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Among patients with chronic kidney disease (CKD), aortic stenosis (AS) is associated with a significantly higher rate of mortality. We aimed to evaluate whether diffuse myocardial fibrosis, determined using native T1 mapping, has prognostic utility in predicting major adverse cardiovascular events (MACEs), including all-cause mortality or heart failure hospitalization, in patients with CKD and severe AS who are evaluated for transcatheter aortic valve implantation. Cardiac magnetic resonance with T1 mapping using the modified Look-Locker inversion recovery technique was performed in 117 consecutive patients with severe AS and CKD (stage ≥3). Patients were followed up to determine the occurrence of MACE. The mean age of the 117 patients in the cohort was 82 ± 8 years. Native T1 was 1,055 ms (25th- to 75th percentiles 1,031 to 1,078 ms), which is higher than previously reported in healthy controls. Patients with higher T1 times were more likely to have higher N-terminal pro-B-type natriuretic peptide levels (4,122 [IQR 1,578 to 7,980] pg/ml vs 1,678 [IQR 493 to 2,851] pg/ml, p = 0.005) and a history of heart failure (33% vs 9%, p = 0.034). After median follow-up of 3.4 years, MACE occurred in 71 patients (61%). The Society of Thoracic Surgeons predicted risk of mortality score (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.02 to 1.12, p = 0.006), native T11,024 ms (HR 2.10, 95% CI 1.09 to 4.06, p = 0.028), and New York Heart Association class (HR 1.56, 95% 1.09 to 2.34, p = 0.016) were independent predictors of MACE. Longer native T1 was associated with MACE occurrence in patients with CKD and severe AS.

With the increased use of medical imaging, there has been an increase in the numbers of pericardial cysts identified. However, there is a paucity of data regarding the clinical course for pericardial cysts. Hence, we aimed to study the clinical features and natural history of pericardial cysts. We retrospectively studied all patients with the diagnosis of pericardial cysts based on computed tomography (CT) chest or cardiac magnetic resonance imaging (CMR) between 2008 and 2014. The maximum diameter of the cyst was measured at the initial study (CT/CMR) and was compared with the most recent follow-up imaging modality of the same type if available. A change in the maximum diameter more than 10% was considered significant. We included 103 patients in the study; 89% were asymptomatic and 67% were females. Twenty-nine asymptomatic patients had repeat imaging with the same modality (CT/CMR) with a mean follow-up of 23 months. The maximum cyst diameter decreased by a mean of 25% in 34% of the patients and increased by a mean of 13% in 17% of the patients. The remaining patients (48%) had no significant change. All 29 patients remained asymptomatic. In conclusion, most pericardial cyst cases were asymptomatic. On repeat imaging, approximately 1/3 of pericardial cysts were found to decrease in size, whereas interval enlargement was infrequent and unlikely to be clinically relevant. Therefore, within the limitations of our study, serial imaging in asymptomatic patients with CT or CMR does not appear to impact management decisions.

The standard echocardiographic evaluation of left ventricular (LV) mass, particularly in ischemic cardiomyopathy (IC) is challenging because it is based on geometric assumptions. The aim of this study was to assess the accuracy of LV mass calculation using echocardiographic modalities compared with cardiac magnetic resonance (CMR) in IC and in nonischemic cardiomyopathy (non-IC). Echocardiography was performed in 104 patients (mean age 55 ± 15 years) referred for CMR: 63 with IC and 41 with non-IC. CMR, M-mode echocardiography, 2-dimensional echocardiography, and 3-dimensional echocardiography (3DE) were analyzed using standard commercial tools to obtain LV mass. LV mass on 3DE showed a higher correlation with CMR than 2-dimensional echocardiography (r = 0.87 vs r = 0.70, p0.001). M-mode echocardiography overestimated LV mass (bias +30%) and 2-dimensional echocardiography underestimated LV mass (bias -11%), whereas measurements on 3DE showed only minimal bias (-2%). LV mass on 3DE in non-IC showed a significantly higher correlation with CMR than in IC (r = 0.92 vs r = 0.84, z = 2.3, p0.05). In non-IC, the mean difference was -2 g (-1% of the mean), with 95% limits of agreement of ±33 g (±19% of the mean). In IC, the mean difference was -7 g (-4% of the mean), with limits of agreement of ±56 g (±31% of the mean). There was a correlation between the absolute LV mass differences (3DE derived and CMR derived) and scar percentage (infarcted mass/total LV mass) using delayed-hyperenhancement images (r = 0.40, p0.05). The net reclassification index with 3DE was +16% for concentric LV hypertrophy. In conclusion, the most accurate and reliable echocardiographic measurement of LV mass is 3DE, but underestimation and variability remain challenges in IC.

We sought to conduct a meta-analysis using available studies to determine the diagnostic efficacy of 64-slice computed tomography (CT) in evaluation of in-stent restenosis (ISR). Sixty-four-slice CT allows optimal noninvasive assessment of coronary artery disease. However, a variety of artifacts limit evaluation of stented coronary segments. We included studies that used 64-slice CT for evaluation of coronary ISR. We pooled efficacy estimates across studies using random-effects models. We identified 14 studies, which included 895 patients (1,447 stents, mean diameter 3.1 mm). Of these, 1,231 (91.4%) stents were adequately assessed by 64-slice CT. Overall sensitivity was 91% (95% confidence interval [CI] 86 to 94), specificity was 91% (95% CI 89 to 92), positive predictive value (PPV) was 68% (95% CI 63 to 73), and negative predictive value (NPV) was 98% (95% CI 97 to 99). The summary receiver operating characteristic curves graph showed a symmetric area under the curve of 0.96. When nonassessable segments were included, overall sensitivity and specificity decreased to 87% (95% CI 81 to 92) and 84% (95% CI 82 to 87), with a PPV of 53% (95% CI 47 to 59) and an NPV of 97% (95% CI 96 to 98), respectively. In conclusion, 64-slice CT detects (high sensitivity and specificity) or excludes ISR (high NPV) with a high degree of confidence; however, precise quantification of ISR is not accurate (low PPV). Efficacy estimates are even lower when nonassessable segments are included. Hence, at this point, stress imaging remains the most acceptable noninvasive technique for diagnosis of ISR.

The geometry of the left ventricle in patients with cardiomyopathy is often sub-optimal for 2-dimensional ultrasound when assessing left ventricular (LV) function and localized abnormalities such as a ventricular aneurysm. The aim of this study was to report the initial experience of real-time 3-D echocardiography for evaluating patients with cardiomyopathy. A total of 34 patients were evaluated with the real-time 3D method in the operating room (n = 15) and in the echocardiographic laboratory (n = 19). Thirteen of 28 patients with cardiomyopathy and 6 other subjects with normal LV function were evaluated by both real-time 3-D echocardiography and magnetic resonance imaging (MRI) for obtaining LV volumes and ejection fractions for comparison. There were close relations and agreements for LV volumes (r = 0.98, p0.0001, mean difference = -15 +/- 81 ml) and ejection fractions (r = 0.97, p0.0001, mean difference = 0.001 +/- 0.04) between the real-time 3D method and MRI when 3 cardiomyopathy cases with marked LV dilatation (LV end-diastolic volume450 ml by MRI) were excluded. In these 3 patients, 3D echocardiography significantly underestimated the LV volumes due to difficulties with imaging the entire LV in a 60 degrees x 60 degrees pyramidal volume. The new real-time 3D echocardiography is feasible in patients with cardiomyopathy and may provide a faster and lower cost alternative to MRI for evaluating cardiac function in patients.

Transthoracic echocardiography is the current standard for assessing aortic regurgitation (AR). AR severity can also be evaluated by flow measurement in the ascending aorta using cardiac magnetic resonance (CMR); however, the optimal site for flow measurement and the regurgitant fraction (RF) severity grading criteria that best compares with the transthoracic echocardiographic assessment of AR are not clear. The present study aimed to determine the optimal site and RF grading criteria for AR severity using phase-contrast flow measurements and CMR. A prospective observational study was performed of 107 consecutive patients who were undergoing CMR of the thoracic aorta. Using CMR, the AR severity and aortic dimensions were measured at 3 levels in the aorta (the sinotubular junction, mid-ascending aorta, and distal ascending aorta). The results were compared to the transthoracic echocardiographic grade of AR severity using multiple qualitative and quantitative criteria (grade 0, none; I+, mild; II+, mild to moderate; III+, moderate to severe; and IV+, severe). The mean RF values were significantly greater at the sinotubular junction than at the distal ascending aorta (13 ± 13.3% vs 9.4 ± 12.6%, respectively; p

Left ventricular (LV) function and the electrocardiogram of 55 patients with coronary artery disease and angina were monitored for a mean of 3.2 +/- 1.9 hours with an ambulatory LV function monitor. During the monitoring interval, patients performed daily activities such as sitting, walking, climbing stairs, and eating. Sixty episodes of transient reduction in ejection fraction of5% lasting60 seconds were observed in 24 patients; 13 episodes were associated with typical angina, but 47 were asymptomatic. Asymptomatic episodes had a shorter duration of ventricular dysfunction (116 +/- 49 vs 189 +/- 113 seconds; p0.05), and smaller increases in relative end-diastolic and end-systolic volumes (end-diastolic 0.9 +/- 5.4% vs 4.6 +/- 4.9% [p0.05], and end-systolic 21 +/- 11% vs 35 +/- 20% [p0.05]) than did symptomatic ones. When a subset of patients with both symptomatic and asymptomatic episodes were analyzed, similar results were observed: in asymptomatic episodes, duration was shorter (82 +/- 31 vs 200 +/- 110 seconds; p0.005), ejection fraction decrease was smaller (-7.3 +/- 2.6% vs -11.0 +/- 4.7%; p0.05), and end-systolic volume increase was smaller (23 +/- 12% vs 37 +/- 19%; p0.05). The data suggest that asymptomatic transient LV dysfunction is less severe and of shorter duration in patients with angina pectoris.

Framingham risk score is an office-based tool used for long-term coronary heart disease risk stratification. Most acute coronary events occur in association with proximal nonobstructive atherosclerotic plaque. Multislice computed tomography detects both obstructive coronary artery disease (CAD) and proximal atherosclerotic plaque with high accuracy. The association of Framingham risk score with obstructive CAD and proximal atherosclerotic plaque was tested. Coronary multislice computed tomography was performed in 295 patients (61% men, mean age 54 +/- 13 years) without documented CAD referred for evaluation of cardiac symptoms. Framingham risk score was computed and patients were stratified according to 10-year risk (n = 213 [72%] low, n = 74 [25%] intermediate, and n = 8 [3%] high). Obstructive CAD was defined asor =50% stenosis inor =1 epicardial coronary artery. Proximal atherosclerotic plaque was defined as calcified or noncalcified plaque in the left main or proximal left anterior descending artery. In the low- and intermediate-Framingham risk score groups, there was a high frequency of proximal atherosclerotic plaque (44% and 75%) and obstructive CAD (16% and 34%), although both findings were more prevalent in the high-Framingham risk score group (63% for atherosclerotic plaque, 88% for obstructive CAD), respectively. Proximal atherosclerotic plaque was noncalcified in approximately 13 of patients. In women (n = 114) and younger (55 years) patients (n = 148), most (93% and 91%, respectively) had a low Framingham risk score. There were 48 women and 51 younger patients with proximal atherosclerotic plaque, of whom only 40% (in each group) were on statin therapy. In conclusion, of patients with a low and intermediate Framingham risk score, a significant proportion had proximal atherosclerotic plaque or obstructive CAD.

Forty-three ambulatory patients with angina of increasing frequency underwent continuous monitoring of left ventricular (LV) function for an average of 2.9 +/- 1.9 hours to determine the incidence and temporal sequence of LV dysfunction, ST-segment depression and chest pain. Indicators of ischemia were: a decrease in ejection fraction greater than 5% lasting greater than 1 minute; horizontal or downsloping ST-segment depression of greater than or equal to 1 mm; or onset of the patient's typical chest pain complex, or a combination of these. During the monitoring interval, subjects performed daily activities such as sitting, walking, climbing stairs and eating. In 11 patients, 22 episodes of chest pain or ST-segment depression, or both, were observed. Eighteen episodes were accompanied by a decrease in ejection fraction (9 patients); chest pain accompanied the decrease in ejection fraction during 13 episodes, whereas ST-segment changes occurred during 7. In 12 of 13 episodes the decrease in ejection fraction began earlier than the onset of chest pain, whereas in 1 patient ejection fraction decrease and chest pain onset started at the same time. The average interval from a decrease in ejection fraction to the onset of chest pain was 56 +/- 41 seconds (range 0 to 120). ST changes occurred after the onset of a decrease in ejection fraction in 6 of 7 episodes. The average interval from the onset of ejection fraction decrease and the onset of ST change was 99 +/- 91 seconds. These data suggest that LV dysfunction manifested by a decrease in ejection fraction is an earlier indicator of myocardial ischemia than is angina pectoris or electrocardiographic evidence of ischemia.

In Takotsubo cardiomyopathy, or transient left ventricular (LV) apical ballooning syndrome, normalization of wall motion can occur after as long as 3 months. We report 1 of the largest series to date outside Japan and emphasize the utility of cardiac magnetic resonance imaging (CMR) to show a lack of irreversible damage in the acute setting, thereby reliably predicting recovery. During the previous 6 years, we saw 22 patients who met the following criteria: (1) a suspected myocardial infarction based on symptoms, an abnormal electrocardiogram, and/or elevated serum cardiac markers; (2) an anteroapical wall motion abnormality; and (3) no significant occlusive epicardial coronary artery disease or observed vasospasm. Ten patients underwent delayed enhancement CMR to assess myocardial viability during the index presentation. All 10 patients had an absence of irreversible damage, as evidenced by lack of gadolinium "hyperenhancement"; later, their LV function returned to normal. Eight other patients, available for outpatient follow-up evaluation, also had normalization of LV function. Takotsubo cardiomyopathy is increasingly being recognized outside Japan and must be distinguished from acute myocardial infarction. In conclusion, CMR is useful to document segmental LV dysfunction and lack of irreversible damage and to predict functional recovery.