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Aims Cardiac resynchronization therapy (CRT) in appropriately selected patients with heart failure improves symptoms and survival. It is necessary to correctly identify patients who will benefit most from this therapy. We aimed to assess the predictive power of the multidisciplinary team's clinical judgement in the short‐term death after CRT implantation. Methods and results Patients with heart failure and referred for the first CRT implant were prospectively included. Prior to implantation, all patients underwent a systematic assessment with a team composed of social work, nurse, psychologist, nutritionist, and clinical cardiologist. Based on this assessment, patients could be contraindicated to CRT or referred to the procedure as favourable or unfavourable. All patients should complete 12 months of follow‐up; 172 patients were referred for CRT, 21 (12.2%) were contraindicated after the multidisciplinary team evaluation, 71 (47%) referred to CRT as non‐favourable implants, and 80 (53%) as favourable implants. All‐cause mortality occurred in only 2 (2.5%) patients in the favourable group and in 30 (42.3%) in the non‐favourable group, P

SUMMARY BACKGROUND: Cardiac resynchronization therapy (CRT) is a therapeutic modality for patients with heart failure (HF). The effectiveness of this treatment for event reduction is based on clinical trials where the population of patients with Chagas' disease (DC) is underrepresented. OBJECTIVE: To evaluate the prognosis after CRT of a population in which CD is an endemic cause of HF. METHODS: A retrospective cohort conducted between January 2015 and December 2016 that included patients with HF and left ventricular ejection fraction (LVEF) of less than 35% and undergoing CRT. Clinical and demographic data were collected to search for predictors for the combined outcome of death or hospitalization for HF at one year after CRT implantation. RESULTS: Fifty-four patients were evaluated, and 13 (24.1%) presented CD as the etiology of HF. The mean LVEF was 26.2± 6.1%, and 36 (66.7%) patients presented functional class III or IV HF. After the mean follow-up of 15 (±6,9) months, 17 (32.1%) patients presented the combined outcome. In the univariate analysis, CD was associated with the combined event when compared to other etiologies of HF, 8 (47%) vs. 9 (13,5%), RR: 3,91 CI: 1,46–10,45, p=0,007, as well as lower values of LVEF. In the multivariate analysis, CD and LVEF remained independent risk factors for the combined outcome. CONCLUSION: In a population of HF patients undergoing CRT, CD was independently associated with mortality and hospitalization for HF. RESUMO INTRODUÇÃO: A terapia de ressincronização cardíaca (TRC) é uma modalidade terapêutica para pacientes com insuficiência cardíaca (IC). A eficácia desse tratamento para redução de eventos baseia-se em ensaios clínicos em que a população de pacientes com doença de Chagas (DC) é sub-representada. OBJETIVO: Avaliar o prognóstico após TRC em uma população em que a DC é uma causa frequente de IC. MÉTODOS: Coorte retrospectiva realizada entre janeiro de 2015 e dezembro de 2016, sendo incluídos pacientes portadores de IC com fração de ejeção do ventrículo esquerdo (Feve) menor que 35% e submetidos à TRC. Os dados clínicos e demográficos foram coletados para pesquisa de preditores para o desfecho combinado de morte ou internação por IC após implante da TRC. RESULTADOS: Foram avaliados 54 pacientes, dos quais 13 (24,1%) apresentavam a DC como etiologia da IC. A Feve média foi de 26,2% (±6,1) e 36 (66,7%) pacientes apresentavam classe funcional de IC III ou IV. Após o seguimento médio de 15 meses, 17 (32,1%) pacientes apresentaram o desfecho combinado. Na análise univariada, a DC esteve associada ao evento combinado quando comparada a outras etiologias de IC, 8 (47%) vs 9 (13,5%), RR: 3,91 IC: 1,46–10,45, p=0,007, assim como valores mais baixos da Feve. Na análise multivariada, a DC e a Feve permaneceram como fatores de risco independentes para o desfecho combinado. CONCLUSÃO: Em uma população de pacientes com IC submetidos à TRC, a doença de Chagas esteve independentemente associada à mortalidade e internação por insuficiência cardíaca no seguimento de 15 meses.

Chagas cardiomyopathy is the most prevalent non-ischaemic cardiomyopathy in Latin America, with high morbidity and mortality even today. Treatment of these patients is based on the use of medications for heart failure. This study evaluated a case series of patients with Chagas heart disease who used sacubitril/valsartan at a referral hospital for this disease in Brazil. After 6 months, there was a symptomatic improvement in these individuals assessed by the New York Heart Association (NYHA) functional class, with a 44.3% reduction in the absolute number of patients classified as III-IV in the period (P = 0.035), but without changes in the parameters on the echocardiogram for reverse ventricular remodelling. There was a high mortality rate and number of hospitalizations. These results emphasize the importance of studying the use of sacubitril/valsartan in Chagas heart disease to better describe its effectiveness considering the particularities of these individuals.

Introduction: Cardiac resynchronization therapy (CRT) improves outcomes in heart failure (HF) patients with left bundle branch block (LBBB). However, the benefits of CRT in patients with previous pacing are uncertain, specially in a population witch Chagas disease is a prevalent cause of HF. Methods and Results: Prospective cohort study that included HF patients indicated for CRT with left ventricular ejection fraction (LVEF) of less than 35%. Clinical and demographic data were collected to investigate mortality predictors after 1 year. The overall survival was calculated by the Kaplan-Meier method and multivariate analysis using Cox’s regression model was performed. Between May 2017 and September 2019, 93 patients were evaluated with a mean follow-up of 1,0 (0.6) year. Of these, 22 (23,7%) were upgraded from right ventricular pacing. Chagas Disease was the most prevalent cause of HF 29 (31,2%). In overall patients, LVEF at 6 months increased after CRT: 24,0% (7,8) to 30,3% (11,5), p=0.007, and there was no significant difference between upgraded patients and de Novo CRT, p=0.26. Overall mortality at 1-year was 28 (30,1%). In the univariate analysis, Chagas disease and upgraded therapy were associated with mortality at follow-up, HR: 3.9, CI: 1.8-8,4, p = 0.001 and HR: 4.7, CI: 2.2-9.9, p < 0.001, respectively. In the multivariate model, only upgraded therapy remained independently associated with the outcome, adjusted HR: 2.9, CI: 1.2-7,2, p = 0.02. Conclusion: In this specific HF population, with a high prevalence of Chagas disease cardiomyopathy, upgraded therapy was independently associated with worsened 1-year survival after CRT.

The diagnosis of peri-procedural myocardial infarction is complex, especially after the emergence of high-sensitivity markers of myocardial necrosis. In this study, patients with normal baseline cardiac biomarkers and formal indication for elective on-pump coronary bypass surgery were evaluated. Electrocardiograms, cardiac biomarkers, and cardiac magnetic resonance imaging with late gadolinium enhancement were performed before and after procedures. Myocardial infarction was defined as more than ten times the upper reference limit of the 99th percentile for troponin I and for creatine kinase isoform (CK-MB) and by the findings of new late gadolinium enhancement on cardiac magnetic resonance. We assessed the release of cardiac biomarkers in patients with no evidence of myocardial infarction on cardiac magnetic resonance. Of 75 patients referred for on-pump coronary bypass surgery, 54 (100%) did not have evidence of myocardial infarction on cardiac magnetic resonance. However, all had a peak troponin I above the 99th percentile; 52 (96%) had an elevation 10 times higher than the 99th percentile. Regarding CK-MB, 54 (100%) patients had a peak CK-MB above the 99th percentile limit, and only 13 (24%) had an elevation greater than 10 times the 99th percentile. The median value of troponin I peak was 3.15 (1.2 to 3.9) ng/mL, which represented 78.7 times the 99th percentile. In this study, different from CK-MB findings, troponin was significantly increased in the absence of myocardial infarction on cardiac magnetic resonance. Thus, CK-MB was more accurate than troponin I for excluding procedure-related myocardial infarction. These data suggest a higher troponin cutoff for the diagnosis of coronary bypass surgery related myocardial infarction. http://www.isrctn.com/ISRCTN09454308 . Registered 08 May 2012.

Objectives This study aimed to evaluate the amount and pattern of cardiac biomarker release after elective percutaneous coronary intervention (PCI) in patients without evidence of a new myocardial infarction (MI) after the procedure as assessed by cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE). Background The release of myocardial necrosis biomarkers after PCI frequently occurs. However, the correlation between biomarker release and the diagnosis of procedure-related MI type 4a has been controversial. Methods Patients with normal baseline cardiac biomarkers who were referred for elective PCI were prospectively included. CMR with LGE was performed in all of the patients before and after the intervention. Measurements of troponin I (TnI) and creatine kinase MB fraction (CK-MB) were systematically performed before and after the procedure. Patients with a new LGE on the post-procedure CMR were excluded. Results Of the 56 patients with no evidence of a procedure-related MI as assessed by CMR after the PCI, 48 (85.1%) exhibited an elevation of TnI above the 99th percentile. In 32 patients (57.1%), the peak was greater than five times this limit. Additionally, 17 patients (30.4%) had a CK-MB peak above the 99th percentile limit, but this peak was greater than five times the 99th percentile in only two patients (3.6%). The median peak release of TnI was 0.290 (0.061-1.09) ng/mL, which was 7.25-fold higher than the 99th percentile. Conclusions In contrast to CK-MB, an abnormal release of TnI often occurs after an elective PCI procedure, despite the absence of a new LGE on CMR.

Introduction There are conflicting data regarding the efficacy of implantable cardioverter-defibrillator (ICD) in Chagas disease (CD) patients. This study aims to evaluate the short-term outcome after ICD for secondary prevention, in a population where CD is a prevalent cause of heart failure (HF). Methods and results Consecutive patients with HF and reduced left ventricular ejection fraction (LVEF), who underwent ICD implantation for secondary prevention of SCD. Clinical and demographic data were collected to investigate mortality predictors at 1 year. During the study period, 117 patients underwent ICD implantation, of which 108 were included. The most frequent causes of HF was CD: 52 (48.1%) and ischemic cardiomyopathy: 20 (18.5%). Chagas and non-Chagas patients were well balanced-male: 32 (61.5%) vs 38 (67.9%), P = .548; age: 59.2 (±10.9) vs 56.8 (±13.4), P = .681; and LVEF: 34.1 (±0.2) vs 31.3 (±8.7), P = .064, respectively. At the mean follow-up of 15.7 months, overall mortality occurred in 14 (12.9%) patients, with a higher incidence in patients with CD cardiomyopathy, 11 (21.2%) vs 3 (5.4%), P = .021 (log-rank). In the multivariate analysis, CD remained as an independent predictor for death (hazard ratio: 4.62, confidence interval [95% CI]: 1.27-16.81, P = .021). Conclusion CD was associated with a poor short-term outcome in patients with HF submitted to ICD implantation for secondary prevention when compared with other HF etiologies. In this specific HF population, ICD indication should be individualized, considering the worst prognosis of these patients.

Background The lack of a correlation between myocardial necrosis biomarkers and electrocardiographic abnormalities after revascularization procedures has resulted in a change in the myocardial infarction (MI) definition. Methods Patients with stable multivessel disease who underwent percutaneous or surgical revascularization were included. Electrocardiograms and concentrations of high-sensitive cardiac troponin I (cTnI) and creatine kinase (CK)-MB were assessed before and after procedures. Cardiac magnetic resonance and late gadolinium enhancement were performed before and after procedures. MI was defined as more than five times the 99th percentile upper reference limit for cTnI and 10 times for CK-MB in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), respectively, and new late gadolinium enhancement for cardiac magnetic resonance. Results Of the 202 patients studied, 69 (34.1%) underwent on-pump CABG, 67 (33.2%) off-pump CABG, and 66 (32.7%) PCI. The receiver operating characteristic curve showed the accuracy of cTnI for on-pump CABG, off-pump CABG, and PCI patients was 21.7%, 28.3%, and 52.4% and for CK-MB was 72.5%, 81.2%, and 90.5%, respectively. The specificity of cTnI was 3.6%, 9.4%, and 42.1% and of CK-MB was 73.2%, 86.8%, and 96.4%, respectively. Sensitivity of cTnI was 100%, 100%, and 100% and of CK-MB was 69.2%, 64.3%, and 44.4%, respectively. The best cutoff of cTnI for on-pump CABG, off-pump CABG, and PCI was 6.5 ng/mL, 4.5 ng/mL, and 4.5 ng/mL (162.5, 112.5, and 112.5 times the 99th percentile upper reference limit) and of CK-MB was 37.5 ng/mL, 22.5 ng/mL, and 11.5 ng/mL (8.5, 5.1, and 2.6 times the 99th percentile upper reference limit), respectively. Conclusions Compared with cardiac magnetic resonance, CK-MB was more accurate than cTnI for diagnosing MI. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI.

OBJECTIVES: The technical difficulty in the revascularization of the circumflex artery territory with off-pump surgery may compromise the outcome of this method in clinical follow-up. We aimed to evaluate cardiac events in patients with stable coronary artery disease and severe obstruction of the circumflex system, undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass. METHODS: MASS III was a single-centre study that evaluated 308 patients with multivessel coronary artery disease randomized to onpump (153) or off-pump (155) CABG. Of this total, 260 (84.4%) patients had, on coronary angiography, at least one 70% obstruction in the circumflex territory (141 on-pump and 119 off-pump). The combined outcome was death, myocardial infarction, target vessel revascularization (angioplasty or surgery) or hospitalization for cardiac causes. Variables with possible associations (P< 0.1) were included in the multivariate analysis. RESULTS: The two groups were well matched for demographics and clinical and angiographic characteristics. After 5 years of follow-up, off-pump CABG had higher combined events than on-pump had: 25 (21%) vs 17 (12%), hazard ratio 1.88, 95% confidence interval 1.02– 3.48, P= 0.041. In the multivariate model with the inclusion of the following variables: age (P= 0.09) and complete revascularization (P= 0.68), off-pump surgery remained as a predictor of combined events in 5 years, P= 0.03. CONCLUSIONS: In patients with multivessel coronary artery disease and severe lesions in the circumflex territory, off-pump coronary artery bypass surgery resulted in a higher incidence of cardiac events at 5-year follow-up. Clinical trial registration number: ISRCTN59539154 (http://www.controlled-trials.com).

BackgroundThe diagnosis of ischemic cardiomyopathy is frequently difficult. Coronary angiography (CA) is limited because it is invasive and the evaluation is exclusively anatomic. Cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) measures patterns of myocardial fibrosis caused by ischemia. However, LGE does not detect ischemia that does not result in fibrosis. Thus, a thorough clinical evaluation by a cardiologist seems to be the most effective option for diagnosis. The aim of this study was to evaluate CA and LGE as complementary methods for the diagnosis of ischemic cardiomyopathy in patients with systolic heart failure of unknown etiology.MethodsPatients with systolic heart failure, left ventricle ejection fraction < 45% and unknown etiology after initial non-invasive evaluation were submitted to CA and MRI with LGE to define the etiology of the disease. Patient evaluation by two cardiologists was the gold standard for the diagnosis of ischemic cardiomyopathy.ResultsTwenty-four patients were included. The sensitivity to detect ischemic cardiomyopathy was 0.45 for CA vs. 0.81 for LGE. The specificity was 1.0 for CA vs. 0.84 for LGE. The positive predictive value was 1.0 vs. 0.81 and the negative predictive value was 0.68 vs. 0.84 for CA and LGE, respectively. LGE accuracy was superior to CA accuracy (0.83 vs. 0.75).ConclusionsLGE was more sensitive than CA to evaluate the etiology of ventricular dysfunction, whereas CA was more specific. The diagnosis of ischemic cardiomyopathy using each one of the methods separately presented limitations.

We aim to evaluate in-hospital events and long-term clinical outcomes in patients over 60 years of age with stable coronary artery disease and preserved left ventricular ejection fraction undergoing off-pump or on-pump coronary artery bypass grafting. The MASS III was a single-center randomized trial that evaluate 308 patients with stable coronary artery disease and preserved ventricular function assigned for: 155 to off-pump and 153 to on-pump CABG. Of this, 176 (58.3%) patients were 60 years or older at the time of randomization (90 of-pump and 86 on-pump). The primary short-term end point was a composite of myocardial infarction, stroke, and overall mortality occurring within 30 days after surgery or before discharge, whichever was later. The primary long-term end point was death from any cause within 5 years, non-fatal myocardial infarction between 30 days and 5 years, or additional revascularization between 30 days and 5 years. On-pump CABG had a higher incidence of 30-day composite outcome than off-pump CABG (15,1% and 5.6%, respectively; P = 0.036). However, after the multivariate analysis, this association lost statistical significance, P = 0.05. After 5-year follow-up, there were no significant differences between both strategies of CABG in the composite end points 16.7% and 15.1%; Hazard Ratio 1.07; CI 0.41 – 1.82; P = 0.71, for off-pump and on-pump CABG respectively. On-pump and off-pump CABG achieved similar results of combined events at short-term and 5-year follow-up. Clinical Trial Registration Information—URL: http://www.controlled-trials.com . Registration number: ISRCTN59539154 .

Background Ischemic preconditioning is a powerful mechanism of myocardial protection and in humans it can be evaluated by sequential exercise tests. Coronary Artery Disease in the presence of diabetes mellitus may be associated with worse outcomes. In addition, some studies have shown that diabetes interferes negatively with the development of ischemic preconditioning. However, it is still unknown whether diabetes may influence the expression of ischemic preconditioning in patients with stable multivessel coronary artery disease. Methods/Design This study will include 140 diabetic and non-diabetic patients with chronic, stable coronary artery disease and preserved left ventricular systolic function. The patients will be submitted to two sequential exercise tests with 30-minutes interval between them. Ischemic parameters will be compared between diabetic and non-diabetic patients. Ischemic preconditioning will be considered present when time to 1.0 mm ST-segment deviation is greater in the second of two sequential exercise tests. Exercise tests will be analyzed by two independent cardiologists. Discussion Ischemic preconditioning was first demonstrated by Murry et al. in dog’s hearts. Its work was reproduced by other authors, clearly demonstrating that brief periods of myocardial ischemia followed by reperfusion triggers cardioprotective mechanisms against subsequent and severe ischemia. On the other hand, the demonstration of ischemic preconditioning in humans requires the presence of clinical symptoms or physiological changes difficult to be measured. One methodology largely accepted are the sequential exercise tests, in which, the improvement in the time to 1.0 mm ST depression in the second of two sequential tests is considered manifestation of ischemic preconditioning. Diabetes is an important and independent determinant of clinical prognosis. It's a major risk factor for coronary artery disease. Furthermore, the association of diabetes with stable coronary artery disease imposes worse prognosis, irrespective of treatment strategy. It’s still not clearly known the mechanisms responsible by these worse outcomes. Impairment in the mechanisms of ischemic preconditioning may be one major cause of this worse prognosis, but, in the clinical setting, this is not known. The present study aims to evaluate how diabetes mellitus interferes with ischemic preconditioning in patients with stable, multivessel coronary artery disease and preserved systolic ventricular function.

INTRODUÇÃO: O diagnóstico da cardiomiopatia isquêmica é frequentemente difícil. A angiografia coronária (AC) é limitada, por ser invasiva e de avaliação exclusivamente anatômica. A ressonância nuclear magnética cardíaca (RNM) com realce tardio pelo gadolínio (RTG) pode mensurar padrões de fibrose miocárdica ocasionados pela isquemia. Porém, o RTG pode não detectar isquemia que não resultou em fibrose. Assim, uma avaliação clínica meticulosa pelo cardiologista parece ser a maneira mais eficaz para definir o diagnóstico. O objetivo deste estudo foi avaliar a AC e o RTG como métodos complementares para o diagnóstico de cardiomiopatia isquêmica em pacientes com insuficiência cardíaca sistólica sem etiologia definida. MÉTODOS: Pacientes com insuficiência cardíaca sistólica, fração de ejeção do ventrículo esquerdo < 45% e etiologia indefinida após avaliação não invasiva inicial foram submetidos à AC e à RNM com RTG para definição etiológica. A análise dos casos por dois cardiologistas foi o padrão-ouro para o diagnóstico de cardiomiopatia isquêmica. RESULTADOS: Foram incluídos 24 pacientes. A sensibilidade para detecção de cardiomiopatia isquêmica foi de 0,45 para AC vs. 0,81 do RTG. A especificidade da AC foi de 1,0 vs. 0,84 do RTG. O valor preditivo positivo foi de 1,0 vs. 0,81, e o valor preditivo negativo foi 0,68 vs. 0,84 para AC e do RTG, respectivamente. A acurácia do RTG foi superior a da AC (0,83 vs. 0,75). CONCLUSÕES: O RTG foi mais sensível do que a AC na avaliação etiológica da disfunção ventricular, enquanto a AC foi mais específica. A definição de cardiomiopatia isquêmica utilizando cada um dos métodos em separado apresentou limitações. BACKGROUND: The diagnosis of ischemic cardiomyopathy is frequently difficult. Coronary angiography (CA) is limited because it is invasive and the evaluation is exclusively anatomic. Cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) measures patterns of myocardial fibrosis caused by ischemia. However, LGE does not detect ischemia that does not result in fibrosis. Thus, a thorough clinical evaluation by a cardiologist seems to be the most effective option for diagnosis. The aim of this study was to evaluate CA and LGE as complementary methods for the diagnosis of ischemic cardiomyopathy in patients with systolic heart failure of unknown etiology. METHODS: Patients with systolic heart failure, left ventricle ejection fraction < 45% and unknown etiology after initial non-invasive evaluation were submitted to CA and MRI with LGE to define the etiology of the disease. Patient evaluation by two cardiologists was the gold standard for the diagnosis of ischemic cardiomyopathy. RESULTS: Twenty-four patients were included. The sensitivity to detect ischemic cardiomyopathy was 0.45 for CA vs. 0.81 for LGE. The specificity was 1.0 for CA vs. 0.84 for LGE. The positive predictive value was 1.0 vs. 0.81 and the negative predictive value was 0.68 vs. 0.84 for CA and LGE, respectively. LGE accuracy was superior to CA accuracy (0.83 vs. 0.75). CONCLUSIONS: LGE was more sensitive than CA to evaluate the etiology of ventricular dysfunction, whereas CA was more specific. The diagnosis of ischemic cardiomyopathy using each one of the methods separately presented limitations.

p.425-427 Submitted by Edileide Reis (leyde-landy@hotmail.com) on 2013-09-11T13:20:27Z No. of bitstreams: 1 27414.pdf: 225864 bytes, checksum: a0b8034a2890e25aaca11dfc7914f4f1 (MD5) Approved for entry into archive by Flávia Ferreira(flaviaccf@yahoo.com.br) on 2013-09-16T17:15:10Z (GMT) No. of bitstreams: 1 27414.pdf: 225864 bytes, checksum: a0b8034a2890e25aaca11dfc7914f4f1 (MD5) Made available in DSpace on 2013-09-16T17:15:10Z (GMT). No. of bitstreams: 1 27414.pdf: 225864 bytes, checksum: a0b8034a2890e25aaca11dfc7914f4f1 (MD5) Previous issue date: 2005 Não há descrição na literatura de comprometimento da função cardíaca associado à cisticercose. Os autores relatam o caso de uma mulher de 46 anos, portadora de cisticercose e insuficiência cardíaca, cujo ecocardiograma é compatível com cardiomiopatia restritiva e o aspecto miocárdico é de microcalcificações, sugerindo infiltração cardíaca pela doença.

Background: The elevation of cardiac biomarkers after percutaneous interventions (PCI) or coronary artery bypass grafting (CABG) is frequent. However, the correlation between the release and the diagnosis of procedure-related myocardial infarction (MI) remains unknown, especially after the emergence of high-sensitive troponin assays. In this study we aim to compare the release of cardiac biomarkers after mechanical interventions with the presence of new late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR) and interpret these findings based on the third Task Force definitions for MI. Methods: We prospectively studied 79 patients with stable multivessel coronary artery disease and preserved ventricular function with formal indication for mechanical revascularization. Measurements of biomarkers such as high-sensitive troponin I (cTnI) and creatine kinase (CKMB) was systematically obtained before and after the procedure, six, twelve, 24, and 36 hours to PCI and until 72 hours to CABG. Furthermore, CMR and LGE was performed in all patients before and after procedures. The diagnosis of procedure-related myocardial injury was defined as up to 5 times and 10 times the 99th percentile, for PCI and CABG, respectively. Results: Of 79 patients studied, 58 (73.4%) underwent CABG and 21 (26.6%) underwent PCI. Using the Task Force definitions, for CABG patients, myocardial injury occurred in 55 (94.8%) with TnI and 14 (24.1%) with CKMB. For PCI patients, myocardial injury occurred in 14 (66.7%) with troponin and 1 (4.8%) with CKMB. 16 (20,3%) patients had new LGE on post procedure CMR, 15 (25.8%) after CABG and 1 (4.7%) after PCI. With the currents cutoffs, TnI has a sensitivity of 100% and specificity of 7.3% for CABG and a sensitivity of 100% and specificity of 5% for PCI. CKMB has a sensitivity of 53.3% and specificity of 85.4% for CABG and a sensitivity of 100% and specificity of 100% for PCI. Based on the receiver operating characteristic (ROC) curve, for CABG patients, the best cutoff of TnI was 3.38 ng/mL (85 times the 99th percentile) with a sensitivity of 80% and specificity of 66%, and of CKMB was 22.8 ng/mL (5 times the 99th percentile) with sensitivity of 73% and specificity of 64%. Conclusion: In this sample, compared with LGE in CMR, CKMB reached better accuracy than cTnl for the diagnosis of myocardial injury. These data suggest a higher troponin cutoff for the diagnosis of procedure-related MI.

Background Although the release of cardiac biomarkers after percutaneous (PCI) or surgical revascularization (CABG) is common, its prognostic significance is not known. Questions remain about the mechanisms and degree of correlation between the release, the volume of myocardial tissue loss, and the long-term significance. Delayed-enhancement of cardiac magnetic resonance (CMR) consistently quantifies areas of irreversible myocardial injury. To investigate the quantitative relationship between irreversible injury and cardiac biomarkers, we will evaluate the extent of irreversible injury in patients undergoing PCI and CABG and relate it to postprocedural modifications in cardiac biomarkers and long-term prognosis. Methods/Design The study will include 150 patients with multivessel coronary artery disease (CAD) with left ventricle ejection fraction (LVEF) and a formal indication for CABG; 50 patients will undergo CABG with cardiopulmonary bypass (CPB); 50 patients with the same arterial and ventricular condition indicated for myocardial revascularization will undergo CABG without CPB; and another 50 patients with CAD and preserved ventricular function will undergo PCI using stents. All patients will undergo CMR before and after surgery or PCI. We will also evaluate the release of cardiac markers of necrosis immediately before and after each procedure. Primary outcome considered is overall death in a 5-year follow-up. Secondary outcomes are levels of CK-MB isoenzyme and I-Troponin in association with presence of myocardial fibrosis and systolic left ventricle dysfunction assessed by CMR. Discussion The MASS-V Trial aims to establish reliable values for parameters of enzyme markers of myocardial necrosis in the absence of manifest myocardial infarction after mechanical interventions. The establishments of these indices have diagnostic value and clinical prognosis and therefore require relevant and different therapeutic measures. In daily practice, the inappropriate use of these necrosis markers has led to misdiagnosis and therefore wrong treatment. The appearance of a more sensitive tool such as CMR provides an unprecedented diagnostic accuracy of myocardial damage when correlated with necrosis enzyme markers. We aim to correlate laboratory data with imaging, thereby establishing more refined data on the presence or absence of irreversible myocardial injury after the procedure, either percutaneous or surgical, and this, with or without the use of cardiopulmonary bypass.