT have worse functional status and present more frequently with radiotracer uptake typical for CDRIE in 99mTc-HMPAO-SPECT/CT. Distribution of extracardiac inflammatory lesions does not differ between groups.

P967 Profile of arrhythmia in pregnant women with different WHO class is similar

Background

Arrhythmia is the most common cardiac complications during pregnancy especially in women with structural heart disease. Methods: Since January 2015 till December 2018 the consecutive 150 pregnant women with different maternal cardiovascular risk according to WHO classification: 100 in WHO I and II (gr 1);50 in WHO II-III, III, IV were enrolled. Each woman had 24-hour Holter- ECG monitoring during at least 2 trimester. Results: Except mild ventricular arrhythmia i.e ventricular extrasystole &gt; 1000 per 24 hour, which occured more often in group1, we did not observe any significant differences in arrhythmic profile of pregnant women with different WHO risk classification (table 1). Delivery: Caesarean section was more frequent in gr 2 (86% vs 62%) but rate of stillbirths were similar among groups. Maternal death did not occurred, there was 2 (4%) foetal mortality in gr 2. Mean duration of pregnancy, children length and birthweight were significantly higher in gr 1(table1).Conclusion: Arrhythmias during pregnancy occurred particularly on the substrate of structural heart disease. According to our observation pregnant women with potentially higher risk of maternal cardiovascular events did not reveal significant arrhythmia including conduction disturbances in comparison to women in WHO class I or II.

Holter monitoring resultes Parameter Group 1; no 100 Group 2, no 50 P value Age 31(27-34) 31(28-33) 0,36 NYHA 1,34 1,32 0,76 SVE &gt; 1000/d 2(2,15%) 2(5,88%) 0,28 VE &gt; 1000/d 20(19,23%) 3(5,88%) 0,03 SVT 6(6,5%) 4(11,43%) 0,35 sVT 1(1%) 0 0,65 nsVT 8(8,79%) 3(8,57%) 0,96 AF/AT 0 2(4%) 0,54 AV I 5(5%) 3(6%) 0,32 AV II Mobitz I 1(1,1%) 1(2%) 0,53 AV III 0 1(2%) 0,41 Duration (weeks) 39(38-40) 37,1 0,017 Weight (grams) 3220+-641 2840+-767 g 0,02 Caesareon section 54(62%) 33(86%) 0,00 Stillbirths 22(21,57% 8(17,78%) 0,6

The role of 99mTc-HMPAO-labelled white blood cell scintigraphy in the diagnosis of cardiac device-related infective endocarditis

Aims

The hybrid technique of single-photon emission tomography and computed tomography with technetium99m-hexamethylpropyleneamine oxime–labelled leucocytes (99mTc-HMPAO-SPECT/CT) is an emerging diagnostic technique in patients with cardiac device-related infective endocarditis (CDRIE). This prospective study assessed the 99mTc-HMPAO-SPECT/CT diagnostic profile and its added value to the modified Duke criteria (mDuke) in CDRIE diagnostic work-up.

Methods and results

The study examined 103 consecutive patients with suspected CDRIE, who underwent 99mTc-HMPAO-SPECT/CT. Diagnostic accuracy was calculated based on a final clinical CDRIE diagnosis, including microbiology, echocardiography, and a 6-month follow-up. Subsequently, we compared the diagnostic value of the initial mDuke classification with a classification including 99mTc-HMPAO-SPECT/CT positive results as an additional major CDRIE criterion: mDuke-SPECT/CT.

Overall, CDRIE was diagnosed in 31 (31%) patients, whereas 35 (34%) 99mTc-HMPAO-SPECT/CT were positive. 99mTc-HMPAO-SPECT/CT was characterized by 86% accuracy, 0.69 Cohen’s kappa coefficient, 84% sensitivity, 88% specificity, 93% negative, and 74% positive predictive values. The original mDuke displayed 83% accuracy, 0.52 kappa, whereas mDuke-SPECT/CT had 88% accuracy, and 0.73 kappa. Compared with mDuke, mDuke-SPECT/CT showed significantly higher sensitivity (87% vs. 48%, P &lt; 0.001). According to mDuke, 49.5% of patients had possible CDRIE, and after reclassification, that figure dropped to 37%. Furthermore, having assessed the diagnosis categorization improvement following the incorporation of 99mTc-HMPAO-SPECT/CT, the net reclassification index value was found to be 31.4%.

Conclusion

In patients with CDRIE, 99mTc-HMPAO-SPECT/CT provides high diagnostic accuracy, whereas a negative scan excludes CDRIE with high probability. Inclusion of 99mTc-HMPAO-SPECT/CT into mDuke diagnostic criteria yields significantly higher sensitivity and a reduction in possible CDRIE diagnoses.

P774Transcoronary transfer of Wharton's jelly mesenchymal pluripotent stem cells in patients with chronic ischaemic heart failure shows safety and unprecedented high-grade myocardial uptake

Background

Chronic ischaemic heart failure (CIHF) remains an important health problem on the patient/family- and society level. In animal models, Wharton's jelly (umbilical cord matrix) multipotent stem cells (WJMSCs) effectively promote angiogenesis, can differentiate to cardiomyocytes, and drive functional myocardial regeneration. Effective uptake of regenerative cells in ischaemic-impaired tissue is fundamental for any therapeutic effect.

Purpose

To evaluate safety and myocardial uptake of WJMSCs transcoronary transfer in CIHF applied as a novel myocardial regeneration strategy employing allogenic yet hypo-immunogenic, off-the-shelf “unlimited” source of therapeutic cells (NCT03418233 pilot cohort).

Material and methods

In ten consecutive patients (age 62.6±2.5), with stable CIHF and no current need for revascularization (LVEF 29.3±3% by echo and 26.3±6% by SPECT; NT-proBNP 1746±329pg/mL; myocardial scar tissue 39.9±3.9% by SPECT) and patency of at least two major native coronary arteries or by-pass graft(s), the CardioCell Investigational Medical Product, based on 30x106 WJMSCs, was administered to viable yet hypokinetic segments using a novel algorithm including a dedicated catheter for transcoronary delivery of cellular therapies. The cells were labeled with 99mTc-extametazime to routinely evaluate their myocardial uptake magnitude.

Results

No symptoms or signs of novel myocardial ischaemia occurred with cell delivery and no patient showed any adverse periprocedural events. One hour after administration, myocardial WJMSCs uptake (SPECT) was 40.3±6%; see Fig for a typical raw data image. By 6 months there were no adverse events in the study cohort.

Figure 1

Conclusions

This work indicates safety and unprecedented high-grade myocardial uptake of WJMSCs in CIHF patients. Together with animal data, this provides basis for continued assessment of this strategy in an endpoint-powered randomized controlled clinical trial employing CardioCell as an “unlimited” off-the-shelf cellular therapy strategy.

Acknowledgement/Funding

K/ZDS/005644 and 265761 (National Centre for Research and Development STRATEGMED)

P3362Added value of radiolabeled leukocyte scintigraphy to cardiac device-related infective endocarditis diagnostic criteria

Background

Radiolabeled leukocyte scintigraphy – hybrid technique of single photon emission tomography and computed tomography with application of technetium99m-hexamethylpropyleneamine oxime-labeled autologous leukocytes (99mTc-HMPAO-SPECT/CT) is an emerging technique in patients with suspected cardiac device-related infective endocarditis (CDRIE).

Purpose

The aim of this prospective study was to assess 99mTc-HMPAO-SPECT/CT added value to modified Duke criteria (mDuke) in CDRIE diagnostic process.

Methods

During the period 2015–2018, we enrolled 103 consecutive patients with suspected CDRIE [70 males (68%), mean age: 61±18 years, mean left ventricle ejection fraction value: 44±17%)]. All patients underwent clinical, microbiologic, echocardiographic evaluation according to ESC guidelines and additionally 99mTc-HMPAO-SPECT/CT (370–740 MBq). Scans were classified as positive in the presence of abnormal tracer uptake involving cardiac and intravascular sections of device electrodes. In the analysis, we added positive 99mTc-HMPAO-SPECT/CT result as an additional major criterion to mDuke classification. Additionally, we compared the diagnostic value of the mDuke classification including 99mTc-HMPAO-SPECT/CT (mDuke-SPET/CT) with the original mDuke classification. The sensitivity and specificity of those two scales were compared with McNemar's test. Diagnostic accuracy was calculated based on final clinical CDRIE diagnosis, including microbiology, echocardiography and 6 month-long follow-up with subsequent outpatient visit.

Results

Overall 58% patients had pacemakers, 25% had implantable cardioverter defibrillators, 16% had resynchronization therapy and 1% had an epicardial lead. Mean time from device implantation was 3.4±3.8 years. Final CDRIE diagnosis was established in 31 (30%) patients. The most common pathogens causing CDRIE were Enterococci (39%) and Staphylococci (35%).

According to the original mDuke classification 16.5% patients had definite CDRIE, 49.5% had possible and in 34% CDRIE was excluded. Overall, 34% of 99mTc-HMPAO-SPECT/CT scans were positive for CDRIE. After reclassification, according to mDuke-SPET/CT the proportion of patients with definite CDRIE increased to 34%, whereas in 37% patients CDRIE was possible and in 29% cases CDRIE was excluded.

Overall, mDuke was characterized with 83% accuracy, 0.52 Cohen's kappa coefficient, 48% sensitivity, 97% specificity, 81% negative predictive value (NPV), 88% positive predictive value (PPV). Whereas mDuke-SPET/CT had 88% accuracy, 0.73 Cohen's kappa coefficient, 87% sensitivity, 89% specificity, 94% NPV, 77% PPV. Compared to mDuke, mDuke-SPET/CT had significantly higher sensitivity (p<0.001).

Conclusions

In patients with suspected CDRIE inclusion of positive radiolabeled leukocyte scintigraphy into modified Duke diagnostic criteria yields significantly higher sensitivity, as well as modest reduction of possible CDRIE diagnoses.

Acknowledgement/Funding

Grant from the Jagiellonian University Medical College (K/DSC/004383)

P4604Insights into left ventricular remodelling and clinical outcomes after Wharton's jelly multipotent stem cells transcoronary administration in a pilot cohort of CIRCULATE-AMI Trial (NCT03404063)

Introduction

CIRCULATE-Acute Myocardial Infarction Trial (NCT03404063) is a double-blind controlled trial (RCT) that is randomizing consecutive patients with their first, large AMI (LVEF ≤45% and/or cMRI -infarct size ≥10% of LV) successfully treated by infarct-related artery (IRA) primary percutaneous coronary intervention reperfusion (TIMI ≥2) to transcoronary administration of Wharton Jelly Multipotent Stem Cells (WJMSCs) vs. placebo (2:1), preceded by evaluation of safety, WJMSCs myocardial uptake, and echocardiographic, cMRI and SPECT left ventricular remodelling and hemodynamic changes in pilot study cohort (PSC).

Purpose

To evaluate LV remodelling and hemodynamic features following WJMSCs transplantation in CIRCULATE-AMI PSC.

Methods

Ten consecutive patients (age 32–65 years) were administered 30 000 000 WJMSCs via the infarct-related artery at ≈5–7 days after AMI using transradial approach and a coronary-non-occlusive catheter dedicated to cell delivery. Within 3 years of follow up SPECT was performed at baseline and 1 year, echo and cMRI were performed at baseline, 1 year and 3 years.

Results

3-year observation (cMRI) shows a significant decrease of median left ventricular mass (LVM) between WJMSCs administration and 1 year 140 g (IQR 128–150) vs. 97 g (95–128), that is sustained at 3 years 93 g (80–119), p<0,001. There were no significant changes of left ventriular end-diastolic volume (LVEDV) in all diagnostic methods: SPECT baseline vs. 1 year (157.1±27.1 ml vs. 174±24 ml); cMRI baseline vs. 1 year vs. 3 years (171.6±17.7 ml vs. 198.2±23.4 ml vs. 181.9±17.6 ml) and Echo (137±13.3 ml vs. 135±2.9 ml vs. 148±21.8 ml), p value >0,05 for all. Furthermore, there was a significant increase in stroke volume measured by SPECT baseline vs. 1 year (53.3±7.6 ml vs. 68.2±5.2ml); cMRI baseline vs. 1 year vs. 3 years (72.7±5.2 ml vs. 96.9±8.1 ml vs. 93.2±7.8 ml) and Echo (64.3±2.9 ml vs. 68.8±4.1 ml vs. 81.9±7.1 ml), p<0,05 for all. By 3 years there was one non-index territory AMI. There were no other adverse events in the study cohort.

cMRI Left Ventricular Mass evolution

Conclusions

Long-term follow up in CIRCULATE-AMI PSC suggests that transcoronary administration of WJMSCs in a recent large AMI in humans might be associated with an inhibition of LV adverse remodelling and a significant hemodynamic improvement. Our currently running randomized double-blind controlled trial will verify LV remodelling evolution in WJMSCs-treated patients.

Acknowledgement/Funding

K/ZDS/00564 Jagiellonian University Medical College; STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland

P1471Multimodality imaging of left ventricular function and volumes in patients with acute and chronic myocardial injury - Novel insights

Introduction

The three main techniques to evaluate myocardial function and volumes: two-dimensional echocardiography (TTE), gated single photon emission computed tomography (SPECT) and cardiac magnetic resonance imaging (cMRI), have important differences in accessibility and practicality.

Purpose

We aimed to evaluate: TTE, SPECT and cMRI in the measurement of left ventricular ejection fraction (LVEF), left ventricular end-diastolic (LVEDV) and left ventricular end-systolic volumes (LVESV) in patients with acute and chronic myocardial ischemic injury.

Methods

Consecutive patients with first large acute myocardial infarction (AMI) [LVEF ≤45% and/or cMRI infarct size ≥10% of left ventricle, 2–5 days after pPCI, n=10] and patients with chronic ischemic heart failure (CIHF) [LVEF ≤45% by SPECT, NYHA class II or III, n=10] were enrolled. Multimodality imaging using the study techniques was performed within 36 hours.

Results

LVEF measured with TTE, SPECT and cMRI did not differ between both groups (AMI: 41±2.5%, 37.9±2.7%, 41±2.7%; p=0.07, CHF: 29.6±3.2%, 29.7±3.0%, 32.9±4.9%; p=0.42). LVEDV and LVESV evaluated by SPECT were +33.6%, +38.2% higher in the AMI group and +40.7%, 40.4% higher in the CIHF group compared with TTE (p<0.001). When measured with cMRI they were +52.1%, +50.5%, +31.5%, +25.5% higher (AMI, CIHF group, respectively), compared with TTE (p<0.001).

There was a strong positive correlation between LVEF derived from TTE and SPECT (r=0.81, AMI; r=0.92, CIHF), TTE and cMRI (r=0.89, AMI; r=0.75, CIHF), SPECT and cMRI (r=0.88, AMI; r=0.76, CIHF; all p<0.01). As well as for LVEDV (r=0.79, 0.88; 0.90, 0.85; 0.76, 0.87; all p<0.05) and LVESV measurements (r=0.90, 0.91; 0.94, 0.89; 0.85, 0.85, all p<0.05).

Figure 1

Conclusions

There is a strong correlations between TTE, SPECT, and cMRI in the assessment of left ventricular function in patients with AMI or CIHF. However, TTE appears to significantly underestimate left ventricular volumes in relation to SPECT and cMRI.

Inflammatory markers in the diagnostic workup of pacemaker- and defibrillator‑related infections in patients referred for transvenous lead extraction

BACKGROUND

Infectious complications can be life‑threatening in patients with permanent transvenous pacemakers and their diagnosis can be challenging.

AIMS

The aim of the study was to assess the diagnostic utility of white blood cell (WBC) count and C‑reactive protein (CRP) concentrations in infectious complications in patients with cardiac pacemakers.

METHODS

The prospective study included patients who underwent transvenous lead extraction (TLE) due to various indications. The diagnosis of lead‑dependent infective endocarditis (LDIE) was based on the modified Duke criteria, and the diagnosis of local infection was based on symptoms related to device pocket. The study population consisted of 640 patients: 63 (9.9%) with LDIE, 61 (9.5%) with local infection, and 516 controls (80.6%) referred for TLE due to noninfectious indications. We evaluated WBC count and CRP concentrations in each group of patients and assessed the predictive value of these tests for the diagnosis of LDIE and local infection.

RESULTS

Patients with local infection did not differ in terms of median WBC and CRP values compared with controls (P = 0.99 and P = 0.13, respectively), whereas patients with LDIE had higher median WBC count and CRP level (P <0.001 and P <0.001, respectively). In the LDIE group, WBC diagnostic test showed 46.0% sensitivity, 95.3% specificity, 90.5% accuracy, 51.8% positive predictive value, and 94.2% negative predictive value. The diagnostic test based on CRP levels showed 84.1% sensitivity, 81.8% specificity, 82.0% accuracy, 33.5% positive predictive value, and 97.9% negative predictive value.

CONCLUSIONS

In patients undergoing TLE due to infectious indications, inflammatory markers (WBC count, CRP level) were within normal range in the local‑infection group and markedly elevated in the LDIE group. Inflammatory markers were useful to determine the extent of the infection in patients with local infection.

99mTc activity concentrations in room air and resulting internal contamination of medical personnel during ventilation-perfusion lung scans

This paper presents the results of measurements of ^99mTc activity concentrations in indoor air in a nuclear medicine department and resulting estimated ^99mTc intake by medical personnel. ^99mTc air activity measurements were conducted at the Nuclear Medicine Department, John Paul II Hospital, Krakow, Poland, during ventilation-perfusion SPECT lung scans. Technetium from the air was collected by means of a mobile aerosol sampler with a Petryanov filter operating at an average flow rate of 10 dm³ min^-1. Measured activities ranged from 99 ± 11 to 6.1 ± 0.5 kBq m^-3. The resulting daily average intake of ^99mTc by medical staff was estimated to be 5.4 kBq, 4.4 kBq, 3.0 kBq and 2.5 kBq, respectively, for male technicians, female technicians, male nurses and female nurses. Corresponding annual effective doses were 1.6 µSv for technicians and 1 µSv for nurses. The highest equivalent dose values were determined for extrathoracic (ET) airways: 5 µSv and 10 µSv for nurses and technicians, respectively. It is concluded that estimated annual absorbed doses are over three orders of magnitude lower than the dose limit established in the Polish Atomic Law Act and in recommendations of the International Commission on Radiological Protection for medical staff.

The usefulness of SPECT-CT with radioisotope-labeled leukocytes in diagnosing lead-dependent infective endocarditis

BACKGROUND

Lead-dependent infective endocarditis (LDIE) is a life-threatening complication of permanent transvenous cardiac pacing. According to the 2015 European Society of Cardiology (ECS) guidelines, the diagnosis of LDIE is based on the modified Duke criteria (MDC), while single-photon emission computed tomography with conventional computed tomography (SPECT-CT) with radioisotope-labeled leukocytes serves as an additional tool in difficult cases. The major challenge is to differentiate between true vegetation and a thrombus.

OBJECTIVES

The aim of the study was to evaluate the usefulness of SPECT-CT with radioisotope-labeled leukocytes in diagnosing LDIE in patients with intracardiac masses (ICMs).

MATERIAL AND METHODS

The prospective registry included 40 consecutive patients admitted with an ICM on the lead and suspicion of LDIE. The confirmation or rejection of the LDIE diagnosis was made according to an algorithm based on the MDC. The cohort was divided into 2 groups: patients with definite and possible LDIE diagnoses based on the MDC (the LDIE-positive group), and patients with negative LDIE diagnoses according to the MDC (the LDIE-negative group). All patients underwent SPECT-CT with radioisotope-labeled leukocytes. The diagnostic ability of SPECT-CT was compared to the gold standard MDC.

RESULTS

The LDIE-positive group with diagnosis based on the MDC consisted of 19 patients (LDIE definite - 11; LDIE possible - 8). The LDIE diagnosis was rejected on the basis of the MDC in 21 patients. The SPECT-CT results were compared with the MDC results and showed 73.7% sensitivity, 81.0% specificity, 77.5% accuracy, 77.8% positive predictive value (PPV), 77.3% negative predictive value (NPV), likelihood ratio positive (LR+) 3.868, likelihood ratio negative (LR-) 0.325, and moderate agreement (κ = 0.548, p < 0.001). After the exclusion of 5 patients treated with antibiotics at the time of the SPECT-CT, LR+ and LRimproved to 5.250 and 0, respectively, and inter-test agreement amounted to almost perfect concordance (κ = 0.773, p < 0.001).

CONCLUSIONS

Single-photon emission computed tomography with conventional CT with radioisotopelabeled leukocytes is a useful, efficient, single-step test for diagnosing LDIE.

Kinetics of selected serum markers of fibrosis in patients with dilated cardiomyopathy and different grades of diastolic dysfunction of the left ventricle

BACKGROUND

Fibrosis of the extracellular matrix (ECM) in dilated cardiomyopathy (DCM) is common and compromises both systolic and diastolic function. The aim of this study was to investigate the kinetics of ECM fibrosis markers over a 12 month follow-up in patients with DCM based on the severity of diastolic dysfunction (DD).

METHODS

Seventy consecutive DCM patients (48 ± 12.1 years, ejection fraction 24.4 ± 7.4%) were included in the study. The grade of DD was determined using the ASE/EACVI algorithm. Markers of ECM fibrosis were measured at baseline and at 3 and 12 month follow-ups: collagen type I and III (PICP, PINP, PIIICP, PIIINP), transforming growth factor beta-1 (TGF1-b), connective tissue growth factor (CTGF) and galectin-3 were measured.

RESULTS

Patients were divided into three groups according to DD severity: 30 patients with grade I, 18 with grade II and 22 with grade III of DD. Levels of PICP, PINP were increased over a 12-month period, while PIIINP decreased and PIIICP unchanged. Levels of TGF1-b decreased from the 3 to the 12-month points in grade I and II DD, and in grade III they remained unchanged. Levels of CTGF decreased over 12 months in grade III DD but were unchanged in grades I and II. Galectin-3 levels remained the same over all observation periods, irrespective of DD grade.

CONCLUSIONS

Regardless of the DD grade, markers of collagen type I synthesis increased, markers of collagen type III decreased. Levels of TGF and CTGF had a tendency to decrease. Galectin-3 was revealed not to be a marker discriminating the severity of DD.

Intravenous N-acetylcysteine for the PRevention Of Contrast-induced nephropathy - a prospective, single-center, randomized, placebo-controlled trial. The INPROC trial

INTRODUCTION

Contrast-induced nephropathy (CIN) is a common clinical problem that is growing in importance as an increasing number of tests and procedures which utilize contrast media (CM) are performed.

AIM

To evaluate the efficacy of intravenous N-acetylcysteine (NAC) for prevention of CIN after diagnostic and/or interventional procedures requiring CM administration.

MATERIAL AND METHODS

In a prospective, single-center, randomized, placebo-controlled trial the preventive effects of N-acetylcysteine were evaluated in 222 patients undergoing elective angiography and/or angioplasty. Patients were randomly assigned to receive either NAC or placebo. All patients received intravenous hydration with normal saline before and after catheterization. Serum creatinine (SCr) and estimated glomerular filtration rate were assessed at baseline, at 48-72 h and 10-15 days after CM administration. Contrast-induced nephropathy was defined as an increase in SCr of at least 44 µmol/l (0.5 mg/dl) or an increase of ≥ 25% of the baseline value 48-72 h after CM administration.

RESULTS

Contrast-induced nephropathy occurred in 30 of 222 patients (13.5%): 9 of 108 patients in NAC (8.3%) and 21 of 114 patients in the control group (18.4%; p = 0.0281). The multivariate Cox analysis revealed that elevated SCr at 10-15 days (HR = 2.69; p = 0.018) and baseline SCr level (HR = 1.009; p = 0.015) were independent prognostic variables for adverse events during follow-up.

CONCLUSIONS

Our findings suggest that intravenous NAC along with intravenous hydration may help prevent declining renal function after CM exposure. Elevated SCr level 10-15 days after CM administration was associated with increased risk of adverse events in long-term observation, while elevated SCr within 72 h was not. Measuring SCr at least 10 days after exposure to CM may provide a better outcome measure.

Noninvasive techniques for the diagnosis of anomalous origin of the left coronary artery from the pulmonary artery in adult patients

Background Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac anomaly which requires surgical treatment, which improves left ventricular function and clinical outcomes. The definitive diagnosis of ALCAPA is based on coronary angiography, however, noninvasive visualization of the origin of the coronary artery is often helpful in the diagnosis of ALCAPA. Objectives The purpose of this study was to evaluate noninvasive techniques for the diagnosis of ALCAPA, and present the clinical outcomes in adults after surgical correction of ALCAPA. Methods Medical charts of five patients with ALCAPA treated at the John Paul II Hospital in Cracow between 2004 and 2012 were analyzed retrospectively. Noninvasive imaging techniques were used to visualize coronary vessels preoperatively. Patients were followed one year after the operation with echocardiograms and assessment of the New York Heart Association functional class. Results Computed tomography showed ALCAPA in four patients. Magnetic resonance imaging showed abnormal left ventricle remodeling suggestive of ischemia of the anterior cardiac wall. Myocardial perfusion imaging revealed ischemia of the middle and periapical segments of the anterior and anterolateral wall of the left ventricle in two patients. Postoperatively, patients had symptomatic improvement, but there was no statistically significant difference in mean ejection fraction. Conclusions Noninvasive techniques can be used to visualize the origin of the coronary arteries and characterize their morphology. Long-term follow-up of adult patients after surgical correction of ALCAPA is not well documented in the literature, but surgical treatment revealed beneficial short-term effects and symptoms relief.