Search

Background: Cardiac magnetic resonance imaging (CMR) remains underutilized as an exercise imaging modality, mostly because of the limited availability of MR-compatible exercise equipment. This study prospectively evaluates the clinical feasibility of a newly developed MR-conditional pedal ergometer for exercise CMR Methods: Ten healthy volunteers (mean age 44 ± 16 years) and 11 patients (mean age 60 ± 9 years) with known or suspected coronary artery disease (CAD) underwent rest and post-exercise cinematic 3T CMR. Visual analysis of wall motion abnormalities (WMA) was rated by 2 experienced radiologists, and volumes and ejection fractions (EF) were determined. Image quality was assessed by a 4-point Likert scale for visibility of endocardial borders. Results: Median subjective image quality of real-time Cine at rest was 1 (IQR 1–2) and 2 (IQR 2–2.5) for post-exercise real-time Cine (p = 0.001). Exercise induced a significant increase in heart rate (62 [62–73] to 111 [104–143] bpm, p < 0.0001). Stroke volume and cardiac index increased from resting to post-exercise conditions (85 ± 21 to 101 ± 19 mL and 2.9 ± 0.7 to 6.6 ± 1.9 L/min/m 2 , respectively; both p < 0.0001), driven by a reduction in end-systolic volume (55 ± 20 to 42 ± 21 mL, p < 0.0001). Patients (2/11) with inducible regional WMA at high-resolution post-exercise cine imaging revealed significant coronary artery stenosis in subsequently performed invasive coronary angiography. Conclusion: Exercise-CMR using our newly developed 3T MR-conditional pedal ergometer is clinically feasible. Imaging of both cardiac response and myocardial ischemia, triggered by dynamic stress, is rapidly conducted while the patient is near their peak heart rate.

Mitral annular disjunction (MAD) represents the detachment of the mitral leaflet hinge-point from the ventricular myocardium. Its role in patients with ST-segment-elevation myocardial infarction (STEMI) is unknown. This study aims to investigate the prevalence of MAD by cardiac magnetic resonance imaging (CMR) in STEMI-patients and its association with serious adverse events.STEMI-patients (n = 621) underwent CMR 4 days [interquartile range (IQR) 2-5] after percutaneous coronary intervention. Presence and longitudinal extent of MAD were obtained in long-axis cine-images, infarct characteristics in late gadolinium enhancement-images. During a median follow-up time of 366 days (IQR 136-454), patients were observed for the occurrence of major adverse cardiac events (MACE), comprising death, myocardial reinfarction, and congestive heart failure.Overall, 307 patients (49 %) had MAD. Longitudinal MAD-distance was 4.6 ± 1.7 mm and the P3-segment was affected most frequently (n = 262, 85 % of MAD-patients). MAD-patients had a significantly smaller infarct size, lower prevalence of microvascular obstruction, and intramyocardial hemorrhage as well as a higher ejection fraction (all p 0.03). During follow-up period, MACE occurred in 52 patients (8 %) and did not show significant difference between patients with and without MAD (7 % vs. 9 %, p = 0.424). Cardiovascular death occurred significantly more often in patients without MAD (n = 10, 3.2 % vs. n = 2, 0.7 %, p = 0.021).MAD is a rather common finding in patients presenting with STEMI. Patients with MAD had less severe infarct characteristics, however, they were not more commonly affected by MACE. Further confirmation and longer follow-up intervals are necessary to define the exact role of MAD in STEMI patients.

The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI. We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (PPCI). Aortic pulse wave velocity (PWV), the most widely used measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 [interquartile range (IQR) 12–31] months. Cox regression- and logistic regression analysis were performed to explore predictors of aortic stiffness and MACCE. Median aortic PWV was 6.6 m/s (IQR 5.6–8.3 m/s). In multivariable analysis, age [odds ratio (OR) 1.10, 95% confidence interval (CI), 1.08–1.14, p 0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis [hazard ratio (HR) 2.45, 95% CI 1.19–5.04, p = 0.014]. In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome post-STEMI, suggesting it as a relevant therapeutic target in this population. Trial (NCT04113356).

BACKGROUND The role of C-reactive protein velocity (CRPv) as an early and sensitive marker of an excessive inflammatory response in the setting of acute ST-elevation myocardial infarction (STEMI) is only poorly understood. The aim of this study was to investigate, in patients with STEMI treated with primary percutaneous coronary intervention (PCI), the association of CRPv with microvascular infarct pathology. METHODS AND RESULTS This prospective cohort study included a total of 316 patients with STEMI undergoing PCI. CRPv was defined as the difference between CRP 24 ± 8 h and CRP at hospital admission, divided by the time (in h) that have passed during the two examinations. The association of biomarker levels with cardiac magnetic resonance (CMR)-determined microvascular obstruction (MVO) was evaluated. CMR was performed at a median of 3 [interquartile range 2-4] days after PCI. After adjustment for cardiac troponin T (cTnT), anterior infarction and TIMI flow pre and post-PCI, CRPv (odds ratio 2.70, 95% confidence interval (CI) 1.54-4.73; p = 0.001) remained significantly associated with the occurrence of MVO. CRPv (area under the curve [AUC] 0.76, 95% CI 0.71-0.81; p < 0.001) was a better predictor for MVO compared to 24 h CRP (AUC difference: 0.03, p = 0.002). The addition of CRPv to peak cTnT resulted in a higher AUC for MVO prediction than peak cTnT alone (AUC 0.86, 95% CI 0.82-0.90; p < 0.001 vs. AUC 0.84, 95% CI 0.79-0.88; p < 0.001. AUC difference: 0.02, p = 0.042). CONCLUSIONS In patients with STEMI treated with primary PCI, CRPv was associated with microvascular infarct pathology with a predictive value incremental to cTnT, suggesting CRPv as an early and sensitive biomarker for more severe infarct pathology and outcome.

Background Spinal cord ischemia (SCI) remains a devastating complication after aortic dissection or repair. A primary hypoxic damage is followed by a secondary damage resulting in further cellular loss via apoptosis. Affected patients have a poor prognosis and limited therapeutic options. Shock wave therapy (SWT) improves functional outcome, neuronal degeneration and survival in murine spinal cord injury. In this first‐in‐human study we treated 5 patients with spinal cord ischemia with SWT aiming to prove safety and feasibility. Methods and Results Human neurons were subjected to ischemic injury with subsequent SWT. Reactive oxygen species and cellular apoptosis were quantified using flow cytometry. Signaling of the antioxidative transcription factor NRF2 (nuclear factor erythroid 2‐related factor 2) and immune receptor Toll‐like receptor 3 (TLR3) were analyzed. To assess whether SWT act via a conserved mechanism, transgenic tlr3 −/− zebrafish created via CRISPR/Cas9 were subjected to spinal cord injury. To translate our findings into a clinical setting, 5 patients with SCI underwent SWT. Baseline analysis and follow‐up (6 months) included assessment of American Spinal Cord Injury Association (ASIA) impairment scale, evaluation of Spinal Cord Independence Measure score and World Health Organization Quality of Life questionnaire. SWT reduced the number of reactive oxygen species positive cells and apoptosis upon ischemia via induction of the antioxidative factor nuclear factor erythroid 2‐related factor 2. Inhibition or deletion of tlr3 impaired axonal growth after spinal cord lesion in zebrafish, whereas tlr3 stimulation enhanced spinal regeneration. In a first‐in‐human study, we treated 5 patients with SCI using SWT (mean age, 65.3 years). Four patients presented with acute aortic dissection (80%), 2 of them exhibited preoperative neurological symptoms (40%). Impairment was ASIA A in 1 patient (20%), ASIA B in 3 patients (60%), and ASIA D in 1 patient (20%) at baseline. At follow‐up, 2 patients were graded as ASIA A (40%) and 3 patients as ASIA B (60%). Spinal cord independence measure score showed significant improvement. Examination of World Health Organization Quality of Life questionnaires revealed increased scores at follow‐up. Conclusions SWT reduces oxidative damage upon SCI via immune receptor TLR3. The first‐in‐human application proved safety and feasibility in patients with SCI. SWT could therefore become a powerful regenerative treatment option for this devastating injury.

Background The inflammatory response due to myocardial tissue injury in the setting of acute ST-elevation myocardial infarction (STEMI) is essential for proper local infarct healing. However, an excessive inflammatory response may aggravate myocardial damage and hampers infarct healing processes. The present study aimed to investigate the association of systemic inflammatory biomarkers with infarct size (IS) dynamics post-STEMI, using cardiac magnetic resonance (CMR) imaging. Methods This prospective observational study included 245 STEMI patients treated with primary percutaneous coronary intervention (pPCI). Peak values of high-sensitivity C-reactive protein (hs-CRP), white blood cell count (WBCc) and fibrinogen were determined serially until 96 hours after pPCI. Infarct healing, defined as relative IS reduction from baseline to 4 months after STEMI, was assessed using late gadolinium enhanced CMR imaging. Results IS significantly decreased from 16% of left ventricular mass (LVM) (Interquartile range [IQR]:8–24) at baseline to 10% (IQR:5–17) at 4 months (p Conclusions In STEMI patients treated with pPCI, hs-CRP was independently associated with 4 months IS reduction as determined by CMR, suggesting a pathophysiological interplay between inflammation and adverse infarct healing in survivors of acute STEMI. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Austrian Society of Cardiology

Mitral annular calcification (MAC) is a chronic, degenerative condition of the fibrous mitral annulus, which may transform to liquefaction necrosis MAC, a rare variant of caseous MAC. We present a series of experiences, showing the varying manifestations of caseous MAC according to multimodal imaging. (Level of Difficulty: Intermediate.), Graphical abstract

Aims Amyloid cardiomyopathy is an underappreciated cause of morbidity and mortality. Recent evidence suggests that ATTR wild‐type cardiomyopathy (ATTRwt‐CM) is probably much more common than widely appreciated. So far, no data are available on comparison of mortality from ATTRwt‐CM and other heart failure aetiologies. Methods and results This was a retrospective, observational, cohort study of 2251 patients and their data collected prospectively from May 2000 to June 2018. Long‐term mortality was the main outcome measure. Underlying cardiomyopathies were classified as amyloid CM (6.1%) [ATTRwt 3.0%; light‐chain amyloidosis (AL) 3.1%], dilated CM (dCMP) (46.4%), ischaemic heart disease (IHD) (24.4%), hypertensive heart disease (HHD) (14.6%), hypertrophic CM (HCM) (5.1%), and valvular heart disease (VHD) (3.4%). Median duration of follow‐up was 7.1 years (interquartile range 3.4–11.3). Five‐year overall survival in the whole cohort was 80.1%. In multivariate analysis, individuals with amyloid CM were 3.74 times [95% confidence interval (CI) 2.72–5.14; P

For patients suffering from acute ST-elevation myocardial infarction (STEMI), it is controversial whether infarct location predicts worse clinical outcome independently of infarct size. We therefore aimed to investigate the prognostic relevance of infarct location in relation to infarct size in STEMI patients treated with contemporary primary percutaneous coronary intervention (PCI).Cardiac magnetic resonance was performed in 355 patients with acute STEMI 3 (interquartile range [IQR]: 2-4) days after primary PCI. Infarct location, infarct size, and microvascular obstruction were assessed by late gadolinium enhancement (LGE). Patients were followed for major adverse cardiac events (MACE) at a median follow-up of 35 (IQR: 12-52) months.One hundred and sixty five patients (47%) had anterior STEMI. These patients had a greater infarct size as compared to non-anterior STEMI patients (19 vs. 12% of left ventricular myocardial mass, p .001), but no significant differences in microvascular obstruction occurrence and extent (p = .26 and p = .09, respectively). MACE occurred in 39 patients (11%). Patients with anterior STEMI had a higher risk of MACE (hazard ratio: 2.01; 95% confidence interval: 1.05-3.83; p = .03). In multivariable analysis, infarct severity by LGE imaging but not its location was independently associated with an increased risk of MACE (hazard ratio: 1.03; 95% confidence interval: 1.01-1.06; p = .01).The higher rate of medium-term MACE in anterior STEMI treated with contemporary primary PCI is explained by a larger extent of myocardial damage as determined by CMR imaging without any further contribution of infarct location.

Background Eosinophilic myocarditis (EM) is a rare disease with different clinical pictures and disease courses. Little literature is available on the various courses of the disease. Case summary A previously healthy 44-year-old male patient presented with acute heart failure and developed complete atrioventricular (AV) block requiring pacing. Acute heart failure was managed with inotropic support, non-invasive ventilation, and implantation of a permanent AV-sequential pacemaker. Cardiac magnetic resonance imaging was suggestive of myocarditis and endomyocardial biopsy diagnosed EM histologically. Endomyocardial biopsy was essential for definite aetiologic assignment, thus dispelling initial reservations about immunosuppressive therapy. Final treatment strategy consisted of steroids and Azathioprine. Discussion Endomyocardial biopsy is essential to establish diagnosis and targeted treatment in EM, which can rapidly lead to life-threatening conditions. Left ventricular function recovered within 2 weeks in response to immunosuppression and the patient was consistently well during follow-up. Despite the otherwise good response to immunosuppression, complete AV block continued over time.

Background: Cardiac troponin (cTn) T and cTnI are considered cardiac specific and equivalent in the diagnosis of acute myocardial infarction. Previous studies suggested rare skeletal myopathies as a noncardiac source of cTnT. We aimed to confirm the reliability/cardiac specificity of cTnT in patients with various skeletal muscle disorders (SMDs). Methods: We prospectively enrolled patients presenting with muscular complaints (≥2 weeks) for elective evaluation in 4 hospitals in 2 countries. After a cardiac workup, patients were adjudicated into 3 predefined cardiac disease categories. Concentrations of cTnT/I and resulting cTnT/I mismatches were assessed with high-sensitivity (hs-) cTnT (hs-cTnT–Elecsys) and 3 hs-cTnI assays (hs-cTnI–Architect, hs-cTnI–Access, hs-cTnI–Vista) and compared with those of control subjects without SMD presenting with adjudicated noncardiac chest pain to the emergency department (n=3508; mean age, 55 years; 37% female). In patients with available skeletal muscle biopsies, TNNT/I1-3 mRNA differential gene expression was compared with biopsies obtained in control subjects without SMD. Results: Among 211 patients (mean age, 57 years; 42% female), 108 (51%) were adjudicated to having no cardiac disease, 44 (21%) to having mild disease, and 59 (28%) to having severe cardiac disease. hs-cTnT/I concentrations significantly increased from patients with no to those with mild and severe cardiac disease for all assays (all P P P TNNT2 , encoding cTnT (but none for TNNI3 , encoding cTnI) versus control subjects (n=16, P Wald R =0.59, P t-statistic R =0.26, P t-statistic =0.031). Conclusions: In patients with active chronic SMD, elevations in cTnT concentrations are common and not attributable to cardiac disease in the majority. This was not observed for cTnI and may be explained in part by re-expression of cTnT in skeletal muscle. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03660969.

Transaortic (TAo) transcatheter aortic valve implantation has become a valid alternative access route in patients with unsuitable femoral arteries. The current literature does not allow to clearly favor one of the alternative access routes. Every approach has its specific advantages. Transaortic (TAo) access is of particular importance in the case of calcifications of the supra-aortic branches and the aortic arch, as under these circumstances other alternative access routes, such as transaxillary or transcarotid, are not feasible. The purpose of this minireview is to give an overview and update on TAo transcatheter aortic valve implantation focusing on indication, technical aspects, and recent clinical data.

Background Cardiac transthyretin (ATTR) amyloidosis is an infiltrative disease caused by the extracellular deposition of misfolded ATTR protein in the myocardium. Early disease recognition and accurate description of cardiac involvement are fundamental, as cardiac ATTR amyloidosis is associated with poor prognosis. Although endomyocardial biopsy (EMB) remains the gold standard in amyloid detection and typing, non-invasive imaging can provide an accurate diagnostic tool. Bone scintigraphy enables early disease detection with high accuracy. However, it remains to be determined whether the degree of cardiac tracer uptake on bone scintigraphy correlates with the extent of histologic amyloid burden in EMB. Aim This single center observational study aimed to compare the histological amyloid load in endomyocardial biopsies with the quantification of cardiac tracer uptake on 99mTechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) scintigraphy in cardiac ATTR amyloidosis. Methods 23 patients with cardiac ATTR amyloidosis were enrolled. Diagnosis was obtained with a combination of invasive and non-invasive methods. Perugini score, mean left ventricular tracer uptake (LV uptake) and left ventricular to corpus sterni uptake ratio (LV/CS ratio) on 99mTc-DPD-scintigraphy were measured, while histological amyloid load was quantified as percentage of the analysed myocardial tissue using Sulfated Alcian Blue staining and the Fiji-ImageJ programme. Bivariate correlation and Pearson correlation coefficient were used to study the relationship between EMB and 99mTc-DPD-scintigraphy findings. Results We found a statistically significant correlation between histological amyloid load and Perugini score (r=0.47 p=0.02), as well as between Perugini score and LV/CS ratio (r=0.31 p=0.046). Mean LV tracer uptake showed a trend for correlation with histological amyloid load (r=0.37 p=0.08), without reaching statistical significance. Conclusion We found a correlation between the extent of histologic amyloid burden in EMB and the degree of cardiac tracer uptake on 99mTc-DPD-scintigraphy. Our results underline the reliability of 99mTc-DPD-scintigraphy as a surrogate of histological amyloid load in the diagnosis of cardiac ATTR amyloidosis. Possible implications for the assessment of prognosis are subject to future studies with a larger number of patients. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer

Background Failed myocardial tissue reperfusion due to microvascular injury despite successful culprit lesion percutaneous coronary intervention (PCI) is associated with poor clinical outcome in patients with ST-elevation myocardial infarction (STEMI). A possible influence of dysglycaemia on myocardial reperfusion injury is unclear. Objectives To investigate the association between glycaemic status and microvascular injury determined by magnetic resonance imaging in STEMI patients. Methods This prospective observational cohort study included 260 consecutive STEMI patients undergoing primary PCI between 2016 and 2019. Peripheral venous blood samples for glucose and HbA1c measurements were drawn on admission. Primary microvascular injury endpoint was defined as presence of intramyocardial haemorrhage (IMH) assessed by cardiac magnetic resonance T2* mapping at 4 (interquartile range [IQR]:2–5) days after PCI. Results HbA1c (odds ratio [OR]: 1.73 [95% CI: 1.24–2.40]; p=0.001), pre-diagnosis of diabetes (OR: 2.63 [95% CI: 1.18–5.90]; p=0.02) and glucose concentration (OR: 1.01 [95% CI: 1.00–1.01]; p=0.01) significantly predicted IMH, which was present in 90 (35%) patients. Of these three parameters, only HbA1c remained significantly associated with IMH (OR: 2.12 [95% CI: 1.12–3.99]; p=0.02) after adjusting for total ischemic time, culprit lesion location, pre- and post-interventional TIMI flow and peak biomarker concentrations (troponin, N-terminal pro-B-type natriuretic peptide and C-reactive protein). The rate of IMH was 24% in patients with HbA1c Conclusions In STEMI patients undergoing primary PCI, admission HbA1c was independently associated with reperfusion injury as determined by IMH. These findings suggest that IMH could represent the underlying pathophysiological link between dysglycaemia and adverse outcomes following STEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FWF - Austrian Science Fund; ÖKG - Austrian Society of Cardiology Figure 1. This figure illustrates the relation between HbA1c and IMH by two patient examples successfully treated with PCI (intervention with stent implantation schematically shown on the very left side). The first patient (upper line), representing the patient group with HbA1c

Background Transthoracic echocardiography (TTE) has become the diagnostic standard for evaluating aortic stenosis (AS) severity, mainly because of its advantages in comparison to the gold standard of cardiac catheterization. However, its inaccuracies in determining stroke volume (SV) and consequentially computing aortic valve area (AVA) call for a more precise and dependable method. Phase contrast cardiovascular magnetic resonance imaging (PC-CMR) is an aspiring tool to push these boundaries. Purpose The aim of this study was to validate a novel and simple approach based on PC-CMR against the invasive and echocardiographic determination of SV and AVA in patients with moderate and severe AS. Methods A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR; AVA by PC-CMR was determined via plotting momentary flow across the valve against momentary flow velocity. SV via CMR was measured directly via PC-CMR and volumetrically using cine images. Invasive SV and AVA were determined via Fick principle and Gorlin formula, respectively. TTE yielded SV and AVA using the continuity equation. Finally, gradients were calculated via the modified Bernoulli equation. Results SV by PC-CMR showed a strong correlation with cine-CMR with no significant bias (r: 0.730, p Conclusion PC-CMR provides a great option to yield reliable and solid SV values in patients with moderate and severe AS. Furthermore, continuous determination of flow volumes and flow velocities is able to determine AVA in these patients in an easy and reproducible manner. Our novel approach shines a light on the diagnostic potential of PC-CMR for non-invasive AS grading, especially in cases where echocardiography reaches its limits and where clinical findings appear inconclusive. Funding Acknowledgement Type of funding sources: None. Central IllustrationCine (l,r) and PC-CMR (m) images in AS

Background The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI. Methods We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (PPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regressionand logistic regression analysis were performed to explore predictors of PWV and MACCE. Results Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p=0.014). Conclusion In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome post-STEMI, suggesting it as a relevant therapeutic target in this population. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology Figure 1. Biorender.com

Background Cardiac magnetic resonance (CMR) data on cardiopulmonary-transit-time (cpTT) and its associates with infarct characteristics and clinical outcome after reperfused ST-elevation myocardial infarction (STEMI) are lacking so far. Purpose cpTT may serve as surrogate parameter for integrative cardiac performance and has been linked to heart failure. Methods A total of 207 patients (179 men [87%], median age 55 [interquartile range (IQR) 49–64] with acute STEMI underwent CMR on day 3 [IQR 2–4] and 4 months (m) [IQR 4–5] after primary percutaneous coronary intervention. cpTT was taken as the time between the peaks of time-intensity curves of gadolinium contrast to pass from the right ventricle (RV) to the left ventricle (LV). Infarct size, extent of microvascular obstruction (MVO), RV and LV dimensions and function were assessed at both occasions. Results cpTT decreased significantly between baseline and 4m CMR scan (8.6 seconds [IQR 7.5–9.6] to 7.8 sec [IQR 7–8.7], respectively, p Conclusion Following reperfused STEMI, cpTT predicts prognosis independently of infarct size and systolic function. Moreover, cpTT provides significantly higher prognostic implication in comparison with LV ejection fraction. Funding Acknowledgement Type of funding sources: None. cpTT over the cardiac cycle.Computation of cpTT in 2 STEMI patients.

Background The role of C-reactive protein velocity (CRPv) as an early and sensitive marker of an excessive inflammatory response in the setting of acute ST-elevation myocardial infarction (STEMI) is only poorly understood. Purpose The aim of this study was to investigate, in patients with STEMI treated with primary percutaneous coronary intervention (PCI), the association of CRPv with microvascular infarct pathology. Methods This prospective cohort study included a total of 316 patients with STEMI undergoing PCI. CRPv was defined as the difference between CRP 24±8h and CRP at hospital admission, divided by the time (in h) that have passed during the two examinations. The association of biomarker levels with cardiac magnetic resonance (CMR)-determined microvascular obstruction (MVO) was evaluated. CMR was performed at a median of 3 [interquartile range 2–4] days after PCI. Results After adjustment for cardiac troponin T (cTnT), culprit lesion location and TIMI-flow post-PCI, CRPv (odds ratio 3.36, 95% confidence interval (CI) 1.72–6.57; p Conclusions In patients with STEMI treated with primary PCI, CRPv was associated with microvascular infarct pathology with a predictive value incremental to cTnT, suggesting CRPv as an early and sensitive biomarker for more severe infarct pathology and outcome. Funding Acknowledgement Type of funding sources: None. ROC analysis for the prediction of MVO.CRPv (median) and clinical outcome.

Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) represents the optimal modality for the diagnosis of left ventricular (LV) thrombus ([1][1]), which is associated with worse outcomes following ST-segment elevation myocardial infarction (STEMI) ([2][2]). However, CMR imaging is

Background Transthoracic echocardiography (TTE) is the diagnostic routine standard for assessing aortic stenosis (AS). However, its inaccuracies in determining stroke volume (SV) and aortic valve area (AVA) call for a more precise and dependable method. Phase-contrast cardiovascular magnetic resonance imaging (PC-CMR) is a promising tool to push these boundaries. Thus, the aim of this study was to validate a novel approach based on PC-CMR against the gold-standard of invasive determination of AVA in AS compared to TTE. Methods A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR. AVA via PC-CMR was determined by plotting momentary flow across the valve against flow-velocity. SV by CMR was measured directly via PC-CMR and volumetrically using cine-images. Invasive SV and AVA were determined via Fick-principle and Gorlin-formula, respectively. TTE yielded SV and AVA using continuity equation. Gradients were calculated via the modified Bernoulli-equation. Results SV by PC-CMR (85 ± 31 ml) correlated strongly (r: 0.73, p 2), correlated moderately (r: 0.54, p 2), resulting in a small bias of 0.08 cm2 (LLoA and ULoA: − 0.36 cm2 and 0.55 cm2, p = 0.017). Inter-methodically, AVA by TTE (0.81 ± 0.23 cm2) compared to invasive determination showed similar correlations (r: 0.58, p 2, LLoA and ULoA: − 0.30 and 0.52, p Conclusions Our novel approach using continuous determination of flow-volumes and velocities with PC-CMR enables simple AVA measurement with no bias to invasive assessment. This approach highlights non-invasive AS grading through CMR, especially when TTE findings are inconclusive.

Background Primary pericardial mesothelioma (PPM) is a rare form of highly aggressive cancer. Many patients are diagnosed only at an advanced stage. Therefore, the overall survival rate is poor with a median survival of 3 months. In some rare cases, the PPM infiltrates the myocardium causing lethal myocardial dysfunction. Case summary A 66-year-old patient was transferred to our centre with the provisional diagnose of pericarditis of unknown origin. Using extensive cardiac imaging [echocardiography, computed tomography (CT), positron emission tomography–CT, cardiac magnetic resonance imaging, left and right heart catheterization, coronary angiography], PPM was finally diagnosed. After consultation with the oncologists, the heart team decided to resect the tumour first due to impaired haemodynamics and then initiate adjuvant chemotherapy. Intraoperatively, myocardial infiltration of the tumour became apparent, which was not detected preoperatively despite intensive imaging. Complete resection of the PPM was not possible and effective decompression of the ventricle could not be achieved. The patient died on the first postoperative day. Discussion Surgical therapy is indicated in many forms of cardiac tumours. However, when a tumour invades the myocardium, surgery often comes to its limits. In this case, myocardial invasion of PPM could not be detected despite extensive imaging. We therefore suggest that possible myocardial infiltration by PPM, and thus potential limitations of cardiac surgery, should be considered independently of imaging results when therapeutic options are discussed.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology Background In patients with first ST-elevation myocardial infarction (STEMI), the evolution of myocardial tissue injury parameters over a decade as assessed by cardiac magnetic resonance (CMR) has not yet been described. Purpose This study examined long-term myocardial tissue injury dynamics in STEMI patients treated with primary percutaneous coronary intervention (PCI), as well as its association with patient characteristics. Methods A total of 104 patients with STEMI were included in this observational study. Sequential late gadolinium enhanced CMR studies (after 3 days [interquartile ranges (IQR) 2-4], 4 months [IQR 4-5] and 9 years [IQR 8-10]) were conducted to assess left ventricular (LV) dimensions and function, infarct size and microvascular obstruction (MVO). T2* mapping was added at 9 year scan to assess the presence of persistent iron within the infarct core. Results Infarct size decreased progressively from 13% of LV myocardial mass [IQR 7-21] to 10.2% [IQR 5.2-16.1] to 8% [IQR 2.4-12.3] (p Conclusion In patients with STEMI, the evolution of infarct size is a dynamic process that extends well beyond the first few months after the acute event. MVO vanishes in the first few weeks after the index event in all patients. However, persistence of iron within the infarct core occurs up to a decade after reperfused STEMI, reflecting its irreversibility and is associated with the initial infarct severity and worse infarct healing.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology Background. Echocardiography is considered the standard method for screening and diagnosing aortic valve stenosis. However, inaccuracies in the determination of stroke-volumes by the continuity equation might particularly make the evaluation of patients with low-flow states difficult. Phase-contrast cardiac magnetic resonance (PC-CMR) is a promising tool in overcoming these limitations by the simultaneous determination of flow volumes and velocities across the stenotic valve. Purpose The aim of this study is to validate a novel approach based on PC-CMR against the invasive determination of the aortic valve area (AVA). Methods. PC-CMR was performed in 50 patients with moderate or severe AS (n = 52; age 72 years [interquartile range (IQR) 66 - 78], 38% of patients with low-flow states). All of them were referred to invasive evaluation of aortic stenosis by cardiac catheterization. Additionally, transthoracic echocardiography (TTE) was performed. Aortic valve area (AVA) was determined by PC-CMR (AVAPC-CMR) via plotting momentary flow across the valve against momentary flow velocity. AVAPC-CMR at different time points over the entire cardiac cycle was compared to invasively determined AVA, calculated according to the Gorlin-formula. Stroke volumes (SV) were determined by the Fick-principle, pressure gradients according to the modified Bernoulli-equation. Results. Mean AVA during the whole systolic phase showed a good correlation (r: 0.544, p Conclusion. PC-CMR with continuous determination of flow volumes and flow velocities is able to determine AVA in patients with severe aortic stenosis with a tendency to overestimate AVA compared to invasively determined AVA.

Aims The severity of myocardial tissue damage following ST-elevation myocardial infarction (STEMI) strongly determines short- and long-term prognosis. This study explored the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated public health restrictions on infarct severity. Methods and results STEMI patients treated with primary percutaneous coronary intervention (PCI) and included in the prospective Magnetic Resonance Imaging in Acute ST-Elevation Myocardial Infarction (MARINA-STEMI) cohort study from 2015- 2020 (n = 474) were categorized according to (i) timeframes with and without major public health restrictions in 2020, and (ii) timeframes of major public health restrictions during 2020 and during the corresponding timeframes between 2015-2019. Myocardial damage was evaluated by cardiac magnetic resonance imaging. During major public health restrictions in 2020 (n = 48), there was an increase in infarct size (22 [IQR 12-29] vs. 14 [IQR 6-23]%, P < 0.01), a higher frequency (77% vs. 52%, P < 0.01) and larger extent of microvascular obstruction (1.5 [IQR 0.1-11.4] vs. 0.2 [IQR 0.0-2.6]%, P < 0.01) and a higher rate of intramyocardial haemorrhage (56% vs. 34%, P = 0.02) as compared to the phases without major restrictions in 2020 (n = 101). These findings were confirmed in adjusted analysis and were consistent when comparing patients admitted in 2020 versus patients admitted in the “pre-pandemic” era (2015-2019). Patient characteristics were comparable between groups, except for a significantly longer total ischemia time (P < 0.01) and higher frequency of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow 0 during times of major restrictions (P = 0.03). Conclusion This study provides novel mechanistic insights demonstrating a significant increase in myocardial damage in STEMI patients admitted during the COVID-19 pandemic with a temporal relation to major public health restrictions., Graphical Abstract Graphical Abstract

Aims Little is known about the clinical relevance of interleukin (IL)-6 in patients with acute ST-elevation myocardial infarction (STEMI). This study examined the possible associations of plasma IL-6 concentrations with infarct size (IS), reperfusion injury and adverse left ventricular remodelling (LVR), in STEMI patients treated with primary percutaneous coronary intervention (PCI). Methods and results We prospectively included 170 consecutive STEMI patients (median age 57 years, 14% women) treated with primary PCI between 2017 and 2019. Blood samples for biomarker analyses including IL-6 were collected on Day 2. Left ventricular ejection fraction (LVEF), IS, and reperfusion injury [microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)] were determined using cardiac magnetic resonance (CMR) imaging on Day 4. Left ventricular remodelling was defined as ≥10% increase in left ventricular end-diastolic volume from baseline to 4 months CMR follow-up. Patients with IL-6 concentrations ≥median (17 ng/L) showed a significantly lower LVEF (43% vs. 52%, P Conclusions High concentrations of circulating plasma IL-6 on Day 2 after STEMI were independently associated with worse myocardial function, larger infarct extent, more severe reperfusion injury, and a higher likelihood for LVR, suggesting IL-6 as a useful biomarker of more serious outcome and potential therapeutic target. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT04113356;NCT04113356.

Aims An invasively measured cardiac index (CI) of ≤2.2 L/min/m2 is one of the strongest prognostic indicators after ST-elevation myocardial infarction (STEMI), however, knowledge is mainly based on invasive evaluations performed in the pre-stent era. Velocity-encoded phase-contrast cardiac magnetic resonance (PC-CMR) allows non-invasive determination of CI. Methods and results In this prospective study, CMR was performed in 406 stable and contemporarily revascularized patients a median of 3 days after STEMI. Forward stroke volume was assessed at the level of the ascending aorta by PC-CMR. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) were determined by cine CMR. Major adverse cardiac events (MACE) were defined as the composite of death, myocardial infarction, or hospitalization for heart failure. Median CI was 2.52 L/min/m2 and 27% of patients had ≤2.2 L/min/m2. Median LVEF was 53% and median GLS was −12.2%. During a median follow-up of 14.2 [95% confidence interval (95% CI) 13.6–14.7] months, 41 patients (10.1%) experienced a MACE. A depressed CI was significantly associated with MACE after adjustment for LVEF, GLS, Thrombolysis in Myocardial Infarction (TIMI) risk score, and infarct size [hazard ratio = 3.15 (95% CI 1.53–6.47); P = 0.002] and led to significant discrimination improvement [net reclassification improvement 0.61 (95% CI 0.25–0.97); P Conclusions A CI of 2.2 L/min/m2 or less as measured by PC-CMR was present in 27% of clinically stable patients after STEMI and strongly and independently predicted medium-term MACE. The prognostic value of a depressed CI was superior and incremental to LVEF, GLS, TIMI risk score, and infarct size.

BackgroundRecently, a simple ECG score (DETERMINE score) has been proposed for estimating myocardial scar in patients with ischaemic cardiomyopathy. We sought to evaluate the usefulness of the DETERMINE score for the assessment of myocardial infarct size (IS) as well as microvascular obstruction (MVO), in the setting of ST-elevation myocardial infarction (STEMI).MethodsThis observational study enrolled 423 patients with STEMI (median age 56, 17% women), revascularised by primary percutaneous coronary intervention (PCI). For evaluation of the DETERMINE and Selvester scoring system (an established but complex ECG score for IS estimation), ECG was conducted before discharge (median: 4 (IQR 2–6) days). Cardiac magnetic resonance (CMR) was conducted within a week after infarction for determination of IS and MVO.ResultsMedian DETERMINE score of the overall cohort was 8 points (IQR 5–11). A higher DETERMINE score was significantly associated with a larger IS (21% vs 11% of left ventricular myocardial mass (LVMM), pConclusionsIn patients undergoing PCI for STEMI, the DETERMINE score provides an easy and inexpensive tool for appropriate estimation of infarct severity as determined by CMR.

Background Since the first documented outbreak of a novel severe acute respiratory syndrome inducing Coronavirus in China at the end of 2019 the virus has spread to all continents, leading the WHO to declare a pandemic in March 2020. While this virus primarily targets the alveoli in the lungs, multiple authors have described an increased rate of thrombo-embolic events in affected patients. We present this case of a myocardial infarction with no obstructive coronary atherosclerosis in an otherwise healthy 48-year-old patient. Case summary A 48-year-old female, presenting with chest pain radiating to her left shoulder with no cardiovascular risk factors other than genetic predisposition, was screened for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and tested positive. Although computed tomography angiography excluded obstructive coronary heart disease, cardiac magnetic resonance imaging showed an acute myocardial infarction with no obstructive coronary arteries of the inferior wall. The patient was treated with dual anti-platelet therapy, an angiotensin-converting-enzyme inhibitor and a statin, and assigned to a cardiac rehabilitation program. Conclusion We report a serious thrombo-embolic event during an oligosymptomatic SARS-CoV-2 infection in a healthy, young patient. While these two diseases may have occurred simultaneously, by chance, it is possible that the pro-thrombotic effects of the SARS-CoV-2 infection facilitated the infarction. This case further demonstrates the significant cardiovascular morbidity potentially caused by SARS-CoV-2.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund Background The magnitude of myocardial damage after acute ST-elevation myocardial infarction (STEMI) is a crucial prognostic determinant. Cardiac magnetic resonance (CMR) imaging offers a precise infarct severity assessment after STEMI; however, limited to restricted availability in daily clinical routine. Recently, a simple ECG score (DETERMINE score) was developed for infarct size (IS) estimation in STEMI patients with prior infarction. We sought to validate this score in patients with first-time STEMI for the assessment of myocardial injury visualized by CMR. Methods In this validation study, 423 revascularized first-time STEMI patients (median age 56, 17% women) were included. ECG was conducted at discharge for evaluation of the DETERMINE and Selvester score. CMR imaging was performed at a median of 3 days for the assessment of infarct characteristics (IS and microvascular obstruction [MVO]). Results Median DETERMINE score of the overall cohort was 8 points (interquartile range: 5-11). Patients presenting with a score > 8 points had more often anterior infarct localization (64% vs. 29%, p Conclusions In survivors of first-time STEMI, the DETERMINE score provides an easy and inexpensive tool for suitable IS estimation. Moreover, the DETERMINE score showed significant and independent association with MVO. Thus, this simple ECG score might help identify patients at high risk of large infarct burden who might benefit from more aggressive treatment strategies.

Funding Acknowledgements Type of funding sources: None. Background The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. Purpose We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI. Methods We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (pPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regression- and logistic regression analysis were performed to explore predictors of PWV and MACCE. Results Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p 0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p = 0.014). Conclusion In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome, suggesting it as a relevant therapeutic target in this population.

Funding Acknowledgements Type of funding sources: None. Background The natural history of thoracic aortic aneurysm (TAA) is one of progressive expansion. Asymptomatic patients who do not meet criteria for repair require conservative management including ongoing aneurysm surveillance, mostly carried out by contrast-enhanced computed tomography angiography (CTA). Purpose To prospectively compare image quality and reliability of a prototype non-contrast, self-navigated 3D whole-heart magnetic resonance angiography (MRA) with contrast-enhanced computed tomography angiography (CTA) for sizing of thoracic aortic aneurysm (TAA). Methods Self-navigated 3D whole-heart 1.5 T MRA was performed in 20 patients (aged 67 ± 8.6 years, 75% male) for sizing of TAA; a subgroup of 18 (90%) patients underwent additional contrast-enhanced CTA on the same day. Subjective image quality was scored according to a 4-point Likert scale and ratings between observers were compared by Cohen’s Kappa statistics. Continuous MRA and CTA measurements were analyzed with regression and Bland-Altman analysis. Results Overall subjective image quality as rated by two observers was 1 [interquartile range (IQR) 1-2] for self-navigated MRA and 1.5 [IQR 1-2] for CTA (p = 0.717). For MRA a perfect inter-observer agreement was found for presence of artefacts and subjective image sharpness (κ=1). Subjective signal inhomogeneity correlated highly with objectively quantified inhomogeneity of the blood pool signal (r = 0.78-0.824, all p Conclusion Self-navigated 3D whole-heart MRA enables reliable contrast- and radiation free aortic dilation surveillance without significant difference to standardized CTA while providing predictable acquisition time and by offering excellent image quality. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Background Preprocedural transcatheter aortic valve intervention (TAVI) evaluation requires reliable aortic root measurements for correct valve sizing. Purpose To prospectively compare image-quality, reliability and graft sizing of a prototype self-navigated and a navigator-gated non-contrast three dimensional (3D) whole-heart magnetic-resonance-angiography (MRA) sequence with computed-tomography-angiography (CTA) for planning transcatheter-aortic-valve-intervention (TAVI). Methods Self- and navigator-gated 1.5T MRA were performed in 27 patients (aged 83 ± 5 years, 41% male) for aortic root sizing and coronary ostia height measurements; 15 (56%) patients underwent additional CTA. Subjective-image quality was graded on a 4-point Likert scale, objective MRA image-quality was assessed by signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). Continuous MRA and CTA measurements were analyzed with regression and Bland-Altman analysis, valve sizing by kappa statistics. Results Median image-quality as rated by two observers was 1.5 [interquartile range (IQR) 1-3] for self-navigated MRA and 1 [IQR 1-2] for navigator-gated MRA (p = 0.059). SNR and CNR were comparable between MRA sequences (p = 0.471 and 0.445, respectively). Acquisition time was shorter for self-navigated MRA compared to navigator-gated MRA (5.5 ± 1 minutes vs, 6.5 ± 2 minutes, p = 0.029). Inter-observer correlation of aortic root measurements was high to very high for both self- and navigator-gated MRA (r = 0.75 to 0.94 and r = 0.85 to 0.96, respectively, all p Conclusion Self-navigated MRA enables aortic annulus TAVI measurements without significant difference to navigator-gated MRA at shortened acquisition time. Prosthesis sizing by self-navigated MRA measurements is equivalent to navigator-gated MRA and CTA-based choice. Abstract Figure.

Background Myocardial tissue injury due to acute ST-elevation myocardial infarction (STEMI) initiates an inflammatory response with a release of systemic inflammatory biomarkers including C-reactive protein (CRP) and white blood cell count (WBCc), which, however, hampers the usefulness of these routine biomarkers to identify concomitant infections. The clinical role of Procalcitonin (PCT), a promising marker of bacterial infections, to detect concomitant infections in acute STEMI is unknown, mainly because it is unclear whether myocardial injury per se induces a systemic PCT release. Purpose To investigate release kinetics of serum PCT in the acute setting of STEMI and possible associations with myocardial injury markers as comprehensively assessed by cardiac magnetic resonance (CMR) imaging. Methods In this prospective observational study, we included 141 STEMI patients treated with primary percutaneous coronary intervention (PCI). Concentrations of PCT, high-sensitivity CRP (hs-CRP), WBCc and high-sensitivity cardiac troponin T (hs-cTnT) were measured serially at day 1 and day 2 after infarction. CMR imaging to assess infarct size (IS), extent of microvascular injury (MVI) and occurrence of intramyocardial haemorrhage (IMH) was performed within the first week following STEMI. Results Median concentrations of PCT were 0.07μg/l at both time points. In 140 patients (99%), both PCT values were within the normal range (≤0.5μg/l). Whereas hs-CRP, WBCc, and hs-TnT were significantly correlated with CMR markers of myocardial damage, PCT did not show significant correlations (all p>0.10) with IS (PCT24h: r=0.07; PCT48h: r=0.13) or MVI (PCT24h: r=−0.03; PCT48h: r=0.09). Furthermore, PCT failed to discriminate between large and small IS or MVI or between presence and absence of IMH (AUC values:0.46–0.55). Conclusions In the acute phase after PCI for STEMI, circulating PCT remained unaffected by the extent of myocardial and microvascular tissue damage as visualized by CMR imaging. These data highlight the clinical potential of PCT to identify concomitant infections and to guide antibiotic treatments in STEMI patients. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund, Tiroler Wissenschaftsförderung

Funding Acknowledgements Type of funding sources: None. Background Although left ventricular ejection fraction (LVEF) is recommended for left ventricular (LV) systolic function assessment and risk stratification of patients with ST-elevation myocardial infarction (STEMI), its prognostic value is limited. Other measures of LV function such as global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE) might provide additional prognostic information post-STEMI. However, comprehensive investigations comparing these parameters in terms of prediction of hard clinical events following STEMI are lacking so far. Purpose We aimed to investigate the comparative prognostic value of LVEF, MAPSE and GLS by cardiac magnetic resonance (CMR) imaging in acute STEMI patients. Methods This observational study included 407 consecutive acute STEMI patients treated with primary percutaneous coronary intervention (PCI). Comprehensive CMR investigations were performed 3 [interquartile range (IQR): 2-4] days after PCI to determine LVEF, GLS and MAPSE as well as myocardial infarct characteristics. Primary endpoint was the occurrence of MACE defined as composite of death, re-infarction and congestive heart failure. Results During a follow-up of 21 [IQR: 12-50] months, 40 (10%) patients experienced MACE. Patients with MACE showed significantly lower LVEF (49% vs. 53%, p = 0.005) and MAPSE (7.9 mm vs. 9.1 mm, p = 0.001), as well as higher GLS values (-10.2% vs. -12.3 %, p Conclusion CMR-derived GLS emerged as strong and independent predictor of MACE after acute STEMI with additive prognostic validity to LVEF and parameters of myocardial damage.

Purpose To evaluate image quality, inter-observer reliability and diagnostic accuracy of self-navigated noncontrast 3D whole-heart magnetic resonance angiography (MRA) for transcatheter aortic valve intervention (TAVI) evaluation in comparison to standardized contrast-enhanced computed tomography angiography (CTA). Methods Whole-heart 1.5 T MRA was performed in 33 patients (aged 84 years [IQR 79–86], 48% male) for aortic root sizing and measurements of coronary ostia heights. A subgroup of 18 (55%) patients underwent additional CTA as gold standard for TAVI measurements. Image quality was assessed by a 4-point Likert scale, continuous MRA and CTA measurements were compared with regression and Bland-Altman analysis, valve sizing by kappa statistics. Results Median image quality of MRA as rated by two observers according was 1.5 [IQR 1.5–2.5]. In 4 patients (12%) one coronary ostium each (right coronary artery 3, left main artery 1) was not clearly definable on MRA. Inter-observer correlation was substantial to excellent (r=0.61 to 0.92) with a bias of 19 mm2 for annulus area (lower limit of agreement −59 mm2, upper limit of agreement 98 mm2; p=0.009). Aortic root and ostia height measurements by MRA and CTA showed substantial to excellent correlation (r=0.65 to 0.90) with no significant bias (all p≥0.333). Mean annulus area for MRA was 414±71 mm2 and for CTA 422±80 mm2 (r=0.9) with a bias of −8 mm2 (lower limit of agreement −79 mm2, upper limit of agreement −62 mm2; p=0.333). Regarding prosthetic valve sizing there was complete consistency between MRA and CTA-based decisions (κ=1). Conclusion Self-navigated noncontrast 3D whole-heart MRA enables reliable aortic root TAVI measurements without significant difference to standardized CTA. Prosthesis sizing by MRA measurements would completely match to CTA-based choice. However, in some cases coronary ostia may be difficult to define. Funding Acknowledgement Type of funding source: None

Background Cardiac magnetic resonance (CMR) is the reference standard for left ventricular (LV) thrombus detection in patients with acute ST-elevation myocardial infarction (STEMI). However, routine CMR imaging is currently not recommended post-STEMI. Objective This observational study sought to develop a practical risk score for the prediction of early LV thrombus formation after STEMI to identify patients in whom routine CMR might be appropriate. Methods and results Five hundred and fifty-six consecutive patients underwent transthoracic echocardiography (TTE) and CMR at 3 [IQR: 2–4] days after primary percutaneous coronary intervention (PCI) for acute STEMI. A LV thrombus was visualized in 12 patients (2.2%) using TTE and in 22 patients (4%) using CMR. A weighted risk score including multivariable associates of LV thrombus formation (LV ejection fraction by TTE, peak high-sensitivity cardiac troponin T and peak high-sensitivity C-reactive protein) and left anterior descending coronary artery as culprit vessel, with a range of 0 to 7 points (median risk score: 2 points) showed a strong and significantly higher area under the curve (0.93 (95% CI 0.88–0.97; p Conclusions The proposed risk score provides incremental value for the prediction of early LV thrombus and could be useful to identify STEMI patients in whom routine CMR for LV thrombus evaluation could be most meaningful. Additional investigation is warranted to validate the clinical application of the score. Funding Acknowledgement Type of funding source: None

Background The age, creatinine and ejection fraction (ACEF) score has originally been developed for risk stratification of patients undergoing elective cardiac surgery. In patients with stable coronary artery disease treated by percutaneous coronary intervention (PCI), the prognostic accuracy of ACEF could be further improved by modifying the original scoring system (called "modified ACEF" or "ACEF-MDRD"). We aimed to specifically adapt the ACEF score for risk assessment of ST-elevation myocardial infarction (STEMI) patients. Methods In this observational study, 390 STEMI patients undergoing primary PCI were included. Clinical endpoint was the occurrence of major adverse cardiovascular events (MACE) comprising all-cause mortality, non-fatal re-infarction, stroke and new congestive heart failure. Results Original ACEF (area under the curve (AUC):0.63 [95%CI:0.53–0.73]; p = 0.01) and ACEF-MDRD score (AUC:0.62 [95%CI:0.53–0.72]; p = 0.01) significantly but weakly predicted MACE ( n = 41, 11%). The addition of creatinine > 2 mg/dl (as suggested in original ACEF, p = 0.32) or eGFR steps as proposed in ACEF-MDRD ( p = 0.17) to age/EF ratio were not associated with net reclassification improvements (NRI), but ΔeGRF (>10 ml/min/1.73 m 2 decrease within three days after PCI) led to an NRI of 0.29 (95%CI:0.14–0.45; p p = 0.03). Conclusions In STEMI patients undergoing primary PCI, the novel ACEF-STEMI score provided strong prognostic value and superior discriminative ability as compared to the previously described original ACEF or ACEF-MDRD scores.

OBJECTIVES This study sought to assess the incremental prognostic value of the psoas muscle area in patients scheduled for transcatheter aortic valve implantation (TAVI). METHODS A total of 1076 consecutive patients undergoing TAVI at 2 centres between 2010 and 2017 were prospectively included in this study. Computed tomography-derived cross-sectional area of the psoas muscle was measured at the superior border of the third (L3) and fourth (L4) lumbar vertebra and indexed to body surface area (PMAi) as well as stratified into tertiles. Multivariable logistic regression and Cox regression analyses were performed to investigate the value of PMAi as a predictor of 30-day and cumulative mortality. The incremental prognostic value of PMAi over the Society of Thoracic Surgeons (STS) score was assessed using a net reclassification analysis. RESULTS The rate of 30-day mortality was 5.8% (n = 62). PMAi at the level of L3 [odds ratio 0.082, 95% confidence interval (CI) 0.011-0.589; P = 0.013] and L4 (odds ratio 0.049, 95% CI 0.005-0.536; P = 0.013) was independently associated with 30-day mortality. During a median follow-up of 435 days (interquartile range 139-904), 292 patients (27.1%) died. PMAi of L3 (hazard ratio 0.200, 95% CI 0.083-0.482; P

Background: Adverse left ventricular remodeling is one of the major determinants of heart failure and mortality in patients surviving ST-segment elevation myocardial infarction (STEMI). The hypothalamic–pituitary–thyroid axis is a key cardiovascular regulator; however, the relationship between hypothalamic–pituitary–thyroid status and post-STEMI left ventricular remodeling is unclear. We aimed to investigate the association between thyroid-stimulating hormone concentrations and the development of left ventricular remodeling following reperfused STEMI. Methods: In this prospective observational study of 102 consecutive STEMI patients, thyroid-stimulating hormone levels were measured at the first day after infarction and 4 months thereafter. Cardiac magnetic resonance scans were performed within the first week as well as at 4 months follow-up to determine infarct characteristics, myocardial function and as primary endpoint left ventricular remodeling, defined as a 20% or greater increase in left ventricular end-diastolic volume. Results: Patients with left ventricular remodeling ( n=15, 15%) showed significantly lower concentrations of baseline (1.20 [0.92–1.91] vs. 1.73 [1.30–2.60] mU/l; P=0.02) and follow-up (1.11 [0.86–1.28] vs. 1.51 [1.15–2.02] mU/l; P=0.002) thyroid-stimulating hormone. The association between baseline thyroid-stimulating hormone and left ventricular remodeling remained significant after adjustment for major clinical (peak high-sensitivity cardiac troponin T and C-reactive protein, heart rate; odds ratio (OR) 5.33, 95% confidence interval (CI) 1.52–18.63; P=0.01) and cardiac magnetic resonance predictors of left ventricular remodeling (infarct size, microvascular obstruction, ejection fraction; OR 4.59, 95% CI 1.36–15.55; P=0.01). Furthermore, chronic thyroid-stimulating hormone was related to left ventricular remodeling independently of chronic left ventricular remodeling correlates (infarct size, ejection fraction, left ventricular end-diastolic volume, left ventricular end-systolic volume; OR 9.22, 95% CI 1.69–50.22; P=0.01). Conclusions: Baseline and chronic thyroid-stimulating hormone concentrations following STEMI were independently associated with left ventricular remodeling, proposing a novel pathophysiological axis in the development of post-STEMI left ventricular remodeling.

Supplemental Digital Content is available in the text., Background: Dickkopf-related protein 3 (DKK3) is a secreted protein that is involved in the regulation of cardiac remodeling and vascular smooth muscle cell differentiation, but little is known about its role in atherosclerosis. Methods: We tested the hypothesis that DKK3 is atheroprotective using both epidemiological and experimental approaches. Blood DKK3 levels were measured in the Bruneck Study in 2000 (n=684) and then in 2005 (n=574). DKK3-deficient mice were crossed with apolipoprotein E-/- mice to evaluate atherosclerosis development and vessel injury-induced neointimal formation. Endothelial cell migration and the underlying mechanisms were studied using in vitro cell culture models. Results: In the prospective population-based Bruneck Study, the level of plasma DKK3 was inversely related to carotid artery intima-media thickness and 5-year progression of carotid atherosclerosis independently from standard risk factors for atherosclerosis. Experimentally, we analyzed the area of atherosclerotic lesions, femoral artery injury-induced reendothelialization, and neointima formation in both DKK3-/-/apolipoprotein E-/- and DKK3+/+/apolipoprotein E-/- mice. It was demonstrated that DKK3 deficiency accelerated atherosclerosis and delayed reendothelialization with consequently exacerbated neointima formation. To explore the underlying mechanisms, we performed transwell and scratch migration assays using cultured human endothelial cells, which exhibited a significant induction in cell migration in response to DKK3 stimulation. This DKK3-induced migration activated ROR2 and DVL1, activated Rac1 GTPases, and upregulated JNK and c-jun phosphorylation in endothelial cells. Knockdown of the ROR2 receptor using specific siRNA or transfection of a dominant-negative form of Rac1 in endothelial cells markedly inhibited cell migration and downstream JNK and c-jun phosphorylation. Conclusions: This study provides the evidence for a role of DKK3 in the protection against atherosclerosis involving endothelial migration and repair, with great therapeutic potential implications against atherosclerosis.

Persistent T-wave inversion (PTI) after ST-elevation myocardial infarction (STEMI) is associated with worse clinical outcome; however, the underlying mechanism between PTI and poor prognosis is incompletely understood. We sought to investigate the relationship between PTI and myocardial damage assessed by cardiac magnetic resonance (CMR) following STEMI.In this prospective observational study, we included 142 consecutive revascularized STEMI patients. Electrocardiography to determine the presence and amplitude of PTI and pathological Q-waves was conducted 4months after infarction. CMR was performed within 1week after infarction and at 4months follow-up to evaluate infarct characteristics and myocardial function.Patients with PTI (n=103, 73%) showed a larger acute (21[11-29] vs. 6[1-13]%; p0.001) and chronic infarct size (IS) (14[8-19] vs. 3[1-8]%; p0.001) and more frequently microvascular obstruction (59 vs. 33%; p=0.02). The association between PTI and chronic IS remained significant (odds ratio: 9.02, 95%CI 3.49-23.35; p0.001) after adjustment for pathological Q-wave and other IS estimators (high-sensitivity cardiac troponin T and C-reactive protein, N-terminal pro B-type natriuretic peptide, culprit vessel, pre-interventional TIMI flow). The value of PTI amplitude for the prediction of large chronic IS11% (AUC: 0.84, 95%CI 0.77-0.90) was significantly higher compared to Q-wave amplitude (AUC: 0.72, 95%CI 0.63-0.80; p=0.009); the combination of PTI with pathological Q-wave (Q-wave/T-wave score) led to a net reclassification improvement of 0.43 (95% CI 0.29-0.57; p0.001) as compared to PTI alone.PTI following STEMI is independently and incrementally associated with more extensive myocardial damage as visualized by CMR. An electrocardiographic score combining PTI with pathological Q-wave allows for a highly accurate IS estimation post-STEMI.

To quantify myocardial edema by using a T2 relaxometry approach with a dual-contrast turbo spin-echo (dcTSE) sequence in patients with acute myocarditis regarding focal late gadolinium enhancement (LGE) burden. CMR T2 relaxometry was performed in 39 patients (age 41 ± 19 years; 36% women) with LGE in a typical myocarditis pattern and in ten healthy volunteers (age 46 ± 12; 60% woman). dcTSE sequence (echo time 29 and 75 ms, respectively) was used for T2 mapping, analysis were performed on the basis of region of interest (ROI). Myocardial T2 relaxation times (T2 RT) in patients-ROI with focal LGE were significantly (p

Background Complete and simplified Selvester QRS score have been proposed as valuable clinical tool for estimating myocardial damage in patients with ST-elevation myocardial infarction (STEMI). We sought to comprehensively compare both scoring systems for the prediction of myocardial and microvascular injury assessed by cardiac magnetic resonance (CMR) imaging in patients with acute STEMI. Methods In this prospective observational study, 201 revascularized STEMI patients were included. Electrocardiography was conducted at a median of 2 (interquartile range 1–4) days after the index event to evaluate the complete and simplified QRS scores. CMR was performed within 1 week and 4 months thereafter to determine acute and chronic infarct size (IS) as well as microvascular obstruction (MVO). Results Complete and simplified QRS score showed comparable predictive value for acute (area under the curve (AUC) = 0.64 vs. 0.67) and chronic IS (AUC = 0.63 vs. 0.68) as well as for MVO (AUC = 0.64 vs. 0.66). Peak high sensitivity cardiac troponin T (hs-cTnT) showed an AUC of 0.88 for acute IS and 0.91 for chronic IS, respectively. For the prediction of MVO, peak hs-cTnT represented an AUC of 0.81. Conclusions In reperfused STEMI, complete and simplified QRS score displayed comparable value for the prediction of acute and chronic myocardial as well as microvascular damage. However, both QRS scoring systems provided inferior predictive validity, compared to peak hs-cTnT, the clinical reference method for IS estimation.

Background: The high accuracy of feature-tracking cardiac magnetic resonance (CMR) imaging qualifies this novel modality as potential gold standard for myocardial strain analyses in ST-elevation myocardial infarction patients; however, the incremental prognostic validity of feature-tracking-CMR over left ventricular ejection fraction (LVEF) and myocardial damage remains unclear. This study therefore aimed to determine the value of myocardial strain measured by feature-tracking-CMR for the prediction of clinical outcome following ST-elevation myocardial infarction. Methods: This prospective observational study enrolled 451 revascularized ST-elevation myocardial infarction patients. Comprehensive CMR investigations were performed 3 (interquartile range, 2–4) days after infarction to determine LVEF, global longitudinal strain (GLS), global radial strain, and global circumferential strain as well as myocardial damage. Primary end point was a composite of death, re-infarction, and congestive heart failure (major adverse cardiac events [MACE]). Results: During a follow-up of 24 (interquartile range, 11–48) months, 46 patients (10%) experienced a MACE event. All 3 strain indices were impaired in patients with MACE (all P P =0.005) than LVEF (area under the curve, 0.64 [95% CI, 0.59–0.68]). The association between GLS and MACE remained significant ( P P Conclusions: GLS by feature-tracking-CMR strongly and independently predicted the occurrence of medium-term MACE in contemporary revascularized ST-elevation myocardial infarction patients. Importantly, the prognostic value of GLS was superior and incremental to LVEF and CMR markers of infarct severity.