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Objectives This study used cardiac magnetic resonance (CMR) to assess left ventricular (LV) remodeling in chronic aortic regurgitation (AR) to identify both forms of myocardial fibrosis and examine its association with clinical outcomes. Background Chronic AR leads to LV remodeling, which is associated with 2 forms of myocardial fibrosis: regional replacement fibrosis that is directly imaged by late gadolinium enhancement (LGE) CMR; and diffuse interstitial fibrosis, which can be inferred by T1 mapping techniques. Methods Patients with chronic AR who were undergoing contrast CMR with T1 mapping for valve assessment from 2011 to 2018 were enrolled. Patients with a confounding etiology of myocardial fibrosis were excluded. In addition to quantification of AR severity and LV volumetrics, LGE and T1 mapping pre- and post-contrast were performed to measure extracellular volume (ECV) and indexed ECV (iECV). Patients were followed up longitudinally to assess for the composite event of death and the need for aortic valve replacement. Results A total of 177 patients with isolated chronic AR were included (66% males, median age 58 years [47.0 years-68.0 years]) with a median follow up of 2.5 years (1.07 years-3.56 years). The iECV significantly increased with AR severity (P Conclusions Among CMR biomarkers of fibrosis, iECV was more closely associated than replacement fibrosis or ECV with survival free of aortic valve replacement.

Myocardial ischemia in hypertrophic cardiomyopathy (HCM) is associated with poor outcomes. Vasodilator stress cardiac magnetic resonance (CMR) can detect and quantitate inducible ischemia in HCM patients. We hypothesized that myocardial ischemia assessed by CMR is associated with myocardial fibrosis and reduced exercise capacity in HCM. In 105 consecutive HCM patients, we performed quantitative assessment of left ventricular volume and mass, wall thickness, segmental wall thickening percent, segmental late Gadolinium enhancement (LGE), and extracellular volume fraction (ECV). Time-signal intensity curves of first pass perfusion sequences were generated for each segment at stress and rest. A myocardial perfusion reserve index (MPRI) (stress/rest slope) was calculated. Patients who underwent an echocardiographic (n = 73) and cardiopulmonary exercise test (n = 37) within 30 days were included. The mean age was 53.2 ± 15.4 years; 60% were male, and 82 patients had asymmetric hypertrophy. Segments with end diastolic thickness ≥ 1.2 cm had a higher burden of LGE (4.1% vs 0.5% per segment), reduced MPRI (2.6 ± 1.5 vs 3.1 ± 1.8) and reduced thickening percent (48.9 ± 41.7% vs. 105.3 ± 59.5%), (P 0.2). In a patient-level multivariable logistic regression model, only LVOT obstruction remained a significant predictor of ischemia burden (P = 0.03). Myocardial ischemia by CMR is associated with myocardial segmental dysfunction and interstitial fibrosis, as assessed by ECV, in HCM patients, even in segments free of LGE. Conversely, quantitative ischemia burden was not associated with replacement fibrosis as assessed by total LGE burden. Patients with ischemia had greater prevalence of dynamic LVOT obstruction; and in a subset of patients with cardiopulmonary exercise testing, ischemia burden was associated with worsened ventilatory efficiency.

Background Cancer therapy-related cardiac dysfunction (CTRD) is a major source of morbidity and mortality in long-term cancer survivors. Decreased GLS predicts decreased left ventricular ejection fraction (LVEF) in patients receiving anthracyclines, but knowledge regarding the clinical utility of baseline GLS in patients at low-risk of (CTRD) is limited. Objectives The purpose of this study was to investigate whether baseline echocardiographic assessment of global longitudinal strain (GLS) before treatment with anthracyclines is predictive of (CTRD) in a broad cohort of patients with normal baseline LVEF. Methods Study participants comprised 188 patients at a single institution who underwent baseline 2-dimensional (2D) speckle-tracking echocardiography before treatment with anthracyclines and at least one follow-up echocardiogram 3 months after chemotherapy initiation. Patients with a baseline LVEF 10% from baseline and an overall reduced LVEF Results Twenty-three patients (12.23%) developed (CTRD). Among patients with (CTRD), the mean GLS was -17.51% ± 2.77%. The optimal cutoff point for (CTRD) was -18.05%. The sensitivity was 0.70 and specificity was 0.70. The area under ROC curve was 0.70. After adjustment for cardiovascular and cancer therapy related risk factors, GLS or decreased baseline GLS ≥-18% was predictive of (CTRD) (adjusted hazards ratio 1.17, 95% confidence interval 1.00, 1.36; p = 0.044 for GLS, or hazards ratio 3.54; 95% confidence interval 1.34, 9.35; p = 0.011 for decreased GLS), along with history of tobacco use, pre-chemotherapy systolic blood pressure, and cumulative anthracycline dose. Conclusions Baseline GLS or decreased baseline GLS was predictive of (CTRD) before anthracycline treatment in a cohort of cancer patients with a normal baseline LVEF. This data supports the implementation of strain-protocol echocardiography in cardio-oncology practice for identifying and monitoring patients who are at elevated risk of (CTRD).

Over the past decade, advances in digital trends and technology have greatly impacted the medical field with rapid delivery of and access to information. The field of cardiovascular medicine in particular has seen major technological advances and is well versed in the use of digital platforms and social media. In these unprecedented times of the COVID-19 pandemic, social media and other digital platforms are essential tools for communication, education, and delivery of information. In this review, we discuss the ways virtual learning and social media are changing medical education and research.

Background Chronic aortic regurgitation (AR) can be associated with myocardial scarring. It is unknown if scarring in AR is linked to poor outcomes and whether aortic valve replacement impacts this association. We investigated the relationship of myocardial scarring to mortality in chronic AR using cardiac magnetic resonance. Methods and Results We enrolled patients with moderate or greater AR between 2009 and 2019 and performed a blinded assessment of left ventricle remodeling, AR severity, and presence and extent of myocardial scarring by late gadolinium enhancement. The primary outcome was all‐cause mortality. We followed 392 patients (median age 62 [interquartile range, 51–71] years), and 78.1% were men, and 25.8% had bicuspid valves. Median aortic valve regurgitant volume was 39 mL (interquartile range, 30–60). Myocardial scar was present in 131 (33.4%) patients. Aortic valve replacement was performed in 165 (49.1%) patients. During follow‐up, up to 10.8 years (median 32.3 months [interquartile range, 9.8–69.5]), 51 patients (13%) died. Presence of myocardial scar (hazard ratio [HR], 3.62; 95% CI, 2.06–6.36; P P P P =0.02). Among patients with myocardial scar, aortic valve replacement was independently associated with a lower risk of mortality (HR, 0.34; 95% CI, 0.12–0.97; P =0.03), even after adjustment for confounders. Conclusions In aortic regurgitation, myocardial scar is independently associated with a 2.5‐fold increase risk in mortality. Aortic valve replacement was associated with a reduction in risk of mortality in patients with scarring.

Objectives The aim of this study was to compare echocardiographic methods of determining tricuspid regurgitation (TR) severity against TR regurgitant volume (TRRV) by cardiovascular magnetic resonance (CMR). Background TR is usually assessed using echocardiography, but it is not known how this compares with quantitative measurements of TR severity by CMR. Methods Echocardiographic and CMR methods were compared in 337 patients. Echocardiographic methods included jet size, hepatic vein flow, inferior vena cava diameter, percentage change in inferior vena cava diameter with inspiration, right atrial end-systolic area and volume, right ventricular end-diastolic and end-systolic areas and fractional area change, vena contracta diameter, effective regurgitant orifice area, and TRRV using the proximal isovelocity surface area method. TRRV by CMR was calculated as the difference between right ventricular end-diastolic and end-systolic volumes and systolic flow through the pulmonic valve. Results Echocardiographic parameters of TR severity had variable accuracy against TRRV by CMR (area under the curve range 0.58 for jet area/right atrial end-systolic area to 0.79 for hepatic vein flow). A multiparametric approach to assessing TR severity according to the 2017 American Society of Echocardiography criteria had 65% agreement with TR severity by CMR. A hierarchal approach based on signals with higher feasibility and accuracy against CMR had 68% agreement, without missing cases of severe TR by CMR. Agreement with CMR by the hierarchal approach was higher than that by the 2017 American Society of Echocardiography guidelines (p = 0.016). Conclusions Several individual echocardiographic parameters of TR severity have satisfactory accuracy against TRRV by CMR. A multiparametric hierarchal approach resulted in 68% agreement with CMR and 100% agreement when a 1-grade difference in TR severity is considered acceptable.

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It is unclear if gender influences aortic regurgitation (AR) related chamber or tissue remodeling. Cardiac magnetic resonance (CMR) accurately determines AR severity and fibrosis burden. We utilized CMR to study gender differences in left ventricular (LV) remodeling to AR. We enrolled patients with

Cardiac magnetic resonance (CMR) allows noninvasive assessment of regional replacement fibrosis and diffuse interstitial fibrosis. Two CMR surrogate biomarkers for diffuse interstitial fibrosis have emerged: extracellular volume (ECV) fraction and indexed ECV. We evaluate CMR biomarkers of

BackgroundPericardial calcification is seen among patients with constrictive pericarditis (CP). However, the pattern of pericardial calcium distribution and the association with clinical outcomes and imaging data are not well described.MethodsThis was a retrospective study from 2007 to 2013 to evaluate the pattern of pericardial calcium distribution by CT in CP using a semiquantitative calcium scoring system to calculate total pericardial calcium burden and distribution. Calcium localisation was allocated to 20 regions named after the corresponding heart structure. Baseline clinical data, imaging data and clinical outcomes were collected and compared between the calcified pericardium and non-calcified pericardium groups. We assessed the effect of pericardial calcium on clinical outcomes and echocardiographic data between the two groups.ResultsOf the 123 consecutive patients with CP (93 male; mean age 61±13 years) between 2007 and 2013, 49 had calcified pericardium and 74 had non-calcified pericardium. Distribution of calcium on the left ventricle (LV) basal anterior, mid-anterior and apical segments in addition to right ventricle (RV) apical segment was involved in 35% of cases. A potential protective role of RV calcium on regional myocardial mechanics was noted.ConclusionPreferential distribution of calcium in CP in a partial band-like pattern (from basal anterolateral LV going inferiorly and then encircling the heart to reach the RV outflow tract) with extension into the mitral and tricuspid annuli was noted. Pericardial calcium was not significantly associated to clinical outcomes.

Background: Coronary angiography (CAG) remains the gold standard to diagnose coronary artery disease (CAD). However, it is associated with multiple risks and its utility is not well defined in the liver transplant population. Alternatives to evaluate for CAD such as coronary artery calcium score (CACS) are being increasingly investigated. Hypothesis: To determine if the absence of coronary arterial calcium (CACS=0) on non-contrast, non-ECG gated chest CT scan can exclude obstructive CAD in liver transplant patients. Methods: We performed a retrospective analysis of data collected from liver transplant recipients. We included patients who had a CT chest without contrast and CAG less than one year apart. Agatston score was derived from non-IV contrast, non-ECG gated chest CT’s utilizing the syngo.via platform (Siemens Healthcare). CACS was compared against CAG. Patients with coronary stents were excluded. We determined NPV, PPV, sensitivity and specificity of using CACS = 0 as predictor of the absence of obstructive CAD. Results: Mean age at date of transplant was 59.03 and males accounted for 68.8% of our population. The negative predictive value for CACS=0 as a predictor of non-obstructive CAD was 100%. Positive predictive value for CACS≥1 was 6.8%. Sensitivity and specificity for the correlation between CACS and CAD were 100% and 33% respectively (Figure 1). CACS was stratified into four subgroups based severity, and we found that all patients with obstructive CAD had scores >400 (Figure 2). Conclusion: The absence of coronary arterial calcium (CACS=0) on non-contrast, non ECG gated chest CT has a high negative predictive value and can exclude the presence of obstructive CAD.

Background Cardiac Allograft Hypertrophy (CAH) assessed by left ventricular mass (LVM) on imaging at 1 year has been validated as an early predictor of mortality and vasculopathy. The biology of such changes could be starting much earlier in the life of the graft and reflect the beginning of a continuum of remodeling of the transplanted heart that finally leads to chronic rejection and graft failure. However, definitive mechanisms and predictors have not been established. Therefore, we aimed to study the molecular mechanisms of CAH characterized by abnormal echo mass in heart transplant patients. We hypothesized there is a specific genetic signature in the myocardium that can predict the morphological mechanisms of CAH. Methods We used data from our heart transplant biopsy repository where consented patients agree for an extra biopsy and blood to be stored for research during their protocol visits. Biopsies are stored at -80C in RNA later. We used samples from 6 month time-point in a small cohort of randomly selected patients and performed full gene expression profiling using Ilumina Beadarray Microarray Technology. Additionally, clinical and echocardiogram parameters were collected at the same time-point. LVM index and relative wall thickness at 6m from transplant were used to define CAH according to ASE Guidelines. Results A total of 16 patients were included in the analysis. 5 patients had normal LV geometry, 8 had concentric remodeling and 3 concentric hypertrophy (CH). Patients in the abnormal group were significantly older than the patients in the normal group (53.4 vs 60.7 years, respectively, p=0.0478) while there were no other statistically significant differences in the rest of the baseline and clinical parameters. Gene expression data showed a distinct signature on the heatmap for CH (Figure 1). There were 40 genes that were differentially expressed in CH group compared to the rest. Conclusion Only 31% of the patients have a normal echo LVM by 6 months and there is a distinct genetic signature for CH suggesting that there is a specific biological change occurring in the heart as early as 6 months that contribute to hypertrophy. We hope to elicit the biological basis of these changes so as to create therapeutic interventions to temper these changes and promote longevity of grafts.

Objective Cardiac amyloidosis (CA) is a rapidly progressive disease that portends poor prognosis. Our objective was to evaluate the prognostic impact of relative regional strain ratio (RRSR, a measure of the relative apical sparing of longitudinal strain (LS)) in CA. Methods This is a retrospective study evaluating 97 patients with CA from 2004 to 2013. Patients were included if they met criteria for CA based on endomyocardial biopsy or advanced imaging criteria coupled with either extracardiac biopsy or genetic analysis. Baseline clinical and imaging data were collected and compared between light-chain amyloidosis (AL) (n=59) and transthyretin amyloidosis (ATTR) (n=38) subtypes. RRSR was defined as the average apical LS divided by the sum of the average mid and basal LS values. A Cox proportional hazards model was used to assess the effects of clinical and echocardiographic characteristics, including RRSR, on the outcome of time to death or heart transplantation. Results Despite younger age, the AL subtype had a statistically significant association with the composite outcome as compared with ATTR (p=0.022). Log-transformed RRSR was independently associated with the composite outcome at 5 years (HR 2.45 (1.36 to 4.40), p=0.003). Patients with low ejection fraction and high RRSR had the worst prognosis. In multivariable analysis, RRSR remained predictive of the primary outcome (p=0.018). Addition of covariates related to systolic function (global LS and ejection fraction) to the model attenuated this effect. Conclusions High RRSR is adversely prognostic in patients with cardiac amyloid. This novel tool is both diagnostic and prognostic and may have implications in management and suitability for treatment.

Recurrent pericarditis (RP) affects 10% to 50% of patients with acute pericarditis. The use of steroids has been associated with increased recurrence rate of pericarditis, along with known major side effects. Cardiac magnetic resonance imaging (CMR) is more frequently used to assess pericardial inflammation and less commonly to guide therapy. The aim of this study was to assess the utility of CMR in the management of RP compared with standard therapy. A total of 507 consecutive patients with RP after the first attack, all of whom were treated with colchicine and nonsteroidal anti-inflammatory drugs as first-line therapy, were retrospectively evaluated. There were 257 patients who were treated with medications and received CMR-guided therapy (group 1) and 250 patients who were treated with medications without CMR (group 2). The 2 groups had similar baseline characteristics and follow-up periods (17 ± 7.9 vs 16.3 ± 16.2 months, respectively, p = 0.97). CMR was used to assess the presence of pericardial inflammation, and on the basis of the results, the clinician made changes to the steroid dose dictated by the severity of inflammation. There was no significant difference in the incidence of constrictive pericarditis, pericardial window, or pericardiectomy between groups during the follow-up. However, group 2 patients had a larger number of steroid pulse therapies (defined as prednisone 50 mg/day orally for 10 days and tapering to none over 4 weeks), and higher overall total milligrams of steroid administered compared with the CMR group (p = 0.003 and p = 0.001, respectively). Recurrence and pericardiocentesis rates were lower in group 1 (p0.0001). In conclusion, CMR-guided therapy modulates the management of RP. This approach decreased pericarditis recurrence and exposure to steroids.

Mortality from cardiogenic shock complicating acute myocardial infarction (MI) remains high despite contemporary treatment. Therapeutic Hypothermia (TH) offers cardiovascular and systemic effects that may prove beneficial in this population, however, current data are limited. This study sought to evaluate the effect of therapeutic hypothermia on serial hemodynamics obtained in subjects with post-cardiac arrest cardiogenic shock.We analyzed serial hemodynamics of 14 consecutive patients with cardiogenic shock after cardiac arrest treated with TH. Study inclusion required baseline hemodynamics obtained prior to initiation of TH confirming cardiogenic shock defined as cardiac index ≤2.2 L/min/m(2) with a systolic blood pressure of ≤90 mmHg, a vasopressor requirement, or need for mechanical circulatory support.In our 14 patients, the mean age was 58 ± 13.1 years, mean ejection fraction was 21 ± 8%, six had an acute MI, 12 required vasopressors, and 10 required mechanical support prior to initiation of TH. When compared to baseline, patients had significant improvements in Fick cardiac index, mixed venous O2 saturations, and serum lactate concentrations while heart rate was reduced following initiation of TH. There was no significant change in mean arterial pressure, however vasopressor requirement was reduced.In patients with cardiogenic shock following cardiac arrest, initiation of TH was associated with favorable changes in invasive hemodynamics suggesting safety in this population. Given potential for favorable hemodynamic and systemic effects of TH in cardiogenic shock, further prospective study of TH as a potentially novel adjunctive therapy to early reperfusion in post-MI cardiogenic shock should be considered.

Introduction: There are no known pathognomonic ECG findings in constrictive pericarditis (CP). Increased pericardial thickness in CP is associated with low QRS voltage secondary to thickening and calcification. We sought to study the correlation between pericardial thickness identified by cardiac magnetic resonance (CMR) and ECG changes pre and post pericardiectomy. Methods and results: 80 consecutive patients with proven constriction underwent pericardiectomy at a Cleveland Clinic between 2009 and 2011. Baseline characteristics, CMR, and pathological specimens were reviewed retrospectively (Table one). Paired t-test and McNemar test were used to analyze pre and post ECG changes for continuous and categorical variables, respectively. There were significantly less patients with Afib, LBBB, RBBB or 1st degree AVB post-pericardiectomy (table1). Also, significant increase in limb and precordial R-wave voltage postop (ΔR 8.2±3.7 and 9±4.3, respectively, p