Cardiovascular magnetic resonance for the diagnosis and management of heart failure with preserved ejection fraction

Heart Failure Reviews - Heart failure with preserved ejection fraction (HFpEF) is characterized by an impaired ventricular filling resulting in the development of dyspnea and other HF symptoms....     

Inflammatory markers and cardiac function in acute coronary syndrome: Difference in ST-segment elevation myocardial infarction (STEMI) and in non-STEMI models

Purpose

No studies have been addressed to the differences in inflammation kinetics between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).

Patients and methods

Forty consecutive patients with acute coronary syndrome (ACS) (n = 23 STEMI, age = 61.7 ± 10.3 years; n = 17 NSTEMI, age = 65.6 ± 11.3 years) were enrolled within 12 h after symptoms. All patients received therapy according to the current Guidelines.Blood samples were collected at admission (t0), on days 7 (t1) and 30 (t2) to evaluate CD40 ligand (CD40L), transforming growth factor (TGF)-beta, interleukin (IL)-6, tumor necrosis factor (TNF)-alpha and its receptors TNFRI and TNFRII, high sensitivity C-reactive protein (hs-CRP), serum amyloid A (SAA) and white blood cells (WBC). Echocardiographic parameters were also evaluated.

Results

STEMI patients, at admission, had significantly higher median values of hs-CRP (p < 0.001), WBC (p < 0.01), ferritin (p < 0.0005) and IL-6 (p < 0.05) than NSTEMI. On the contrary, NSTEMI patients had lower median levels of every inflammatory marker except for CD40L (p < 0.05) that was significantly higher. Moreover, three out of four deceased patients presented levels of CD40L higher than the median. At admission, STEMI showed a reduced ejection fraction (EF, p < 0.01) and increased wall motion score index (WMSI, p < 0.001) and end-diastolic volume (EDV, p < 0.05) vs NSTEMI. An inverse correlation between admission values of inflammatory markers (SAA and WBC) and cardiac function was observed (p < 0.05). Moreover, the necrosis marker troponin I was positively correlated with both WMSI (p < 0.05) and hs-CRP (p < 0.05).Regarding the inflammation kinetics, a difference was observed in the two groups only for WBC (p < 0.05) and SAA (p < 0.05). SAA showed higher values in STEMI at t0 and t1. In both groups, TGF-beta had an increase at t1 and t2 with respect to admission, while IL-6 had a decreasing trend.The total incidence of major adverse clinical events (MACE) was 22.5% at t2, with a mortality rate of 10%.

Conclusion

These observations suggest a differential inflammatory pattern in STEMI and NSTEMI patients. The absence of significant correlations between inflammatory indexes and myocardial infarction in NSTEMI supports the hypothesis that a different pattern of inflammation occurs in these patients. CD40L may have an important role as a marker for risk stratification in patients with ACS.     

OCT-guided stenting of a spontaneous coronary artery dissection

We present the case of a 67 year-old patient that presented to our institution with acute and severe chest pain. Optical coherence tomography high-resolution images of the coronary lumen, allowed us to confirm diagnosis of spontaneous coronary artery dissection, guide treatment, and verify the results of our intervention.     

Oxidative stress and inflammation: determinants of anthracycline cardiotoxicity and possible therapeutic targets

Heart Failure Reviews - Chemotherapy with anthracycline-based regimens remains a cornerstone of treatment of many solid and blood tumors but is associated with a significant risk of cardiotoxicity,...     

Cardiac magnetic resonance in cocaine-induced myocardial damage: cocaine,heart, and magnetic resonance

Heart Failure Reviews - The use of cocaine constitutes a major health problem. Cocaine use is associated with acute and chronic complications that might involve any system, the most common being...     

Regional heterogeneity in cardiac sympathetic innervation in acute myocardial infarction: relationship with myocardial oedema on magnetic resonance

Purpose

To assess the relationships between myocardial structure and function on cardiac magnetic resonance (CMR) imaging and sympathetic tone on ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) scintigraphy early after myocardial infarction (MI).

Methods

Ten patients underwent ¹²³I-MIBG and ^99mTc-tetrofosmin rest cadmium zinc telluride scintigraphy 4?±?1 days after MI. The segmental left ventricular (LV) relative radiotracer uptake of both ^99mTc-tetrofosmin and early ¹²³I-MIBG was calculated. The day after scintigraphy, on CMR imaging, the extent of ischaemia-related oedema and of myocardial fibrosis (late gadolinium enhancement, LGE) was assessed. Accordingly, the extent of oedema and LGE was evaluated for each segment and segmental wall thickening determined. Based on LGE distribution, LV segments were categorized as "infarcted" (56 segments), "adjacent" (66 segments) or "remote" (48 segments).

Results

Infarcted segments showed a more depressed systolic wall thickening and greater extent of oedema than adjacent segments (p?<?0.001) and remote segments (p?<?0.001). Interestingly, while uptake of ^99mTc-tetrofosmin was significantly depressed only in infarcted segments (p?<?0.001 vs. both adjacent and remote segments), uptake of ¹²³I-MIBG was impaired not only in infarcted segments (p?<?0.001 vs. remote) but also in adjacent segments (p?=?0.024 vs. remote segments). At the regional level, after correction for ^99mTc-tetrofosmin and LGE distribution, segmental ¹²³I-MIBG uptake (p?<?0.001) remained an independent predictor of ischaemia-related oedema.

Conclusion

After acute MI the regional impairment of sympathetic tone extends beyond the area of altered myocardial perfusion and is associated with myocardial oedema.     

CSF diversion in refractory idiopathic intracranial hypertension: single-centre experience and review of efficacy

Purpose

The current surgical management strategies for refractory cases of idiopathic intracranial hypertension (IIH) remain unresolved. We evaluated the outcome of our paediatric patients who were offered a CSF diversion procedure in order to control their symptoms.

Methods

We retrospectively reviewed the medical notes of the patients under 16 years of age, who presented in our centre from 2005 to 2010, with a confirmed diagnosis of IIH, and ultimately had a lumboperitoneal shunt (LPS). We describe their immediate postoperative course, shunt-related complications and recent outcome.

Results

Seven patients presented at a mean age of 8.7 years. Two presented with significant visual loss and had a shunt acutely; the remaining five presented with headaches and were shunted within 2 years. In the immediate postoperative period two patients experienced low-pressure symptoms. All patients required shunt revisions; in total 15 revisions took place, mainly secondary to symptomatic overdrainage or obstruction. After a mean follow-up of 26 months, two patients have diminished visual acuity at least on one side; only one patient became headache-free, despite resolution of the CSF pressure post diversion in four out of the six remaining patients.

Conclusions

All patients required shunt revisions and 6/7 (85.7 %) had persisting headaches at their last follow-up. It is apparent that once functional, the LPS seems adequate to lower the CSF pressure but not effective in eliminating symptoms.     

‘Image-navigated 3-dimensional late gadolinium enhancement cardiovascular magnetic resonance imaging: feasibility and initial clinical results’

Background

Image-navigated 3-dimensional late gadolinium enhancement (iNAV-3D LGE) is an advanced imaging technique that allows for direct respiratory motion correction of the heart. Its feasibility in a routine clinical setting has not been validated.

Methods

Twenty-three consecutive patients referred for cardiovascular magnetic resonance (CMR) examination including late gadolinium enhancement (LGE) imaging were prospectively enrolled. Image-navigated free-breathing 3-dimensional (3D) T1-weighted gradient-echo LGE and two-dimensional (2D LGE) images were acquired in random order on a 1.5 T CMR system. Images were assessed for global, segmental LGE detection and transmural extent. Objective image quality including signal-to-noise (SNR), contrast-to-noise (CNR) and myocardial/blood sharpness were performed.

Results

Interpretable images were obtained in all 2D–LGE and in 22/23 iNAV-3D LGE exams, resulting in a total of 22 datasets and 352 segments. LGE was detected in 5 patients with ischemic pattern, in 7 with non-ischemic pattern, while it was absent in 10 cases. There was an excellent agreement between 2D and 3D data sets with regard to global, segmental LGE detection and transmurality. Blood-myocardium sharpness measurements were also comparable between the two techniques. SNR_blood and CNR_blood-myo was significantly higher for 2D LGE (P?<?0.001, respectively), while SNR_myo was not statistically significant between 2D LGE and iNAV-3D LGE.

Conclusion

Diagnostic performance of iNAV-3D LGE was comparable to 2D LGE in a prospective clinical setting. SNR_blood and CNR_blood-myo was significantly lower in the iNAV-3D LGE group.