Search

Aims To non-invasively characterize, by means of late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), scar differences, and potential variables associated with ventricular tachycardia (VT) occurrence in chronic post-myocardial infarction (MI) patients. Methods and results A case–control study was designed through retrospective LGE-CMR data analysis of chronic post-MI patients (i) consecutively referred for VT substrate ablation after a first VT episode (n = 66) and (ii) from a control group (n = 84) with no arrhythmia evidence. The myocardium was characterized differentiating core, border zone (BZ), and BZ channels (BZCs) using the ADAS 3D post-processing imaging platform. Clinical and scar characteristics, including a novel parameter, the BZC mass, were compared between both groups. One hundred and fifty post-MI patients were included. Four multivariable Cox proportional hazards regression models were created for total scar mass, BZ mass, core mass, and BZC mass, adjusting them by age, sex, and left ventricular ejection fraction (LVEF). A cut-off of 5.15 g of BZC mass identified the cases with 92.4% sensitivity and 86.9% specificity [area under the ROC curve (AUC) 0.93 (0.89–0.97); P Conclusions The mass of BZC is the strongest independent variable associated with the occurrence of sustained monomorphic ventricular tachycardia in post-MI patients after adjustment for age, sex, and LVEF. Border zone channel mass measurement could permit a more accurate VT risk stratification than LVEF in chronic post-MI patients.

Aims Ventricular tachycardia (VT) substrate-based ablation has an increasing role in patients with structural heart disease-related VT. VT is linked to re-entry in relation to myocardial scarring with areas of conduction block (core scar) and areas of slow conduction [border zone (BZ)]. VT substrate can be analysed by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Our study aims to analyse the role of LGE-CMR in identifying predictors of VT recurrence after ablation. Methods and results We analysed 110 consecutive patients who underwent VT ablation from 2013 to 2018. All patients underwent a preprocedural LGE-CMR, and in 94 patients (85.5%), the CMR was used to aid the ablation. All LGE-CMR images were semi-automatically processed using dedicated software to detect scarring and conducting channels. After a median follow-up of 2.7 ± 1.6 years, the overall VT recurrence was 41.8% with an implantable cardioverter-defibrillator shock reduction from 43.6% to 28.2% before and after ablation, respectively. The amount of BZ (26.6 ± 13.9 vs. 19.6 ± 9.7 g, P = 0.012), the total amount of scarring (37.1 ± 18.2 vs. 29 ± 16.3 g, P = 0,033), and left ventricular (LV) mass (168.3 ± 53.3 vs. 152.3 ± 46.4 g, P Conclusion Pre-procedural LGE-CMR is a helpful and feasible technique to identify patients with high risk of VT recurrence after ablation. LV mass, septal LGE distribution, and transmural channels were predictive factors of post-ablation VT recurrence.

BACKGROUND Left atrial wall thickness (LAWT) has been related to pulmonary vein (PV) reconnections after atrial fibrillation (AF) ablation. The aim was to integrate 3D-LAWT maps in the navigation system and analyze the relationship with local reconnection sites during AF-redo procedures. METHODS Consecutive patients referred for AF-redo ablation were included. Procedure was performed using a single catheter technique. LAWT maps obtained from multidetector computerized tomography (MDCT) were imported into the navigation system. LAWT of the circumferential PV line, the reconnected segment and the reconnected point, were analyzed. RESULTS Sixty patients [44 (73%) male, age 61 ± 10 years] were included. All reconnected veins were isolated using a single catheter technique with 55 min (IQR 47-67) procedure time and 75 s (IQR 50-120) fluoroscopy time. Mean LAWT of the circumferential PV line was 1.46 ± 0.22 mm. The reconnected segment was thicker than the rest of segments of the circumferential PV line (2.05 + 0.86 vs. 1.47 + 0.76, p

Resumen Introduccion y objetivos La enolasa neuronal especifica (ENE) es un marcador pronostico en pacientes con parada cardiorrespiratoria extrahospitalaria (PCR-EH) tratados con hipotermia moderada terapeutica (HMT). Objetivos: analizar la correlacion entre cambios dinamicos en ENE y eventos principales; y determinar los tiempos de medicion de ENE que mejor pronostican el estado neurologico. Metodos Estudio de cohortes multicentrico de pacientes ingresados despues de un PCR-EH con ritmo desfibrilable y tratados con HMT. Se determino la ENE serica en dos fechas y se calculo Δ-ENE (%) como 100 x (Δ-ENE 2-Δ-ENE 1) / Δ-ENE 1. La mortalidad y el estado neurologico, segun la escala Cerebral Performance Category (CPC), se evaluaron durante la hospitalizacion y a los 6 meses. Resultados Se incluyeron 166 pacientes ingresados en cuatro hospitales. La mortalidad intrahospitalaria fue del 31.9%. El 58,2% tuvo buena recuperacion neurologica (CPC 1-2). El incremento de ENE se asocio, en el analisis de regresion logistica, con mayor mortalidad hospitalaria y peor CPC al alta y a los 6 meses (p Conclusiones El cambio dinamico de ENE es un buen marcador de eventos clinicos despues de un PCR-EH por ritmo desfibrilable en pacientes tratados con HMT. Las mediciones de ENE en intervalos especificos despues del PCR-EH pueden incrementar la precision pronostica.

Aims Ventricular tachycardia (VT) substrate-based ablation has become a standard procedure. Electroanatomical mapping (EAM) detects scar tissue heterogeneity and define conduction channels (CCs) that are the ablation target. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is able to depict CCs and increase ablation success. Most patients undergoing VT ablation have an implantable cardioverter-defibrillator (ICD) that can cause image artefacts in LGE-CMR. Recently wideband (WB) LGE-CMR sequence has demonstrated to decrease these artefacts. The aim of this study is to analyse accuracy of WB-LGE-CMR in identifying the CC entrances. Methods and results Thirteen consecutive ICD-patients who underwent VT ablation after WB-LGE-CMR were included. Number and location of CC entrances in three-dimensional EAM and in WB-LGE-CMR reconstruction were compared. Concordance was compared with a historical cohort matched by cardiomyopathy, scar location, and age (26 patients) with LGE-CMR prior to ICD and VT ablation. In WB-CMR group, 101 and 93 CC entrances were identified in EAM and WB-LGE-CMR, respectively. In historical cohort, 179 CC entrances were identified in both EAM and LGE-CMR. The EAM/CMR concordance was 85.1% and 92.2% in the WB and historical group, respectively (P = 0.66). There were no differences in false-positive rate (CC entrances detected in CMR and absent in EAM: 7.5% vs 7.8% in WB vs. conventional CMR, P = 0.92) nor in false-negative rate (CC entrances present in EAM not detected in CMR: 14.9% vs.7.8% in WB vs. conventional CMR, P = 0.23). Epicardial CCs was predictor of poor CMR/EAM concordance (OR 2.15, P = 0.031). Conclusion Use of WB-LGE-CMR sequence in ICD-patients allows adequate VT substrate characterization to guide VT ablation with similar accuracy than conventional LGE-CMR in patients without an ICD.

Objectives This study aimed to characterize the long-term scar remodeling process after an acute myocardial infarction (AMI) and the underlying scar-related arrhythmogenic substrate using serial late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Background Little is known about the time course needed for completion of the scar healing process after an AMI, which can be assessed by noninvasive cardiac imaging techniques such as LGE-CMR. Methods Fifty-six patients with revascularized ST-segment elevation AMI (STEMI) were consecutively included. LGE-CMR (3-T) was obtained at 7 days, 6 months, and 4 years after STEMI. The myocardium was segmented into 10 layers from the endocardium to epicardium, characterizing the core, border zone (BZ), and BZ channels (BZCs) using a dedicated post-processing software. Results Mean age of the patients was 57 ± 11 years; 77% were men. Left ventricular ejection fraction improved at 6 months from 47% to 51% (p Conclusions CMR data post-processing permitted a dynamic assessment of quantitative and qualitative post-AMI scar characteristics. Scar size and number of BZCs steadily decreased 4 years after AMI. BZC distribution was significantly modified during this time. These dynamic parameters could be reliably assessed with CMR; their evaluation might be of prognostic value.

BACKGROUND: Cardiac magnetic resonance (CMR) performed early after ST-segment elevation myocardial infarction (STEMI) can improve major adverse cardiac event (MACE) risk prediction. We aimed to create a simple clinical-CMR risk score for early MACE risk stratification in STEMI patients.; METHODS: We performed a multicenter prospective registry of reperfused STEMI patients (n=1118) in whom early (1-week) CMR-derived left ventricular ejection fraction (LVEF), infarct size and microvascular obstruction (MVO) were quantified. MACE was defined as a combined clinical endpoint of cardiovascular (CV) death, non-fatal myocardial infarction (NF-MI) or re-admission for acute decompensated heart failure (HF).; RESULTS: During a median follow-up of 5.52 [2.63-7.44] years, 216 first MACE (58 CV deaths, 71 NF-MI and 87 HF) were registered. Mean age was 59.3±12.3years and most patients (82.8%) were male. Based on the four variables independently associated with MACE, we computed an 8-point risk score: time to reperfusion >4.15h (1 point), GRACE risk score>155 (3 points), CMR-LVEF 1.5 segments (1 point). This score permitted MACE risk stratification: MACE per 100 person-years was 1.96 in the low-risk category (0-2 points), 5.44 in the intermediate-risk category (3-5 points), and 19.7 in the high-risk category (6-8 points): p4.15h and GRACE risk score>155) and CMR (LVEF 1.5 segments) variables allows for simple and straightforward MACE risk stratification early after STEMI. External validation should confirm the applicability of the risk score. Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.

Immunoglobulin light-chain (AL) amyloidosis is a systemic disease characterized by the production and deposition of light chain-derived amyloid fibrils in different organs. Prompt treatment directed to the underlying plasma cell clone is crucial in order to achieve a rapid, deep and durable hematologic response. The decrease in the production of the amyloidogenic light chains is a required condition to obtain the organ response, which is commonly delayed. Meanwhile, supportive treatment is aimed to maintain quality of life of these patients and preserve their involved organs’ function. From simple measures, such as salt restriction or compressive stockings, to very complex interventions, such as heart transplantation in very selected patients with isolated severe cardiac involvement, this supportive care is essential and has to be necessarily included in the multidisciplinary management of this disease.

To investigate the role of classical (CLM, CD14++CD16−), intermediate (INTM, CD14++CD16+), and non-classical (Non-CLM, CD14+CD16++) monocytes in scar formation after ST-elevation myocardial infarction (STEMI), evaluated with cardiac magnetic resonance (CMR). One hundred two patients with a first STEMI had serial blood analyses after 1, 3, and 7 days. A CMR was performed at 7 days and 6 months, depicting scar core (CO), border zone (BZ), and the presence of BZ channels. CLM and INTM levels progressively decreased, correlated with the scar mass, CO, and BZ at 7 days and 6 months (p

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” Background. Cardiovascular magnetic resonance (CMR) is the best tool for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of sequential LVEF assessment for major adverse cardiac event (MACE) prediction after ST-segment elevation myocardial infarction (STEMI) is uncertain. Purpose. We explored the prognostic impact of sequential assessment of CMR-derived LVEF after STEMI to predict subsequent MACE. Methods. We recruited 1036 STEMI patients in a large multicenter registry. LVEF (reduced [r]: 3 months of follow-up. MACE was regarded as cardiovascular death or re-admission for acute heart failure after follow-up CMR. Results. During a 5.7-year mean follow-up, 82 MACE (8%) were registered. The MACE rate was higher only in patients with LVEF Conclusions. LVEF constitutes a pivotal CMR index for simple and dynamic post-STEMI risk stratification. Detection of reduced LVEF (

Coronavirus disease 19 (COVID-19) presents with disease severities of varying degree. In its most severe form, infection may lead to respiratory failure and multi-organ dysfunction. Here we study the levels and evolution of the damage associated molecular patterns (DAMPS) cell free DNA (cfDNA), extracellular histone H3 (H3) and neutrophil elastase (NE), and the immune modulators GAS6 and AXL in relation to clinical parameters, ICU scoring systems and mortality in patients (n = 100) with severe COVID-19. cfDNA, H3, NE, GAS6 and AXL were increased in COVID-19 patients compared to controls. These measures associated with occurrence of clinical events and intensive care unit acquired weakness (ICUAW). cfDNA and GAS6 decreased in time in patients surviving to 30 days post ICU admission. A decrease of 27.2 ng/mL cfDNA during ICU stay associated with patient survival, whereas levels of GAS6 decreasing more than 4.0 ng/mL associated with survival. The presence of H3 in plasma was a common feature of COVID-19 patients, detected in 38% of the patients at ICU admission. NETosis markers cfDNA, H3 and NE correlated well with parameters of tissue damage and neutrophil counts. Furthermore, cfDNA correlated with lowest p/f ratio and a lowering in cfDNA was observed in patients with ventilator-free days., The study was supported through grants from the dedSciLifeLab/KAW national COVID-19 research program project grant (MH), by Scilifelab, the Knut and Alice Wallenberg Foundation and in part by the Swedish Research Council (RF, grant no 2014-02569 and 2014-07606), and the Netherlands Thrombosis Foundation (GN).

Background Magnetic resonance imaging (MRI) is the most accurate imaging technique for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of LVEF assessment at any time after ST-segment elevation myocardial infarction (STEMI) for subsequent major adverse cardiac event (MACE) prediction is uncertain. Purpose To explore the prognostic impact of MRI-derived LVEF at any time post-STEMI to predict subsequent MACE (cardiovascular death or re-admission for acute heart failure). Study Type Prospective. Population One thousand thirteen STEMI patients were included in a multicenter registry. Field Strength/Sequence 1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences. Assessment Post-infarction MRI-derived LVEF (reduced [r]: = 50%) was sequentially quantified at 1 week and after >3 months of follow-up. Statistical Tests Multi-state Markov model to determine the prognostic value of each LVEF state (r-, mr- or p-) at any time point assessed to predict subsequent MACE. A P-value During a 6.2-year median follow-up, 105 MACE (10%) were registered. Transitions toward improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to a higher incidence of subsequent MACE. The observed transitions from r-LVEF, mr-LVEF, and p-LVEF states to MACE were: 15.3%, 6%, and 6.7%, respectively. Regarding the adjusted transition intensity ratios, patients in r-LVEF state were 4.52-fold more likely than those in mr-LVEF state and 5.01-fold more likely than those in p-LVEF state to move to MACE state. Nevertheless, no significant differences were found in transitions from mr-LVEF and p-LVEF states to MACE state (P-value = 0.6). Data Conclusion LVEF is an important MRI index for simple and dynamic post-STEMI risk stratification. Detection of r-LVEF by MRI at any time during follow-up identifies a subset of patients at high risk of subsequent events. Level of Evidence 2 Technical Efficacy Stage 2

Funding Acknowledgements Type of funding sources: None. Introduction Myocardial T1 mapping constitutes a reliable indicator of heart diseases related to changes of myocardial extracellular content (e.g. oedema, fibrosis) as well as fat, iron and amyloid content. T1-mapping techniques rely on fitting a model to a series of MRI measurements. Alignment between these measurements is required for accurate T1 estimation. This is limited by triggering accuracy and patient motion. Image registration is often applied to improve the alignment. In the case of MOLLI series, registration is compromised by contrast variation between the images. We present the validation of a new registration method, designed to account for the contrast properties of MOLLI data. Methods A cohort of 186 patients referred for a CMR was included in this study (115 M / 71 F; weight 75 ± 15 Kg; age 55 ± 16). Scans on a 3.0T MR included a MOLLI sequence with target parameters: 2D bSSFP, 160x148, pFOV 0.8-1.0, 1.4x1.4mm², ST 8mm, TE 1.4ms, TR 3.0ms, FA 35deg, NEX 1, BW 100kHz, 2x ASSET, 5(3)3. Cartesian 2D reconstruction followed by motion correction was applied retrospectively. A new correction algorithm was implemented, based on a similarity criterion that accounted for T1 relaxation: It consisted of an iterative approach alternating polarity estimation, T1 fitting, relaxation simulation and frame registration. The coefficient of determination (R²) was used as a quality measure. A representative subset of the results was reviewed by two experienced cardiologists. Results All reconstructions (totalling 1133 2D MOLLI series) yielded qualitatively correct T1 maps. Results with the new method were compared to conventional motion correction and no correction. The number of pixels with R²>0.95 was 85%±9% with standard motion correction and 90%±7% with the new dedicated method. In terms of improvement w.r.t. uncorrected data, the standard method yielded +3%±8% and the new one +9%±8%. Motion correction caused noticeable performance degradation in 12% of cases with the standard method, compared to 0.2% with the proposed method. The relative performance of the different methods can be appreciated in Figure 3. Discussion Despite T1 mapping techniques constituting a reliable diagnostic tool in cardiac imaging, they remain sensitive to patient motion and triggering inaccuracies, making them vulnerable to arrhythmia episodes. Improving the similarity criterion by accounting for T1 relaxation significantly decreased the incidence of misregistration and subsequent T1 inaccuracies. Using the R² of the voxel-wise T1 fit as a surrogate of alignment allowed to confirm the increased robustness of the new, dedicated motion correction method for MOLLI series. Conclusion We have demonstrated a new reconstruction pipeline with built-in registration, optimized for MOLLI T1-mapping. Using a large database of clinical data, the new method has been shown to improve the robustness to motion of cardiac T1 mapping. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Introduction Myocardial delayed enhancement (MDE) MRI plays an important role in the identification of several cardiac conditions, both ischemic and non-ischemic (e.g. myocarditis, IDC, amyloidosis). 3D imaging offers increased resolution, full heart coverage and better depiction of complex pathologies, but its image quality is limited by long acquisition times. Deep learning (DL) models enable advanced reconstruction algorithms that yield regularized images in practical computation times. In this study we evaluate a novel 3D-DL reconstruction to overcome the trade-off between reconstructed quality and acquisition time on MDE data. Methods A group of 14 subjects referred for CMR (5 F / 9 M, 59 ± 11 y.o., 78 ± 13 kg) were scanned with a 3D MDE sequence prototype: SPGR with IR preparation, fat & spatial saturation, respiratory navigator, ARC 2x, FOV 40x40cm, ST 1.4-2.4mm, matrix 280²-320², FA 20deg, BW 62.5 kHz, TE 2.1 ± 0.1ms, TI based on a CINE IR scout. All were retrospectively reconstructed using a 3D DL algorithm, trained on a database of over 700 datasets to reconstruct high-quality images with adjustable noise reduction. The images were compared with standard 3D Cartesian reconstruction by two experienced cardiologists, to identify alterations in morphology or contrast distribution. Noise was estimated using the intensity standard deviation on a blood pool ROI. Feature preservation was estimated using the structural similarity index (SSI). Results The new method improved perceived image quality without loss of structural information or resolution (fig 1). Quantitative analysis (fig 2) confirmed these results: The average coefficient of variation in the blood was 0.08 ± 0.02 in the reference and 0.05 ± 0.02 with the new method; Given a target image noise level, DL reconstruction yielded up to 10% better SSI, compared to anisotropic filtering. The clinical review didn’t reveal diagnostically significant alterations of structure or uptake pattern. A perceived reduction of sharpness was initially reported but individual examination of landmarks (e.g. pulmonary and coronary arteries) confirmed that no relevant features were being lost with the new reconstruction. Discussion The 3D MDE images obtained with DL reconstruction improved the trade-off between image noise -estimated by the blood pool intensity deviation- and feature preservation -estimated by SSI-. Consistent improvement of image quality without morphological alterations of diagnostic relevance indicates that the new method can be considered for clinical practice. The next step in the validation process will require testing the robustness over a large set of cases with heterogeneous acquisition settings. Conclusion We presented the preliminary evaluation of a deep learning reconstruction method with 3D myocardial delayed enhancement data. The results show systematic improvement of overall image quality without loss of relevant diagnostic information. Abstract Figure.

[EN] Background Cardiac magnetic resonance (CMR) permits robust risk stratification of discharged ST-segment-elevation myocardial infarction patients, but its indiscriminate use in all cases is not feasible. We evaluated the utility of left ventricular ejection fraction (LVEF) by echocardiography for a selective use of CMR after ST-segment-elevation myocardial infarction. Methods Echocardiography and CMR were performed in 1119 patients discharged for ST-segment-elevation myocardial infarction included in a multicenter registry. The prognostic power of CMR beyond echocardiography-LVEF was assessed using adjusted C statistic, net reclassification improvement index, and integrated discrimination improvement index. Results During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 readmissions for acute heart failure). In the entire group, CMR-LVEF (but not echocardiography-LVEF) independently predicted MACE occurrence. The MACE rate significantly increased only in patients with CMR-LVEF= 50%: 7%, 40%-49%: 9%, = 50% (629, 56%), and they had a low MACE rate (57/629, 9%). In patients with echocardiography-LVEF= 40% (24/278, 9%) but significantly increased in patients with CMR-LVEF= 50% (C statistic 0.66 versus 0.66; net reclassification improvement index, 0.17; integrated discrimination improvement index, 0.01). Conclusions A straightforward strategy based on a selective use of CMR for risk prediction in ST-segment-elevation myocardial infarction patients with echocardiography-LVEF, This work was supported by Instituto de Salud Carlos III and Fondos Europeos de Desarrollo Regional FEDER (grant numbers PI15/00531, PI17/01836, PI20/00637 and, CIBERCV16/11/00486), Marato TV3 (grant number 20153030-31-32), a grant from the Catalonian Society of Cardiology 2015, and Generalitat Valenciana (grant number GV/2018/116). The study was partially funded by Siemens Healthcare, which provided financial support to conduct CMR studies in 94 subjects of this series. D.M. acknowledges financial support from the Agencia Valenciana de la Innovacion, Generalitat Valenciana (grant number INNCAD00/19/085), and from the Conselleria d'Educacio, Investigacio, Cultura i Esport, Generalitat Valenciana (grant number AEST/2019/037).

Objectives The authors sought to evaluate cardiac activity of angiotensin-converting enzyme (ACE) and ACE2 after heart transplantation (HT) and its relation with acute rejection (AR) and chronic allograft vasculopathy (CAV). Background The renin-angiotensin system is altered in heart failure and HT. However, ACE and ACE2 activities in post-HT acute and chronic rejection have not been previously studied. Methods HT patients (n = 45) were included when appropriate serial endomyocardial biopsies (EMB) and coronary angiography were available for analysis. In 21 patients, three post-HT time points were selected for CAV study in EMB tissue: basal (0–3 wks), second (2–3 months) and third (4–5 months). At 10 years post-HT, CAV was evaluated by coronary angiography (CA) and patients were grouped by degree of CAV: 0–1, non-CAV (n = 15) and 2–3, CAV (n = 6). For the AR study, 28 HT patients with evidence of one EMB rejection at grade 3 and two EMB grade 1A and/or 1B rejections were selected. Results Post-HT, ACE2 activity was increased in the CAV group, compared to non-CAV. Patients with AR showed increased ACE, but not ACE2, activity. Conclusions Our results suggest that early post-HT cardiac ACE2 activity may have an important role in CAV development. In contrast, ACE activity was increased in AR. The renin-angiotensin system seems to be altered after HT and strategies to balance the system may be useful.

Aims Left ventricular (LV) outflow tract ventricular arrhythmias (OTVA) are associated with hypertension (HT), older age, and LV dysfunction, suggesting that LV overload plays a role in the aetiopathogenesis. We hypothesized that anatomical modifications of the LV outflow tract (LVOT) could predict left vs. right OTVA site of origin (SOO). Methods and results Fifty-six (32 men, 53 ± 18 years old) consecutive patients referred for OTVA ablation were included. Cardiac multidetector computed tomography was performed before ablation and then imported to the CARTO system to aid the mapping and ablation procedure. Anatomical characteristics of the aortic root as well as aortopulmonary valvular planar angulation (APVPA) were analysed. The LV was the OTVA SOO (LVOT-VA) in 32 (57%) patients. These patients were more frequently male (78% vs. 22%, P = 0.001), older (57 ± 18 vs. 47 ± 18 years, P = 0.055), and more likely to have HT (59% vs. 21%, P = 0.004), compared to right OTVA patients. Aortopulmonary valvular planar angulation was higher in LVOT-VA patients (68 ± 5° vs. 55 ± 6°, respectively; P

Background Patients with transmural myocardial infarction (MI) who undergo endocardial-only substrate ablation are at increased risk for ventricular tachycardia recurrence. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) can be used to assess infarct transmurality (IT). However, the degree of IT associated with an epicardial arrhythmogenic substrate (AS) has not been determined. Objective The purpose of this study was to determine the degree of IT observed by LGE-CMR and multidetector computed tomography (MDCT) that predicts the presence of epicardial AS. Methods The study included 38 post-MI patients. Ten patients with a subendocardial infarction underwent endocardial-only mapping, and 28 with a classic transmural MI (C-TMI), defined as hyperenhancement ≥75% of myocardial wall thickness (WT), underwent endo–epicardial mapping. LGE-CMR/MDCT data were registered to high-density endocardial or epicardial maps to be analyzed for the presence of AS. Results Of the 28 post-MI patients with C-TMI, 18 had epicardial AS (64%) and 10 (36%) did not. An epicardial scar area ≥14 cm2 on LGE-CMR identified patients with epicardial AS (sensitivity 1, specificity 1). Mean WT in the epicardial scar area in these patients was lower than in patients without epicardial AS (3.14 ± 1.16 mm vs 5.54 ± 1.78 mm; P = .008). A mean WT cutoff value ≤3.59 mm identified patients with epicardial AS (sensitivity 0.91, specificity 0.93). Conclusion An epicardial scar area ≥14 cm2 on LGE-CMR and mean CT-WT ≤3.59 mm predict epicardial AS in post-MI patients.

Background: Serum soluble AXL (sAXL) and its ligand, Growth Arrest-Specific 6 protein (GAS6), intervene in tissue repair processes. AXL is increased in end-stage heart failure, but the role of GAS6 and sAXL in ST-segment elevation myocardial infarction (STEMI) is unknown. Objectives: To study the association of sAXL and GAS6 acutely and six months following STEMI with heart failure and left ventricular remodelling. Methods: GAS6 and sAXL were measured by enzyme-linked immunosorbent assay at one day, seven days and six months in 227 STEMI patients and 20 controls. Contrast-enhanced magnetic resonance was performed during admission and at six months to measure infarct size and left ventricular function. Results: GAS6, but not sAXL, levels during admission were significantly lower in STEMI than in controls. AXL increased progressively over time ( p1) had higher values of sAXL at day 1 (48.9±11.9 vs. 44.0±10.7 ng/ml; pConclusion: sAXL levels increased following STEMI. Patients with heart failure and left ventricular remodelling have higher sAXL levels acutely and at six month follow-up. These findings suggest a potential role of the GAS6–AXL system in the pathophysiology of left ventricular remodelling following STEMI.

Predicting sudden cardiac death risk in the first months after ST-segment elevation myocardial infarction (STEMI) remains challenging.The purpose of this study was to investigate the ability of late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) to identify the potentially arrhythmogenic substrate and its temporal evolution after STEMI.One hundred consecutive patients with a first STEMI were included. Three-dimensional high-resolution LGE-CMR was obtained at 3 T on days 7 and 180. Left ventricular wall was segmented and characterized by pixel signal intensity algorithm in 5 layers from endocardium to epicardium. A 3-dimensional color-coded shell map was obtained for each layer, depicting scar core and border zone (BZ) distribution. Presence and characteristics of BZ channels were registered for each layer.At 180 days, left ventricular ejection fraction had improved significantly (from 46.7% ± 10% to 51.5% ± 10%; P.001) and scar mass was reduced (from 22.6 ± 20 g to 13.8 ± 12 g; P.001). Most BZ channels (89%) were identified in the same myocardial layer and American Heart Association (AHA) segment, with the same orientation and morphology in both studies. Early LGE-CMR had 96% sensitivity and 90% specificity for predicting presence of BZ channels at 180 days. Greater presence was observed in patients with no-reflow phenomenon at baseline (P = .01).Most BZ channels can be identified by LGE-CMR at day 7 post-STEMI and, despite scar mass reduction, remain unaltered at 6 months, suggesting that the potentially arrhythmogenic substrate is established within the first week post-STEMI.

Introduction Hereditary transthyretin amyloidosis (ATTRv) is often associated with progressive infiltrative cardiac involvement, with cardiac symptoms occurring sometimes years prior to diagnosis. Hypothesis ATTRv patients demonstrate significant cardiovascular symptom manifestations and healthcare utilization prior to diagnosis. Methods Newly diagnosed ATTRv patients in IBM® MarketScan® Commercial and Medicare Supplemental data (US) were identified using a claims-based algorithm. Diagnosis required ≥1 claim with relevant amyloidosis diagnosis code (ICD-10-CM: E85.0-.4, E85.89, E85.9) during identification (ID) period (1/2016-12/2017), and the occurrence of ≥1 qualifying criteria during 2011-2017: ≥15 days diflunisal use, liver transplant, or claim with code E85.1 (neuropathic heredofamilial amyloidosis) or E85.2 (heredofamilial amyloidosis unspecified). Index date was defined as date of first claim with amyloidosis code in ID period, and the pre-index period as the 5 years prior to index date. Patients with an ICD-9/10 amyloidosis code during this period were excluded to focus on the newly diagnosed. Control subjects without ATTRv were identified and matched (age, gender, region) to ATTRv patients (ratio 3:1); meeting the same index and enrollment requirements. Frequency of selected cardiovascular (CV) conditions and healthcare use were measured in the pre-index period; demographics and Charlson comorbidity index (CCI) were measured 1 year pre-index. Results Among 141 patients with ATTRv and 423 matched controls, mean (SD) age was 62.5 (14.2) years and 53.9% were female. Mean CCI for ATTRv patients was 2.7 (3.0) vs 1.1 (1.9) for controls. In the pre-index period, CV conditions were more common among ATTRv patients relative to controls: chest pain (51.8 vs. 28.1%), dyspnea (49.6 vs 25.8%), bleeding (41.8 vs 21.3%), edema (27.0 vs 12.8%), heart failure (23.4 vs 5.9%), ventricular hypertrophy (19.9 vs 5.7%), hypotension (18.4 vs 6.1%), atrial fibrillation/flutter (18.0 vs 8.9%), stroke (12.8 vs 6.1%), and aortic stenosis (10.6 vs 4.5%); conditions were relatively higher in each pre-index year. Hospitalization (47.5 vs. 24.3%), emergency department visits (60.3 vs. 47.0%) and cardiac testing (81.6 vs. 65.7%) were also more frequent among ATTRv patients. Median time (months) to ATTRv diagnosis from initial symptom manifestation were largest for chest pain (43.0), dyspnea (41.1), aortic stenosis (39.2), and atrial fibrillation/flutter (34.3). Conclusions ATTRv patients have considerable CV disease burden in the 5 years preceding diagnosis. Increased awareness of characteristic CV manifestations may increase clinical suspicion, leading to early diagnosis and prompt intervention.

Aims Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) permits characterizing ischaemic scars, detecting heterogeneous tissue channels (HTCs) which constitute the arrhythmogenic substrate (AS). Late gadolinium enhancement cardiac magnetic resonance also improves the arrhythmia-free survival when used to guide ventricular tachycardia (VT) substrate ablation. However, its availability may be limited. We sought to evaluate the performance of multidetector cardiac computed tomography (MDCT) imaging in identifying HTCs detected by LGE-CMR in ischaemic patients undergoing VT substrate ablation. Methods and results Thirty ischaemic patients undergoing both LGE-CMR and MDCT before VT substrate ablation were included. Using a dedicated post-processing software, two blinded operators, assigned either to LGE-CMR or MDCT analysis, characterized the presence of CMR and computed tomography (CT) channels, respectively. Cardiac magnetic resonance channels were classified as endocardial (layers < 50%), epicardial (layers ≥ 50%), or transmural. Cardiac magnetic resonance- vs. CT-channel concordance was considered when showing the same orientation and American Heart Association (AHA) segment. Mean age was 69 ± 10 years; 90% were male. Mean left ventricular ejection fraction was 35 ± 10%. All patients had CMR channels (n = 76), whereas only 26/30 (86.7%) had CT channels (n = 91). Global sensitivity (Se) and positive predictive values for detecting CMR channels were 61.8% and 51.6%, respectively. MDCT performance improved in patients with epicardial CMR channels (Se 80.5%) and transmural scars (Se 72.2%). In 4/11 (36%) patients with subendocardial myocardial infarction (MI), MDCT was unable to identify the AS. Conclusions Compared to LGE-CMR, myocardial wall thickness assessment using MDCT fails to detect the presence of AS in 36% of patients with subendocardial MI, showing modest sensitivity identifying HTCs but a better performance in patients with transmural scars.

Background Hereditary transthyretin amyloidosis (hATTR or ATTRv [variant]) is a progressive and fatal disease often associated with infiltrative cardiac involvement, with cardiac symptoms sometimes occurring years before diagnosis. Because there are available treatments for hATTR, prompt recognition and early diagnosis is imperative. Nurses who work closely with patients with heart failure are positioned to recognize the symptoms and early signs that should raise clinical suspicion and uncover an underlying diagnosis of hATTR. Objective To determine whether patients with hATTR demonstrate significant cardiovascular symptom manifestations and health care utilization before diagnosis. Methods Patients with newly diagnosed hATTR were identified in IBM® MarketScan® Commercial and Medicare Supplemental data (United States) using a claims-based algorithm. Diagnosis required ≥1 claim with relevant amyloidosis diagnosis code (ICD-10-CM: E85.0-.4, E85.89, E85.9) during the identification (ID) period (January 2016-December 2017), and the occurrence of ≥1 qualifying criterion during 2011-2017: ≥15 days diflunisal use, liver transplant, or claim with code E85.1 (neuropathic heredofamilial amyloidosis) or E85.2 (heredofamilial amyloidosis unspecified). Index date was defined as date of first claim with amyloidosis code in the ID period, and preindex period was defined as the 5 years before index date. Patients with a preexisting ICD-9/10 amyloidosis code during this period were excluded to focus on patients who were newly diagnosed. Control subjects without hATTR were identified and matched (age, sex, region) to patients with hATTR (ratio 3:1); these subjects were assigned same index and met same continuous enrollment requirement during preindex period. Frequency of selected cardiovascular conditions and health care use were measured in the preindex period; demographics and Charlson comorbidity index (CCI) were measured 1 year preindex. Results Among 141 patients with hATTR and 423 matched controls, mean (SD) age was 62.5 (14.2) years and 53.9% were female. Mean CCI for patients with hATTR was 2.7 (3.0) versus 1.1 (1.9) for controls. In the preindex period, cardiovascular conditions/symptoms were more common among patients with hATTR relative to controls: chest pain (51.8 vs 28.1%; P Conclusions Patients with hATTR have considerable cardiovascular disease burden in the 5 years preceding diagnosis. Increased awareness of characteristic cardiovascular manifestations among nurses may increase clinical suspicion, leading to early diagnosis and prompt intervention.

Aims ST-segment elevation myocardial infarction (STEMI) triggers remote extracellular matrix expansion. Myocardial extracellular volume fraction (ECV), determined by cardiovascular magnetic resonance, permits quantification of interstitial space expansion. Our aim was to determine the relationship between early serum fibrosis biomarkers and 180-day post-infarct remote myocardium remodeling using ECV. Methods and results In 26 patients with STEMI, functional imaging, T1-mapping, and late-gadolinium-enhancement were performed on a 3-T CMR scanner at baseline (days 3 to 5) and 180days. Biomarkers were measured at days 1, 3, and 7 after STEMI. The mean initial and follow-up left ventricular ejection fraction (LVEF) were 48.3±18.1% and 52.6±12.3%, respectively. Initial infarct size was 11.6±16.8% of LV mass. ECV in the remote myocardium at 180days correlated with indexed end-systolic volume (r=0.4, p=0.045). A significant correlation was observed between galectin-3 at day 7 and ECV at 6months (r=0.428, p=0.037). A trend towards a direct correlation was found for BNP (r=0.380, p=0.059). Multivariate analysis revealed that BNP and galectin-3 were independent predictors of long-term changes in ECV and explained nearly 30% of the variance in this parameter (r 2 =0.34; p=0.01). A galectin-3 cutoff value of 10.15ng/mL was the most powerful predictor of high ECV values (≥28.5%) at follow-up. Galectin-3 at day 7 was an independent predictor of high ECV values at follow-up (OR=22.51; CI 95%: 2.1–240.72; p=0.01) with 0.76 AUC (CI: 0.574–0.964; p=0.03). Conclusions Galectin-3 measured acutely after STEMI is an independent predictor of increased ECV at 6-month follow-up that might be useful for long-term risk stratification.

Aims Ablation of frequent premature ventricular complexes (PVCs) improves left ventricular ejection fraction in patients with left ventricular (LV) systolic dysfunction. This study aims to evaluate the long-term hard outcomes and potential prognostic variables in this population. Methods and results Prospective multicentre study including 101 consecutive patients [56 ± 12 years old, 62 (61%) men] with LV systolic dysfunction and frequent PVCs who underwent PVC ablation before November 2015. The last evaluation performed was considered the long-term follow-up (LTFUP) evaluation. Mean follow-up was 34 ± 16 months (range 24–84 months). Ablation was successful in 95 (94%) patients. There was a significant reduction in the PVC burden from 21 ± 12% at baseline to 3.8 ± 6% at LTFUP, P Conclusion In patients with LV systolic dysfunction, ablation of frequent PVCs induces a significant improvement in functional, structural, and neurohormonal status, which persists at LTFUP. A sustained reduction in the baseline PVC burden is associated with a lower risk of cardiac mortality, cardiac transplantation, or hospitalization for heart failure during follow-up.

Introduction and objectives: Neuron-specific enolase (NSE) is a prognostic marker in out-of-hospital cardiopulmonary arrest (OHCA) survivors treated with mild therapeutic hypothermia (MTH). The objectives were to analyze the correlation between dynamic changes in NSE and outcomes and to determine the measurement timing that best predicts neurological status. Methods: Multicenter cohort study including patients admitted after shockable rhythm OHCA and treated with MTH. Serum NSE was sampled at 2 different times and Delta-NSE (%) was calculated as 100 x (NSE2-NSE1)/NSE1. In-hospital mortality and neurological outcome, as assessed by the Cerebral Performance Category (CPC) scale, were evaluated during admission and after a 6-month follow-up. Results: We included 166 patients admitted to 4 hospitals. In-hospital mortality was 31.9%. Almost 60% of patients had a good neurological recovery (CPC 1-2). On univariate and multivariate logistic regression analyses, an increase in NSE levels was associated with higher in-hospital mortality and worse CPC on discharge and after 6-months (P

The mobilization pattern and functionality of endothelial progenitor cells after an acute ischemic event remain largely unknown. The aim of our study was to characterize and compare the short- and long-term mobilization of endothelial progenitor cells and circulating endothelial cells after acute myocardial infarction or atherothrombotic stroke, and to determine the relationship between these cell counts and plasma concentrations of vascular cell adhesion molecule (VCAM-1) and Von Willebrand factor (VWF) as surrogate markers of endothelial damage and inflammation. In addition, we assessed whether endothelial progenitor cells behave like functional endothelial cells. We included 150 patients with acute myocardial infarction or atherothrombotic stroke and 145 controls. Endothelial progenitor cells [CD45-, CD34+, KDR+, CD133+], circulating endothelial cells [CD45-, CD146+, CD31+], VWF, and VCAM-1 levels were measured in controls (baseline only) and in patients within 24h (baseline) and at 7, 30, and 180 days after the event. Myocardial infarction patients had higher counts of endothelial progenitor cells and circulating endothelial cells than the controls (201.0/mL vs. 57.0/mL; p

Aims Non-invasive depiction of conducting channels (CCs) is gaining interest for its usefulness in ventricular tachycardia (VT) ablation. The best imaging approach has not been determined. We compared characterization of myocardial scar with late-gadolinium enhancement cardiac magnetic resonance using a navigator-gated 3D sequence (3D-GRE) and conventional 2D imaging using either a single shot inversion recovery steady-state-free-precession (2D-SSFP) or inversion-recovery gradient echo (2D-GRE) sequence. Methods and results We included 30 consecutive patients with structural heart disease referred for VT ablation. Preprocedural myocardial characterization was conducted in a 3 T-scanner using 2D-GRE, 2D-SSFP and 3D-GRE sequences, yielding a spatial resolution of 1.4 × 1.4 × 5 mm, 2 × 2 × 5 mm, and 1.4 × 1.4 × 1.4 mm, respectively. The core and border zone (BZ) scar components were quantified using the 60% and 40% threshold of maximum pixel intensity, respectively. A 3D scar reconstruction was obtained for each sequence. An electrophysiologist identified potential CC and compared them with results obtained with the electroanatomic map (EAM). We found no significant differences in the scar core mass between the 2D-GRE, 2D-SSFP, and 3D-GRE sequences (mean 7.48 ± 6.68 vs. 8.26 ± 5.69 and 6.26 ± 4.37 g, respectively, P = 0.084). However, the BZ mass was smaller in the 2D-GRE and 2D-SSFP than in the 3D-GRE sequence (9.22 ± 5.97 and 9.39 ± 6.33 vs. 10.92 ± 5.98 g, respectively; P = 0.042). The matching between the CC observed in the EAM and in 3D-GRE was 79.2%; when comparing the EAM and the 2D-GRE and the 2D-SSFP sequence, the matching decreased to 61.8% and 37.7%, respectively. Conclusion 3D scar reconstruction using images from 3D-GRE sequence improves the overall delineation of CC prior to VT ablation.

Resumen Introduccion y objetivos Un 4% de los pacientes con dolor toracico agudo y troponinas y electrocardiograma normales presentan eventos cardiacos adversos como consecuencia del sindrome coronario agudo no diagnosticado. El presente estudio compara la utilidad diagnostica de la tomografia cardiaca y el ecocardiograma de ejercicio en pacientes con probabilidad baja-intermedia de enfermedad coronaria. Metodos Se incluyo prospectivamente a 69 sujetos con dolor toracico agudo y troponinas y electrocardiograma normales a los que se realizo una tomografia cardiaca y un ecocardiograma de ejercicio. Los pacientes con al menos una lesion ≥ 50% o una puntuacion de calcio de Agatston ≥ 400 en la tomografia cardiaca, ecocardiograma de ejercicio positivo o con resultados no concluyentes ingresaron para completar estudio. Resultados El sindrome coronario agudo se confirmo en 17 casos (24,6%), cifra inferior al 42% sospechado segun los hallazgos de la tomografia cardiaca (p Conclusiones La tomografia cardiaca es una alternativa valida al ecocardiograma de ejercicio para el diagnostico de sindrome coronario agudo en pacientes con probabilidad baja-intermedia de enfermedad coronaria. La combinacion de ambas tecnicas podria mejorar el diagnostico.

Currently, the decision to implant an implantable cardiac defibrillator (ICD) as primary prevention (PP) of sudden cardiac death (SCD) is based on the presence of severe left ventricle dysfunction and the New York Heart Association functional class. However, only a minority of PP patients with an indication for an ICD based on these variables will require ICD therapies during follow-up, especially those experiencing nonischemic cardiomyopathy. Thus, better risk stratification tools are needed to improve the identification of patients at SCD risk who could benefit from ICD implant. See Article by Jablonowski et al Myocardial scar provides the substrate for the vast majority of life-threatening ventricular arrhythmias (VAs) and reentry circuits contained in the scar tissue are essential for ventricular tachycardia to occur. Late gadolinium enhancement (LGE) by Cardiac magnetic resonance (CMR) allows identification and quantification of myocardial scar and enables classification into 2 types of tissues: dense scar and border zone (BZ) depending on the signal intensity produced by LGE. BZ tissue can be distributed around the scar as the transition toward normal myocardium and can also be located in the scar thereby creating corridors of BZ inside the scar that connect with normal myocardium. These BZ corridors have a reasonably good correlation with conducting channels on the electroanatomical maps and have been shown to be the substrate for ventricular tachycardias. …

Background Regional citrate anticoagulation (RCA) is being used increasingly in continuous renal replacement therapy (CRRT) as a safer alternative to heparin. However, complex metabolic control to avoid side effects have generated discrepancies about its introduction into everyday practice. We aimed to compare both anticoagulation techniques in terms of efficacy, safety and feasibility. Methods Observational retrospective study performed in 3 specialized ICUs in patients receiving CVVHDF with RCA between January 2013 and May 2016. Heparin-treated patients matched by age, sex and disease severity treated in the preceding year were selected as historic controls. Filter lifetime, number of filters used, haemorrhagic complications and metabolic complications were recorded. Results 54 patients (27 treated with RCA and 27 with heparin) were included in the study. Filter lifetimes in the first 72 hours were 55.1 ± 21.8 hours in the RCA group compared to 38.8 ± 24.8 hours in the heparin group, (p = 0.004). In addition, the number of filters used in the first 72 hours was significantly higher in the heparin group (2.4 ± 1.3 vs. 1.5 ± 0.7; p = 0.004). There was a trend toward a lower incidence of bleeding in the RCA group, with a significantly lower red blood cell transfusion rate (p = 0.027) in the citrate group. No clinically significant metabolic disturbances were observed in the RCA group. Regarding outcomes, there were no significant differences between groups. Conclusions These results suggest that the implementation of CVVHDF with RCA using concentrated citrate solutions prolongs filter lifetime, achieves a longer effective hemodiafiltration time and is a safe and feasible method.

Current European Society of Cardiology guidelines encourage complete reperfusion of non-infarct-related artery lesions in ST-segment elevation myocardial infarction patients. However, the influence that multivessel disease and complete myocardial revascularization may have in left ventricular (LV)

Aims The endocardial vs. epicardial origin of ventricular arrhythmia (VA) can be inferred from detailed electrocardiogram (ECG) analysis. However, despite its clinical usefulness, ECG has limitations. Alternatively, scarred tissue sustaining VAs can be identified by contrast-enhanced cardiac magnetic resonance (ce-CMR). The objective of this study was to determine the clinical value of analysing the presence and distribution pattern of scarred tissue in the ventricles to identify the VA site of origin and the ablation approach required. Methods and results A ce-CMR study was carried out before the index ablation procedure in a cohort of 80 patients with non-idiopathic VA. Hyper-enhancement (HE) in each ventricular segment was coded as absent, subendocardial, transmural, mid-myocardial, or epicardial. The endocardial or epicardial VA site of origin was also assigned according to the approach needed for ablation. The clinical VA was successfully ablated in 77 (96.3%) patients, all of them showing HE on ce-CMR. In segments with successful ablation of the clinical ventricular tachycardia, HE was absent in 3 (3.9%) patients, subendocardial in 19 (24.7%), transmural in 36 (46.7%), mid-myocardial in 8 (10.4%), and subepicardial in 11 (14.3%) patients. Epicardial ablation of the index VA was necessary in 3 (6.1%) ischaemic and 12 (42.9%) non-ischaemic patients. The presence of subepicardial HE in the successful ablation segment had 84.6% sensitivity and 100% specificity in predicting an epicardial origin of the VA. Conclusion Contrast-enhanced cardiac magnetic resonance is helpful to localize the target ablation substrate of non-idiopathic VA and also to plan the approach needed, especially in non-ischaemic patients.

Results The mean age of patients was 50 � 13 years old, and 43% were women. At 6 months, LVEF did not change in the intervention group but significantly decreased in controls, resulting in a � 3.1% absolute difference by echocardiography (p ¼ 0.035) and � 3.4% (p ¼ 0.09) in the 59 patients who underwent CMR. The corresponding absolute difference (95% confidence interval [CI]) in LVEF was � 6.38% (95% CI: � 11.9 to � 0.9) in patients with acute leukemia and � 1.0% (95% CI: � 4.5 to 2.5) in patients undergoing autologous HSCT (p ¼ 0.08 for interaction between treatment effect and disease category). Compared to controls, patients in the intervention group had a lower incidence of the combined event of death or heart failure (6.7% vs. 22%, p ¼ 0.036) and of death, heart failure, or a final LVEF

Left Atrial Sphericity Predicts AF Ablation Outcome Background Atrial fibrillation (AF) ablation outcome is mainly determined by atrial remodeling that, nowadays, is only estimated through clinical presentation (persistent vs. paroxysmal) and left atrial (LA) dimension. The aim of the study was to stage the atrial remodeling process using the Left Atrial Sphericity (LASP) and determine whether this technique may help to predict AF ablation outcome. Methods Consecutive patients who underwent contrast-enhanced cardiac magnetic resonance angiography before AF ablation were included in the study. Three-dimensional reconstruction of LA excluding pulmonary veins and the LA appendage was used to define the LA cavity. The LASP was automatically obtained with self-customized software. Results 106 patients were included and categorized in 3 groups (Gs): discoid-LA (G1), intermediate-LA (G2), and spherical-LA (G3). The G3 patients had larger LA anteroposterior diameter than G1 and G2 patients (47 ± 7 vs 43 ± 6 and 39 ± 5mm; P < 0.001), greater LA volume (90 ± 39 vs 86 ± 24 and 73 ± 20 mm; P = 0.012), and higher prevalence of persistent AF (75% vs 48% and 29%; P = 0.034) structural heart disease (75% vs 19% and 19%; P < 0.001), and AF recurrence at 12 months follow-up (58% vs 29% and 5%, P < 0.001). The LASP had linear correlation to predicted probability of recurrence. Multivariate analysis identified LASP (OR 1.320 [1.096–1.591], P = 0.004) and hypertension (OR 3.694 [1.282–10.645]; P = 0.016) as independent risk factors for arrhythmia recurrence. Conclusion Left Atrial Sphericity is a new independent predictor of recurrence after AF ablation and may be useful in selecting the best candidates for AF ablation.

BACKGROUND Frequent premature ventricular complexes (PVCs) can induce or worsen left ventricular (LV) systolic dysfunction. OBJECTIVE The purpose of this study was to identify the clinical pattern of patients having a "pure PVC-induced" cardiomyopathy at presentation. METHODS This prospective multicenter study included 155 consecutive patients (age 55612 years, 96 men [62%], 23% +/- 12% mean PVC burden) with LV dysfunction and frequent PVCs submitted for ablation and followed up for at least 12 months. Patients with a previously diagnosed structural heart disease (50 [32%]) and those without complete PVC abolition during follow-up who did not normalize LV ejection fraction (LVEF) (24 [15%]) were excluded from the analysis. RESULTS Of the remaining 81 patients, 41 (51%) had a successful sustained ablation, did not have normalized LVEF, and were classified as having PVC-worsened nonischemic cardiomyopathy, and 40 (49%) who had normalized LVEF were considered as having pure PVC-induced cardiomyopathy. The latter group had higher baseline PVC burden (27% +/- 12% vs 12% +/- 8%; P < .001), smaller LV end-diastolic diameter (58 +/- 5 mmvs 60 +/- 6 mm; P=.05), and shorter Kintrinsic QRS (105 +/- 12 vs 129 +/- 24 ms; P130 ms, baseline PVC burden 63 mm. CONCLUSION Almost half of patients with frequent PVCs and low LVEF of unknown origin normalize LVEF after sustained PVC abolition, and these patients can be identified before ablation.

Background Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) provides tissue characterization of ventricular myocardium and scar that can be depicted as pixel signal intensity (PSI) maps. Objective To assess the possible benefit of guiding the ventricular tachycardia (VT) substrate mapping by integrating these PSI maps into the navigation system. Methods In total, 159 consecutive patients (66 ± 11 years old, 151 men [95%]) with scar-related left ventricular (LV) VT were included. VT substrate ablation used the scar dechanneling technique. A CMR-aided ablation using the PSI maps was performed in 54 patients (34%). Procedural data as well as acute and long-term outcomes were compared with those of the remaining 105 patients (66%). Results Mean procedure duration and fluoroscopy time were 229 ± 67 minutes and 20 ± 9 minutes, respectively, without significant differences between groups. Both the number of radiofrequency (RF) applications and RF delivery time were lower in the CMR-aided group (28 ± 18 applications vs 36 ± 18 applications, P = .037, and 19 ± 12 minutes vs 27 ± 16 minutes, P = .009, respectively). After substrate ablation, monomorphic VT inducibility was lower in the CMR-aided than in the control group (17 [32%] vs 53 [51%] patients, P = .022). After a mean follow-up period of 20 ± 19 months, patients from the CMR-aided group had a lower recurrence rate than those in the control group (10 patients [18.5%] vs 46 patients [43.8%], respectively, P = .002; log-rank P = .017). Multivariate analysis found that CMR-aided ablation (hazard ratio, 0.48 [95% Confirdence Interval (CI) 0.24–0.96], P = .037) was an independent predictor of recurrences. Conclusion CMR-aided scar dechanneling is associated with a lower need for RF delivery, higher noninducibility rates after substrate ablation, and a higher VT-recurrence-free survival.

During premature ventricular contractions (PVCs), a spatial displacement of the ventricles and the target ablation site with respect to the sinus rhythm (SR) position is observed during mapping and ablation.To analyze this displacement and its relevance for image integration and PVC ablation.The electroanatomical activation maps (EAMs) of 55 consecutive patients who underwent PVC ablation were analyzed. Spatial displacement between each point position during PVC and SR was obtained.A total of 6923 points from 71 EAMs were analyzed. Overall, the median distance between the point position during SR and PVC for all the points was 9.42 mm (interquartile range [IQR]: 6.19-12.85). The EAM points from the right ventricle showed more displacement than did those from the left ventricle: 10.35 mm (IQR: 7.16-13.95) vs 7.62 mm (IQR: 5.20-10.81); P.001. The ventricular end-diastolic volume of the EAM during SR was greater than that during PVC (median difference: 9.75 [IQR: 0.37-19.67] mL; P = .002). A shorter coupling interval of the PVC was associated with greater spatial displacement (r = -.521; P.001), higher end-diastolic volume reduction with respect to the SR beat (r = -.718; P = .001), and worse image integration (mean point-to-surface distance between EAM and 3-dimensional computed tomography-derived structure; r = -.642; P = .018).There is a significant spatial displacement between the point position in SR and PVC, mainly in the right ventricle. This displacement increases with the shortening of the PVC coupling interval and can result in poorer image fusion and difficult catheter navigation/positioning for ablation.

Aims There is insufficient evidence to implant a combined cardiac resynchronization therapy (CRT) device with defibrillation capabilities (CRT-D) in all CRT candidates. The aim of the study was to assess myocardial scar size and its heterogeneity as predictors of sudden cardiac death (SCD) in CRT candidates. Methods and results A cohort of 78 consecutive patients with dilated cardiomyopathy and class I indication for CRT-D were prospectively enrolled. Before CRT-D implantation, a contrast-enhanced cardiac magnetic resonance (ce-CMR) was performed. The core and border zone (BZ) of the myocardial scar were characterized and quantified with a customized post-processing software. The first appropriate implantable cardioverter defibrillator (ICD) therapy was considered as a surrogate of SCD. During a mean follow-up of 25 months (25–75th percentiles, 15–34), appropriate ICD therapy occurred in 11.5% of patients. In a multivariate Cox proportional hazards regression model for clinical and ce-CMR variables, the scar mass percentage [hazards ratio (HR) per 1% increase 1.1 (1.06–1.15), P < 0.01], the BZ mass [HR per 1 g increase 1.06 (1.04–1.09), P < 0.01], and the BZ percentage of the scar [HR per 1% increase 1.06 (1.02–1.11), P < 0.01], were the only independent predictors of appropriate ICD therapy. Receiver-operating characteristic curve analysis showed that a scar mass

Background— Scar heterogeneity identified with contrast-enhanced cardiac magnetic resonance (CE-CMR) has been related to its arrhythmogenic potential by using different algorithms. The purpose of the study was to identify the algorithm that best fits with the electroanatomic voltage maps (EAM) to guide ventricular tachycardia (VT) ablation. Methods and Results— Three-dimensional scar reconstructions from preprocedural CE-CMR study at 3T were obtained and compared with EAMs of 10 ischemic patients submitted for a VT ablation. Three-dimensional scar reconstructions were created for the core (3D-CORE) and border zone (3D-BZ), applying cutoff values of 50%, 60%, and 70% of the maximum pixel signal intensity to discriminate between core and BZ. The left ventricular cavity from CE-CMR (3D-LV) was merged with the EAM, and the 3D-CORE and 3D-BZ were compared with the corresponding EAM areas defined with standard cutoff voltage values. The best match was obtained when a cutoff value of 60% of the maximum pixel signal intensity was used, both for core ( r 2 =0.827; P r 2 =0.511; P =0.020), identifying 69% of conducting channels (CC) observed in the EAM. Matching improved when only the subendocardial half of the wall was segmented (CORE: r 2 =0.808; P r 2 =0.485; P =0.025), identifying 81% of CC. When comparing the location of each bipolar voltage intracardiac electrogram with respect to the 3D CE-CMR–derived structures, a Cohen κ coefficient of 0.70 was obtained. Conclusions— Scar characterization by means of high resolution CE-CMR resembles that of EAM and can be integrated into the CARTO system to guide VT ablation.

Aims To assess the short- and long-term effects of postconditioning (p-cond) on infarct size, extent of myocardial salvage, and left ventricular ejection fraction (LVEF) in a series of patients presenting with evolving ST-elevation myocardial infarction (STEMI). Previous studies have shown that p-cond during primary percutaneous coronary intervention (PCI) confers protection against ischaemia–reperfusion injury and thus might reduce myocardial infarct size. Methods and results Seventy-nine patients undergoing PCI for a first STEMI with TIMI grade flow 0–1 and no collaterals were randomized to p-cond ( n = 39) or controls ( n = 40). Postconditioning was performed by applying four consecutive cycles of 1 min balloon inflation, each followed by 1 min deflation. Infarct size, myocardial salvage, and LVEF were assessed by cardiac-MRI 1 week and 6 months after MI. Postconditioning was associated with lower myocardial salvage (4.1 ± 7.2 vs. 9.1 ± 5.8% in controls; P = 0.004) and lower myocardial salvage index (18.9 ± 27.4 vs. 30.9 ± 20.5% in controls; P = 0.038). No significant differences in infarct size and LVEF were found between the groups at 1 week and 6 months after MI. Conclusion This randomized study suggests that p-cond during primary PCI does not reduce infarct size or improve myocardial function recovery at both short- and long-term follow-up and might have a potential harmful effect.

ObjectiveThis study aims to evaluate the influence of myocardial scar after premature ventricular complexes (PVC) ablation in patients with left ventricular (LV) dysfunction.Methods70 consecutive patients (58±11 years, 58 (83%) men, 23% (18–32) mean PVC burden) with LV dysfunction and frequent PVCs submitted for ablation were included. A late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) was performed prior to the ablation and a quantitative and qualitative analysis of the scar was done.ResultsLeft ventricular ejection fraction progressively improved from 34.3%±9% at baseline to 44.4%±12% at 12 months (pConclusionsPresence of myocardial scar modulates, but does not preclude, the probability of response to PVC ablation in patients with LV dysfunction.

Objectives This study examined the contribution of symptom-to-reperfusion time, collateral flow, and antegrade flow in the infarct-related artery on myocardial salvage using a combined angiographic–cardiac magnetic resonance (CMR) method. Background The myocardium supplied by an acutely occluded artery defines the anatomical area at risk for infarction. This area can be determined independently of residual coronary flow to the risk region. Moreover, the difference between this area and infarct size constitutes viable myocardium that has been salvaged. Methods In 121 subjects presenting with ST-segment elevation myocardial infarction revascularized by primary percutaneous intervention, the angiographic anatomical area at risk was retrospectively measured using the Bypass Angioplasty Revascularization Investigation Myocardial Jeopardy Index (BARI score). Within 1 week, CMR was performed in the entire cohort and repeated in 89 subjects at 5 ± 3 months to determine infarct size and wall motion recovery. The myocardial salvage index (MSI) was computed as (BARI score − infarct size)/left ventricular mass. Results The MSI was negligible in patients with Thrombolysis In Myocardial Infarction (TIMI) flow grade ≤1, absent collateral vessels, and >4 h of symptom-to-reperfusion time, as compared with patients with TIMI flow grade >1 or existent collateral vessels (0.2 ± 1.0 vs. 6.1 ± 2.0, p Conclusions Early mechanical reperfusion and maintenance of antegrade or collateral flow independently preserves myocardial salvage primarily through a reduction in infarct transmurality. This novel integration of coronary angiography and CMR techniques to quantify myocardial salvage predicts functional recovery and improved prognosis.

The usefulness of contrast-enhanced cardiac magnetic resonance (ce-CMR) to guide the ventricular tachycardia (VT) ablation procedure has not been yet studied. Applied to tissue characterization, ce-CMR has demonstrated its ability to differentiate between normal and scarred tissue, providing details that also permit us to identify dysfunctional but viable myocardium. It has been suggested that the zones characterized as viable myocardium are probably the substrate for the VT reentry circuits.1 On the other hand, it has been described that the lesions produced by radiofrequency (RF) application in the myocardium may be detected by ce-CMR in animal experiments.2,3 However, there is no evidence showing that RF lesions can be observed in vivo in humans. We report the case of a 79-year-old patient with normal coronary arteries and 48% left ventricular (LV) ejection fraction, who presented with repetitive episodes of well tolerated VT (Figure 1). A 1.5-T ce-CMR study was performed the day before the ablation and repeated 24 hours after the procedure. Ten minutes after intravenous administration of gadolinium (gadodiamide, GE Healthcare) at a dose of 0.2 mmol/kg, sequential short axis …

[EN] Conclusion: Assessment of infarct size and MVO with cardiac MR imaging soon after STEMI enables one to make a decision in the prediction of reverse remodeling. (C) RSNA, 2015, Supported by the Instituto de Salud Carlos III and FEDER (grant PI1400271) and the Generalitat Valenciana (grant PROMETEO/2013/007).

Myocardial fibrosis is always present in end-stage heart failure and is a major independent predictor of adverse cardiac outcome. Cardiac magnetic resonance (CMR) is an imaging method that permits a non-invasive assessment of the heart and has been established as the “gold standard” for the evaluation of cardiac anatomy and function, as well as for quantifying focal myocardial fibrosis in both ischaemic and non-ischaemic heart disease. However, cardiac pathologies characterised by diffuse myocardial fibrosis cannot be evaluated by late gadolinium enhancement (LGE) imaging, as there are no reference regions of normal myocardium. Recent improvements in CMR imaging techniques have enabled parametric mapping of relaxation properties (T1, T2 and T2*) clinically feasible within a single breath-hold. T1 mapping techniques performed both with and without contrast enable the quantification of diffuse myocardial fibrosis and myocardial infiltration. This article reviews current imaging techniques, emerging applications and the future potential and limitations of CMR for T1 mapping. Teaching points • Myocardial fibrosis is a common endpoint in a variety of cardiac diseases. • Myocardial fibrosis results in myocardial stiffness, heart failure, arrhythmia and sudden death. • T1-mapping CMR techniques enable the quantification of diffuse myocardial fibrosis. • Native T1 reflects myocardial disease involving the myocyte and interstitium. • The use of gadolinium allows measurement of the extracellular volume fraction, reflecting interstitial space.