Electrocardiographic predictors of left ventricular scar in athletes with right bundle branch block premature ventricular beats

AIMS

Right bundle branch block (RBBB) morphology non-sustained ventricular arrhythmias (VAs) have been associated with the presence of non-ischaemic left ventricular scar (NLVS) in athletes. The aim of this cross-sectional study was to identify clinical and electrocardiogram (ECG) predictors of the presence of NLVS in athletes with RBBB VAs.

METHODS AND RESULTS

Sixty-four athletes [median age 39 (24-53) years, 79% males] with non-sustained RBBB VAs underwent cardiac magnetic resonance (CMR) with late gadolinium enhancement in order to exclude the presence of a concealed structural heart disease. Thirty-six athletes (56%) showed NLVS at CMR and were assigned to the NLVS positive group, whereas 28 athletes (44%) to the NLVS negative group. Family history of cardiomyopathy and seven different ECG variables were statistically more prevalent in the NLVS positive group. At univariate analysis, seven ECG variables (low QRS voltages in limb leads, negative T waves in inferior leads, negative T waves in limb leads I-aVL, negative T waves in precordial leads V4-V6, presence of left posterior fascicular block, presence of pathologic Q waves, and poor R-wave progression in right precordial leads) proved to be statistically associated with the finding of NLVS; these were grouped together in a score. A score ≥2 was proved to be the optimal cut-off point, identifying NLVS athletes in 92% of cases and showing the best accuracy (86% sensitivity and 100% specificity, respectively). However, a cut-off ≥1 correctly identified all patients with NLVS (absence of false negatives).

CONCLUSION

In athletes with RBBB morphology non-sustained VAs, specific ECG abnormalities at 12-lead ECG can help in detecting subjects with NLVS at CMR.

Cardiac Magnetic Resonance for Prophylactic Implantable-Cardioverter Defibrillator Therapy in Ischemic Cardiomyopathy: The DERIVATE-ICM International Registry

BACKGROUND

Implantable cardioverter-defibrillator (ICD) therapy is the most effective prophylactic strategy against sudden cardiac death (SCD) in patients with ischemic cardiomyopathy (ICM) and left ventricle ejection fraction (LVEF) ≤35% as detected by transthoracic echocardiograpgy (TTE). This approach has been recently questioned because of the low rate of ICD interventions in patients who received implantation and the not-negligible percentage of patients who experienced SCD despite not fulfilling criteria for implantation.

OBJECTIVES

The DERIVATE-ICM registry (CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy; NCT03352648) is an international, multicenter, and multivendor study to assess the net reclassification improvement (NRI) for the indication of ICD implantation by the use of cardiac magnetic resonance (CMR) as compared to TTE in patients with ICM.

METHODS

A total of 861 patients with ICM (mean age 65 ± 11 years, 86% male) with chronic heart failure and TTE-LVEF <50% participated. Major adverse arrhythmic cardiac events (MAACE) were the primary endpoints.

RESULTS

During a median follow-up of 1,054 days, MAACE occurred in 88 (10.2%). Left ventricular end-diastolic volume index (HR: 1.007 [95% CI: 1.000-1.011]; P = 0.05), CMR-LVEF (HR: 0.972 [95% CI: 0.945-0.999]; P = 0.045) and late gadolinium enhancement (LGE) mass (HR: 1.010 [95% CI: 1.002-1.018]; P = 0.015) were independent predictors of MAACE. A multiparametric CMR weighted predictive derived score identifies subjects at high risk for MAACE compared with TTE-LVEF cutoff of 35% with a NRI of 31.7% (P = 0.007).

CONCLUSIONS

The DERIVATE-ICM registry is a large multicenter registry showing the additional value of CMR to stratify the risk for MAACE in a large cohort of patients with ICM compared with standard of care.

Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy international study: prognostic value of cardiac magnetic resonance-derived right ventricular parameters substudy

AIMS

Right ventricular systolic dysfunction (RVSD) is an important determinant of outcomes in heart failure (HF) cohorts. While the quantitative assessment of RV function is challenging using 2D-echocardiography, cardiac magnetic resonance (CMR) is the gold standard with its high spatial resolution and precise anatomical definition. We sought to investigate the prognostic value of CMR-derived RV systolic function in a large cohort of HF with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Study cohort comprised of patients enrolled in the CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DefibrillAtor ThErapy registry who had HFrEF and had simultaneous baseline CMR and echocardiography (n = 2449). RVSD was defined as RV ejection fraction (RVEF) <45%. Kaplan-Meier curves and cox regression were used to investigate the association between RVSD and all-cause mortality (ACM). Mean age was 59.8 ± 14.0 years, 42.0% were female, and mean left ventricular ejection fraction (LVEF) was 34.0 ± 10.8. Median follow-up was 959 days (interquartile range: 560-1590). RVSD was present in 936 (38.2%) and was an independent predictor of ACM (adjusted hazard ratio = 1.44; 95% CI [1.09-1.91]; P = 0.01). On subgroup analyses, the prognostic value of RVSD was more pronounced in NYHA I/II than in NYHA III/IV, in LVEF <35% than in LVEF ≥35%, and in patients with renal dysfunction when compared to those with normal renal function.

CONCLUSION

RV systolic dysfunction is an independent predictor of ACM in HFrEF, with a more pronounced prognostic value in select subgroups, likely reflecting the importance of RVSD in the early stages of HF progression.

AI Cardiac MRI Scar Analysis Aids Prediction of Major Arrhythmic Events in the Multicenter DERIVATE Registry

Background Scar burden with late gadolinium enhancement (LGE) cardiac MRI (CMR) predicts arrhythmic events in patients with postinfarction in single-center studies. However, LGE analysis requires experienced human observers, is time consuming, and introduces variability. Purpose To test whether postinfarct scar with LGE CMR can be quantified fully automatically by machines and to compare the ability of LGE CMR scar analyzed by humans and machines to predict arrhythmic events. Materials and Methods This study is a retrospective analysis of the multicenter, multivendor CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy (DERIVATE) registry. Patients with chronic heart failure, echocardiographic left ventricular ejection fraction (LVEF) of less than 50%, and LGE CMR were recruited (from January 2015 through December 2020). In the current study, only patients with ischemic cardiomyopathy were included. Quantification of total, dense, and nondense scars was carried out by two experienced readers or a Ternaus network, trained and tested with LGE images of 515 and 246 patients, respectively. Univariable and multivariable Cox analyses were used to assess patient and cardiac characteristics associated with a major adverse cardiac event (MACE). Area under the receiver operating characteristic curve (AUC) was used to compare model performances. Results In 761 patients (mean age, 65 years ± 11, 671 men), 83 MACEs occurred. With use of the testing group, univariable Cox-analysis found New York Heart Association class, left ventricle volume and/or function parameters (by echocardiography or CMR), guideline criterion (LVEF of ≤35% and New York Heart Association class II or III), and LGE scar analyzed by humans or the machine-learning algorithm as predictors of MACE. Machine-based dense or total scar conferred incremental value over the guideline criterion for the association with MACE (AUC: 0.68 vs 0.63, P = .02 and AUC: 0.67 vs 0.63, P = .01, respectively). Modeling with competing risks yielded for dense and total scar (AUC: 0.67 vs 0.61, P = .01 and AUC: 0.66 vs 0.61, P = .005, respectively). Conclusion In this analysis of the multicenter CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy (DERIVATE) registry, fully automatic machine learning-based late gadolinium enhancement analysis reliably quantifies myocardial scar mass and improves the current prediction model that uses guideline-based risk criteria for implantable cardioverter defibrillator implantation. ClinicalTrials.gov registration no.: NCT03352648 Published under a CC BY 4.0 license. Supplemental material is available for this article.

CarDiac magnEtic Resonance for prophylactic Implantable-cardioVerter defibrillAtor ThErapy in Non-Ischaemic dilated CardioMyopathy: an international Registry

AIMS

The aim of this registry was to evaluate the additional prognostic value of a composite cardiac magnetic resonance (CMR)-based risk score over standard-of-care (SOC) evaluation in a large cohort of consecutive unselected non-ischaemic cardiomyopathy (NICM) patients.

METHODS AND RESULTS

In the DERIVATE registry (www.clinicaltrials.gov/registration: RCT#NCT03352648), 1000 (derivation cohort) and 508 (validation cohort) NICM patients with chronic heart failure (HF) and left ventricular ejection fraction <50% were included. All-cause mortality and major adverse arrhythmic cardiac events (MAACE) were the primary and secondary endpoints, respectively. During a median follow-up of 959 days, all-cause mortality and MAACE occurred in 72 (7%) and 93 (9%) patients, respectively. Age and >3 segments with midwall fibrosis on late gadolinium enhancement (LGE) were the only independent predictors of all-cause mortality (HR: 1.036, 95% CI: 1.0117-1.056, P < 0.001 and HR: 2.077, 95% CI: 1.211-3.562, P = 0.008, respectively). For MAACE, the independent predictors were male gender, left ventricular end-diastolic volume index by CMR (CMR-LVEDVi), and >3 segments with midwall fibrosis on LGE (HR: 2.131, 95% CI: 1.231-3.690, P = 0.007; HR: 3.161, 95% CI: 1.750-5.709, P < 0.001; and HR: 1.693, 95% CI: 1.084-2.644, P = 0.021, respectively). A composite clinical and CMR-based risk score provided a net reclassification improvement of 63.7% (P < 0.001) for MAACE occurrence when added to the model based on SOC evaluation. These findings were confirmed in the validation cohort.

CONCLUSION

In a large multicentre, multivendor cohort registry reflecting daily clinical practice in NICM work-up, a composite clinical and CMR-based risk score provides incremental prognostic value beyond SOC evaluation, which may have impact on the indication of implantable cardioverter-defibrillator implantation.

Contact-force monitoring increases accuracy of right ventricular voltage mapping avoiding “false scar” detection in patients with no evidence of structural heart disease

Purpose

Electroanatomical mapping (EAM) could increase cardiac magnetic resonance imaging (CMR) sensitivity in detecting ventricular scar. Possible bias may be scar over-estimation due to inadequate tissue contact. Aim of the study is to evaluate contact-force monitoring influence during EAM, in patients with idiopathic right ventricular arrhythmias.

Methods

20 pts (13 M; 43 ± 12 y) with idiopathic right ventricular outflow tract (RVOT) arrhythmias and no structural abnormalities were submitted to Smarttouch catheter Carto3 EAM. Native maps included points collected without considering contact-force. EAM scar was defined as area ≥1 cm² including at least 3 adjacent points with signal amplitude (bipolar <0.5 mV, unipolar 3,5 mV), surrounded by low-voltage border zone. EAM were re-evaluated offline, removing points collected with contact force <5 g. Finally, contact force-corrected maps were compared to the native ones.

Results

An EAM was created for each patient (345 ± 85 points). After removing poor contact points, a mean of 149 ± 60 points was collected. The percentage of false scar, collected during contact force blinded mapping compared to total volume, was 6.0 ± 5.2% for bipolar scar and 7.1 ± 5.9% for unipolar scar, respectively. No EAM scar was present after poor contact points removal. Right ventricular areas analysis revealed a greater number of points with contact force < 5 g acquired in free wall, where reduced mean bipolar and unipolar voltage were recorded.

Conclusions

To date this is the first work conducted on structurally normal hearts in which contact-force significantly increases EAM accuracy, avoiding “false scar” related to non-adequate contact between catheter and tissue.

Clinical significance of ST depression at exercise stress testing in competitive athletes: usefulness of coronary CT during screening

BACKGROUND

Congenital coronary anomalies (CCAs) and coronary artery disease (CAD) arouse intense scientific and clinical interest in sports medicine and sports cardiology medical communities because of their potential to trigger sudden cardiac death (SCD) in athletes. Exercise stress testing represent the first instrumental assessment to evaluate electrocardiographic changes during effort. Coronary computed tomography angiography (CCTA) is an advanced accurate noninvasive imaging modality for excluding CAD and abnormalities of origin and course of coronary vessels. The aim of this study is to investigate with CCTA the clinical significance of ST depression suggestive for myocardial ischemia during exercise stress testing in athletes and to determine the prevalence of CAD and/or CCAs.

METHODS

Sixty-five consecutive athletes showing electrocardiographic findings positive or equivocal for myocardial ischemia on exercise stress testing during pre-participation screening were investigated with CCTA.

RESULTS

Among the 65 athletes investigated, 36 showed Myocardial Bridge (MB), one showed an anomalous coronary origin and seven showed CAD. Among 36 athletes with MB, 4 were associated with mild coronary artery stenosis. Three athletes with CAD needed percutaneous transluminal coronary angioplasty or coronary artery bypass surgery.

CONCLUSIONS

In competitive athletes even with excellent workload capacities, in absence of cardiomyopathy, the presence of ischemic electrocardiographic abnormalities could be mainly determined by a coronary congenital or acquired pathology. In this population CCTA is a useful imaging modality of choice for the risk stratification and for the diagnostic process, to allow eligible athletes to compete and to follow-up subjects requiring medical surveillance.

Cardiac MR With Late Gadolinium Enhancement in Acute Myocarditis With Preserved Systolic Function: ITAMY Study

BACKGROUND

The prognostic role of cardiac magnetic resonance (CMR) and late gadolinium enhancement (LGE) has not been clarified in acute myocarditis (AM) with preserved left ventricular (LV) ejection fraction (EF).

OBJECTIVES

This study sought to evaluate the role of CMR and LGE in the prognosis of AM with preserved LVEF.

METHODS

This study analyzed data from ITAMY (ITalian multicenter study on Acute MYocarditis) and evaluated CMR results from 386 patients (299 male; mean age 35 ± 15 years) with AM and preserved LVEF. Clinical follow-up was performed for a median of 1,572 days. A clinical combined endpoint of cardiac death, appropriate implantable cardioverter-defibrillator firing, resuscitated cardiac arrest, and hospitalization for heart failure was used.

RESULTS

Among the 374 patients with suitable images, LGE involved the subepicardial layer inferior and lateral wall in 154 patients (41%; IL group), the midwall layer of the anteroseptal wall in 135 patients (36%; AS [anteroseptal] group), and other segments in 59 patients (16%; other-LGE group), and it was absent in 26 patients (no-LGE group). The AS group had a greater extent of LGE and a higher LV end-diastolic volume index than other groups, but levels of inflammatory markers were lower than in the other groups. Kaplan-Meier curve analysis indicated that the AS group had a worse prognosis than the other groups (p < 0.0001). Finally, in multivariable analysis, AS LGE was the best independent CMR predictor of the combined endpoint (odds ratio: 2.73; 95% confidence interval: 1.2 to 5.9; p = 0.01).

CONCLUSIONS

In patients with AM and preserved LVEF, LGE in the midwall layer of the AS myocardial segment is associated with a worse prognosis than other patterns of presentation.

Relationship between Regional Fat Distribution and Hypertrophic Cardiomyopathy Phenotype

Background

Hypertrophic cardiomyopathy (HCM), the most common genetic heart disease, is characterized by heterogeneous phenotypic expression. Body mass index has been associated with LV mass and heart failure symptoms in HCM. The aim of our study was to investigate whether regional (trunk, appendicular, epicardial) fat distribution and extent could be related to hypertrophy severity and pattern in HCM.

Methods

Cardiovascular magnetic resonance was performed in 32 subjects with echocardiography-based diagnosis of HCM (22M/10F, 57.2±12.6 years) characterized by predominant hypertrophy at the interventricular septum (IVS). Regional fat distribution was assessed by dual-energy X-ray absorptiometry.

Results

Gender differences were detected in maximum IVS thickness (M: 18.3±3.8 mm vs. F: 14.3±4 mm, p = 0.012), right ventricle (RV) systolic function (M: 61.3±6.7%; F: 67.5±6.3%, p = 0.048), indexed RV end-diastolic (M: 64.8±16.3 ml/m²; F: 50.7±15.5 ml/m², p = 0.04) and end-systolic volumes (M: 24.3±8.3 ml/m²; F: 16.7±7.4 ml/m², p = 0.04). After adjusting for age and gender, maximum IVS thickness was associated with truncal fat (Tr-FAT) (β = 0.43, p = 0.02), but not with either appendicular or epicardial fat. Epicardial fat resulted independently associated with NT-proBNP levels (β = 0.63, p = 0.04). Late Gadolinium Enhancement-positive subjects displayed greater maximum IVS thickness (p = 0.02), LV mass index (p = 0.015) and NT-proBNP levels (p = 0.04), but no associations with fat amount or distribution were observed.

Conclusion

Truncal, but not appendicular or epicardial fat amount, seems to be related with maximum IVS thickness, the hallmark feature in our cohort of HCM patients. Further prospective researches are needed to assess a potential causative effect of central adiposity on HCM phenotype.

Intraaortic migration of an epicardial pacing wire: percutaneous extraction

Infrequent but serious complications have been described in association with temporary epicardial pacing wires. We describe the case of an intraaortic migration of an infected retained atrial temporary epicardial pacing wire and the transfemoral percutaneous interventional approach for its extraction.

Emergency treatment of a salmonella-infected abdominal aortic aneurysm associated with spondylodiscitis

AIM

To report surgical treatment of a ruptured abdominal aortic aneurysm (AAA) associated with spondylodiscitis due to Salmonella in emergency setting.

CASE REPORT

A 69-year-old male with an history of hypertension, presented with a ruptured AAA infected by nontyphoidal Salmonella (type H), associated with spondylodiscitis. Patient underwent an emergency operation consisting in surgical debridment of infected tissue and aortic replacement with a prosthetic Dacron graft impregnated with Gentamycine. The postoperative course was uneventful and the patient was discharged at day 20 after the index procedure in good clinical condition. antimicrobial therapy was continued for 8 weeks. A CT scan and nuclear medicine studies performed two months later demonstrated minimal sign of residual aortitis. A CT scan 21 months after the procedure showed complete anatomic resolution of the disease.

CONCLUSIONS

A rare but increasing number of aneurysms as a consequence of Salmonellosis can be observed with a high rate of morbidity and mortality, mainly in patients with a concurrent infection of the spine and paravertebral tissue. Combined antimicrobial therapy and one-stage surgical treatment can be associated with good outcome.

KEYWORDS

Abdominal aorta aneurysm, Mycotic aortic aneurysms, Salmonellosis, Spondylodiscitis.

Diffusion tensor magnetic resonance imaging of prostate cancer

PURPOSE

To explore the feasibility of 3T magnetic resonance (MR) diffusion tensor imaging (DTI) and fiber tracking (FT) in patients with prostate cancer.

MATERIALS AND METHODS

Thirty consecutive patients (mean age, 62.5 years) with biopsy proven prostate cancer underwent 3T-MR imaging (MRI) and DTI using a 6-channel external phased-array coil before radical prostatectomy. Regions of interest of 14 pixels were defined in tumors and nonaffected areas in the peripheral zone (PZ) and central gland (CG), according to histopatology after radical prostatectomy. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values were determined. Differences in mean ADC and FA values among prostate cancer, normal PZ and CG were compared by 2-sided Student t test. The predominant diffusion direction of the prostate anisotropy was color coded on a directionally encoded color (DEC) map. A 3D reconstruction of fiber tract orientations of the whole prostate was determined using the continuous tracking method. The overall image quality for tumor localization and local staging was assessed in retrospective matching with whole-mount section histopathology images. Nodules detected at MRI were classified as matched lesions if tumor presence and extension were evidenced at histopathology.

RESULTS

For all the patients, the DTI sequence images were suitable for the evaluation of the zonal anatomy of the prostate gland and the tumor localization. Quantitative evaluation of the regions of interest (ROIs) showed a mean ADC value significantly lower in the peripheral neoplastic area (1.06 +/- 0.37 x 10(-3) mm2/s) than in the normal peripheral portion (1.95 +/- 0.38 x 10(-3) mm2/s) (P < 0.05). The mean FA values calculated in the normal peripheral (0.47 +/- 0.04) and central area (0.41 +/- 0.08) were very similar (P > 0.05). The mean FA values in the neoplastic lesion (0.27 +/- 0.05) were significantly lower (P < 0.05) than in the normal peripheral area and in the normal central and adenomyomatous area. DEC map showed a top-bottom type preferential direction in the peripheral but not in the central area, with the tumor lesions reducing the diffusion coding direction represented as color zones tending toward gray. Tractographic analysis permitted good delineation of the prostate anatomy (capsule outline, peripheral and central area borders) and neoplastic lesion extension and capsule infiltration compared with histopathology.

CONCLUSIONS

Three Tesla DTI of the prostate gland is feasible and has the potential for providing improved diagnostic information.

Correlation of diffusion-weighted MR imaging with cellularity of renal tumours

BACKGROUND

Diffusion is a physical process based on the random movement of water molecules known as Brownian movement. Diffusion-weighted imaging (DWI) is a magnetic resonance (MR) technique that provides information about the biophysical properties of tissues such cell organization and density, microstructure and microcirculation.

MATERIALS AND METHODS

Twenty healthy volunteers and 18 patients with renal tumor were enrolled in our study. The DWI was obtained before contrast media injection with a single-shot SE EPI Inversion Recovery (IR) sequence. The tumor cellularity of each resected lesion was evaluated.

RESULTS

The mean apparent diffusion coefficient (ADC) value of renal tumors was significantly lower than the mean ADC value of normal renal parenchyma. In our series, the mean ADC value of renal tumors did not significantly correlate with tumor cellularity, but correlated with histological architecture.

CONCLUSION

These preliminary results indicate the utility of DWI in the acquisition of tissue characterization data of renal masses using a minimal acquisition time (17 sec).

[Cardiac MRI with SENSE technology: study of ventricular and valvular functionality in 30 patients]

PURPOSE

The latest innovation in MR imaging is SENSE (SENSitivity Encoding), a technology providing an important solution for the time necessary for signal encoding. In the SENSitivity Encoding (SENSE) approach, an array of multiple, simultaneously operated receiver coils is used for signal acquisition. In particular, the efficacy of SENSE technology is able to reduce the number of phase encodings by a factor (named R factor or Reduction factor) and to evaluate the same k space with fewer readout lines obtaining higher spatial and temporal resolution.

MATERIALS AND METHODS

An heterogeneous group of 30 patients with a variety of clinically proven diagnoses underwent Cardiac MR with SENSE technology to evaluate the technique's diagnostic efficacy. The sequences used were "Balanced" Ultrafast Gradient Echo (B-FFE) characterised by a hyper-intense blood signal with multislice multiphase and single slice multiphase acquisitions.

RESULTS

In addition to reducing scan times, SENSE technology improved spatial and temporal resolution (40 frames/cardiac cycle) providing optimal dynamic evaluation of valve structures and wall kinesis. Furthermore, the use of the SENSE technique with B-FFE sequences (sB-FFE) enabled the qualitative evaluation of abnormal blood movements and transvalvular flows.

CONCLUSIONS

The considerable time savings allowed by SENSE technology and the clear improvement in image quality constitute a step forward in cardiac MR imaging. The possibility of executing morphologic, dynamic, perfusional and spectroscopic studies in the same MR examination session with short acquisition times and good image quality are becoming more feasible.

MRI lung perfusion 2D dynamic breath-hold technique in patients with severe emphysema

BACKGROUND

Our aim was to prospectively evaluate a semi-quantitative pulmonary perfusion MR technique using a breath-hold 2D dynamic sequence in patients with severe pulmonary emphysema.

MATERIALS AND METHODS

Thirty patients with severe emphysema were studied with pulmonary perfusion MRI. Results were compared with those obtained through lung scintigraphy, considered as the gold standard technique. We used Fast Field Echo (FFE) pulse sequences in the coronal and sagittal planes, with paramagnetic contrast agent administration. Ten healthy volunteers were studied as the control group. Three thoracic radiologists independently reviewed all the subjects, evaluating the site and entity of perfusional defects. Peak intensity and apparent mean transit time were calculated.

RESULTS

MRI showed high sensitivity (86.7%) and good specifity (80.0%) in detecting perfusional defects. We observed lower peak signal intensities in emphysematous regions.

CONCLUSION

Lung perfusion MR is a potential alternative to Nuclear Medicine in the evaluation of severe pulmonary emphysema.