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Objectives The IMPACT-CABG trial is the first North American multicenter phase II randomized study of intramyocardial delivery of autologous CD133 + stem cells in patients with chronic ischemic cardiomyopathy undergoing coronary artery bypass grafting. The primary objective was to demonstrate safety, including freedom from major adverse cardiac events. The secondary objective was to evaluate feasibility of same-day autologous cell preparation. Although the trial was not powered to evaluate LV function, exploratory data were collected. Methods After 7 open-label patients who received cells, patients randomly received stem cells or placebo (N = 40 total, 20 per center). After completion of coronary anastomoses, up to 10 million CD133 + , CD34 + , CD45 + triple-positive cells or placebo were injected into the infarct and border zones. Patients were followed up clinically and underwent magnetic resonance imaging preoperatively and after 6 months. Results There were no procedural complications from bone marrow isolation and cell injection, no in-hospital mortality, and no protocol-related complications. Four patients had transient renal insufficiency, with 1 death during 6-month follow-up. Magnetic resonance imaging revealed that left ventricular volumes and ejection fractions improved in all patients (no difference between groups). Conclusions The trial successfully met both primary and secondary objectives, demonstrating that same-day isolation and autologous CD133 + cell delivery with coronary artery bypass grafting is safe and feasible. The positive findings support a larger randomized, multicenter trial, with higher numbers of transplanted cells to demonstrate beneficial effects. The upcoming IMPACT-CABG II trial will evaluate higher cell doses and pharmacologic enhancement to determine whether these cells improve perfusion and myocardial function.

We present a case of a 63-year-old male with an early caseous form of mitral annular calcification, which was incidentally found on a routine echocardiogram and initially suspicious for a malignant cardiac tumor. We show the relevance of using cardiac MRI in the workup of this important differential diagnosis of cardiac tumors.

We examine a time of flight (TOF) approach for the analysis of contrast enhanced 4D volumetric CT angiography scans to derive and display blood velocity in arteries. Software was written to divide blood vessels into a series of cross sections and to track contrast bolus TOF along the central vessel axis, which was defined by a user, from 4D CT source data. Time density curves at each vessel cross section were fit with quadratic, Gaussian, and gamma variate functions to determine bolus time to peak (TTP). A straight line was used to plot TTP versus vessel path length for all three functions and the slope used to calculate intraluminal velocity. Software was validated in a simulated square channel and non-pulsatile flow phantom prior to the calculation of blood velocity in the major cerebral arteries of 8 normal patients. The TOF algorithm correctly calculates intra-luminal fluid velocity in eight flow conditions of the CT flow phantom where quadratic functions were used. Across all conditions, in phantoms and in vivo, the success of calculations depended strongly on having a sufficiently long path length to make measurements and avoiding venous contamination. Total blood flow into the brain was approximately 17 % of a normal 5 L cardiac output. The technique was explored in vivo in a patient with subclavian steal syndrome, in the pulmonary arteries and in the iliac artery from clinical 4D CT source data. Intravascular blood velocity and flow may be calculated from 4D CT angiography using a TOF approach.

Background— In hypertrophic cardiomyopathy (HCM), heterogeneous myocardial hypertrophy and fibrosis are responsible for abnormalities of left ventricular (LV) function. We aimed to characterize LV global and regional myocardial mechanics in HCM, according to segmental hypertrophy and fibrosis. Methods and Results— Fifty-nine patients with HCM underwent standard echocardiography, 3-dimensional speckle tracking echocardiography, and cardiac magnetic resonance with late gadolinium enhancement (LGE); all 3 tests were r =0.32, P =0.01; maximum LV wall thickness, r =0.34, P =0.009; number of segments ≥15 mm, r =0.44, P r =0.47, P r =−0.75, P Conclusions— Both hypertrophy and fibrosis contribute to regional impairment of myocardial shortening in HCM. The extent of hypertrophy is the primary factor altering global myocardial mechanics. Circumferential myocardial shortening seems to be directly involved in preservation of LV systolic performance in HCM.

To determine the relationship between deep basal inferoseptal crypts and disease-causing gene mutations in hypertrophic cardiomyopathy (HCM).Institutional research and ethics board approval was obtained for this retrospective study, and the requirement to obtain informed consent was waived. Two readers, who were blinded to genetic status, independently assessed cardiac magnetic resonance (MR) images obtained in 300 consecutive unrelated genetically tested patients with HCM. Readers documented the morphologic phenotype, the presence of deep basal inferoseptal crypts, and the imaging plane in which crypts were first convincingly visualized. The Student t test, the Fisher exact test, and multivariate logistic regression were used for comparisons and to evaluate the relationship between these crypts and the detection of disease-causing mutations.The frequency of deep basal inferoseptal crypts was significantly higher in patients with disease-causing mutations than in those without disease-causing mutations (36% and 4%, respectively; P.001). The presence of crypts was a stronger predictor of disease-causing mutations than was reverse septal curvature (P = .025). Patients with these crypts had a higher likelihood of having disease-causing mutations than non-disease-causing mutations (P.001). Thirty-one of the 34 patients with both deep basal inferoseptal crypts and reverse septal curvature (91%) had disease-causing mutations (sensitivity, 26%; specificity, 98%). The presence of deep basal inferoseptal crypts (odds ratio: 6.64; 95% confidence interval: 2.631, 16.755; P.001) and reverse septal curvature (odds ratio: 4.8; 95% confidence interval: 2.552, 9.083; P.001) were predictive of disease-causing mutations. Both observers required additional imaging planes to identify approximately half of all crypts.Deep basal inferoseptal crypts occur more commonly in patients with HCM with disease-causing mutations than in those with genotype-negative HCM.

The purpose of this study is to examine the effect of different iron chelation regimens on the distribution of myocardial iron in patients with transfusion-dependent anemias. Institutional review board approval was obtained. Patients treated with iron chelation therapy who had undergone baseline and 1-year follow-up cardiac T2* MR studies in a four-year period were identified retrospectively. One hundred and eight patients (44 % male, mean age 31.6 ± 9.7 years) were included. The interventricular septum on three short-axis slices (basal, mid and apical) was divided into anterior and inferior regions of interest for T2* analysis. Cardiac iron concentration (CIC) was calculated from T2* values. Statistical analysis included analysis of variance and paired t-test, using Bonferroni adjustment in all pairwise comparisons. At baseline, T2* measurements varied significantly across all six regions (p < 0.001): lowest in the mid anteroseptum (mean 22.3 ± 10.1 ms) and highest in the apical inferoseptum (mean 26.2 ± 12.8 ms). At follow-up, T2* and CIC values improved significantly in all segments [mean change of 3.78 ms (95 % CI (2.93, 4.62), p < 0.001) and 0.23 mg/g (95 % CI (0.16, 0.29), p < 0.001), respectively]. Change in T2* values varied significantly between segments (p < 0.001) with greatest improvement in the apical inferoseptum [4.26 ms, 95 % CI (2.42, 6.11)] and least improvement in the basal anteroseptum [2.95 ms, 95 % CI (1.37, 4.54)]. The largest improvement in T2* values was noted in patients treated with deferiprone [4.96 ms, 95 % CI (2.34, 7.58)]. There was a statistically significant difference in improvement in CIC values between chelation regimens (p = 0.016). This is the first study to report heterogeneity in response to iron chelating drugs with variable segmental changes in T2* values.

Percutaneous coronary intervention (PCI) is frequently attempted to open chronic total occlusions (CTOs) and restore epicardial coronary flow. Data suggest adverse outcomes in the case of PCI failure. We hypothesized that failure to open a CTO might adversely affect regional cardiac function and promote deleterious cardiac remodelling, and success would improve global and regional cardiac function assessed using cardiac magnetic resonance and velocity vector imaging.Thirty patients referred for PCI to a CTO underwent cardiac magnetic resonance examination before and after the procedure. Left ventricular function and transmural extent of infarction was assessed in these patients. Regional cardiac function using Velocity Vector Imaging version 3.0.0 (Siemens) was assessed in 20 patients.Successful CTO opening (thrombolysis in myocardial infarction 3 flow) occurred in 63% of patients. Left ventricular ejection fraction significantly increased after successful PCI (50 ± 13% to 54 ± 11%; P0.01). Global longitudinal strain (GLS) fell significantly in the failed group (Δ = -25 ± 17%; P = 0.02) in contrast with successful PCI in which GLS did not change (Δ 20 ± 32%; P = 0.17). GLS rate followed a pattern similar to GLS (failed, Δ -30 ± 17%; P0.01 vs success Δ 25 ± 48%; P = 0.34). In contrast, radial and circumferential strain/strain rate were not different between groups after success/failed PCI.Regional cardiac function assessment using velocity vector imaging showed a significant decline in GLS and GLS rate in patients in whom PCI failed to open a CTO, with no change in global measures of cardiac function.

Methods Cardiovascular magnetic resonance (CMR) data sets of 300 consecutive unrelated HCM patients who underwent genetic testing were reviewed independently by two experienced clinical CMR readers who were blinded to results of genetic testing. Readers assessed for presence or absence of deep basal inferoseptal crypts (DBISC) on cine steady state free precession and late gadolinium enhancement sequences and documented the imaging plane in which DBISC were convincingly visualized. Imaging and genetic testing results were correlated.

We report the case of a 42-year-old patient with hypertrophic cardiomyopathy (HCM) who presented to the emergency department with severe shortness of breath one week following uneventful cesarean delivery. Thoracic CT ruled out pulmonary embolus and confirmed pulmonary edema. Asymmetric interventricular septal thickening was clearly identified, demonstrating that the heart may be evaluated even on a non-ECG gated study. Acute pulmonary edema in the postpartum period is an unusual clinical presentation of HCM.

Background The diagnosis of pericardial constriction (PC) remains challenging and cardiac magnetic resonance (CMR) is increasingly used as a diagnostic tool. The objective of this study was to evaluate CMR findings for the prediction of subsequent surgical pericardiectomy. Methods CMR studies of 36 patients referred to assess for PC were evaluated retrospectively. Patients were divided into two groups depending on whether they subsequently had their pericardium stripped (n=18) or did not (n=18). IVC and aortic areas were determined by manual contouring on a single axial-SSFP image in maximum systole at the level of the esophageal hiatus. The ratio of IVC to aortic (I:A) area was calculated. Cross-sectional areas were indexed to body surface area (BSA). Quantitative data was assessed with a two-sample t-test and qualitative data was assessed with Fisher’s exact test. A logistic regression model was used to determine the predictive probability of surgical pericardiectomy based on CMR features. Odds ratios (ORs) were calculated and receiver operating characteristic (ROC) analysis was performed. Results Mean age of patients was 53.9±15.3 years, 72% (n=26) male, with no significant difference in mean age between the two groups (p=0.429). In patients with constriction, the underlying etiology was idiopathic (39%, n=7), infectious (28%, n=5), post-surgical (17%, n=3), connective-tissue disease (11%, n=2), and post-radiation (6%, n=1). IVC area, indexed IVC area, I:A ratio, pericardial thickness, RV area and indexed RV area were significantly different in patients who underwent pericardiectomy compared to those who did not (Table 1). Pericardiectomy was significantly associated with pericardial enhancement (p=0.011) as well as septal bounce (p

A 54-year-old man was admitted with a 4-year history of recurrent urinary tract infections. He had a history of osteoarthritis of the left hip and benign prostatic enlargement. Physical examination showed clubbing with cyanosis (fi gure), and a grade 4/6 systolic murmur throughout the praecordium. Electrocardiogram showed right ventricular hypertrophy with features of pressure overload (appendix). His haemoglobin was raised at 200 g/L, with a haematocrit of 0·53. A CT scan of the genitourinary system showed multiple large urinary bladder stones (fi gure), urinary bladder wall thickening, trabeculations and diverticulae, and bilateral hydroureters and hydronephrosis. Cardiac MRI showed features consistent with unrepaired tetralogy of Fallot, including a large ventricular septal defect with bidirectional shunting. Cardiac catheterisation showed normal coronary arteries and pulmonary vascular resistance. Ten large bladder stones were removed by open surgery, for symptom relief and to decompress the related obstructive uropathy, measuring up to 3·3 cm in diameter (fi gure). Gas chromatography-mass spectrometry showed that the stones were composed of uric acid. Our patient later had corrective surgery for prognostic and symptomatic improvement of his suprasystemic right ventricular systolic pressure and pulmonary stenosis. Patients with cyanotic heart disease have compensatory erythrocytosis as a physiological response to persistent hypoxia, associated with a shortened red blood cell lifespan. This can cause increased red cell turnover leading to high purine metabolism and uric acid production. The most common factors that promote uric acid stone formations are persistently low urinary pH, dehydration leading to low urinary volume, and high uric acid production. Nitrogen atoms from urate interact with free protons to form uric acid that is 20 times less soluble than urate. Low pH promotes urate conversion to uric acid, which is less soluble and so more prone to forming crystals. At persistently low pH uric acid crystals can form and stabilise even with normal urinary urate concentration. Intermittent alkalinisation of urine dissolves crystals that have formed and promotes urinary stone resorption, although patients with hyperuricosuria do not form uric acid stones in the presence of alkaline urine. The underlying physiology that leads to persistently low urinary pH is poorly understood. Oral agents to modify urinary pH are available, but minimally invasive surgery is the treatment of choice for patients with symptomatic urinary bladder stones. Our patient had slightly raised plasma uric acid, with normal 24-h urinary uric acid and plasma creatinine levels. The electronic patient record had recorded a persistently low urinary pH over the last few years. He now has regular urological follow-up. We suggest that hyperuricaemia combined with persistently low urinary pH, which led to bladder stone formation, was caused by appropriate secondary erythrocytosis, turnover, and breakdown in the setting of cyanotic congenital heart disease.

The myocardial contraction fraction (MCF) is a volumetric index of myocardial shortening, defined as the ratio of LV stroke volume to myocardial volume. We hypothesize that MCF: may be associated with delayed enhancement, is correlated with functional capacity and is associated with SCD in HCM. As

Background For the primary prevention of sudden cardiac death, guidelines provide left ventricular ejection fraction (EF) criteria for implantable cardioverter defibrillator (ICD) placement without specifying the technique by which it should be measured. We sought to investigate the potential impact of performing cardiovascular magnetic resonance (CMR) for EF on ICD eligibility. Methods The study population consisted of patients being considered for ICD implantation who were referred for EF assessment by CMR. Patients who underwent CMR within 30 days of echocardiography were included. Echocardiographic EF was determined by Simpson’s biplane method and CMR EF was measured by Simpson’s summation of discs method. Results Fifty-two patients (age 62±15 years, 81% male) had a mean EF of 38 ± 14% by echocardiography and 35 ± 14% by CMR. CMR had greater reproducibility than echocardiography for both intra-observer (ICC, 0.98 vs 0.94) and inter-observer comparisons (ICC 0.99 vs 0.93). The limits of agreement comparing CMR and echocardiographic EF were – 16 to +10 percentage points. CMR resulted in 11 of 52 (21%) and 5 of 52 (10%) of patients being reclassified regarding ICD eligibility at the EF thresholds of 35 and 30% respectively. Among patients with an echocardiographic EF of between 25 and 40%, 9 of 22 (41%) were reclassified by CMR at either the 35 or 30% threshold. Echocardiography identified only 1 of the 6 patients with left ventricular thrombus noted incidentally on CMR. Conclusions CMR resulted in 21% of patients being reclassified regarding ICD eligibility when strict EF criteria were used. In addition, CMR detected unexpected left ventricular thrombus in almost 10% of patients. Our findings suggest that the use of CMR for EF assessment may have a substantial impact on management in patients being considered for ICD implantation.

Scar delineation with late gadolinium-enhanced MRI can direct VT substrate mapping and ablation, but imaging is poor and relatively contraindicated in the majority of patients with ICDs. We present a case of scar definition using late iodine-enhanced multidetector CT in a patient with ischemic cardiomyopathy and multiple ICD shocks for VT. CT images were acquired using a novel intracoronary contrast delivery protocol which provided high-resolution subendocardial scar visualization. The segmented scar images were subsequently imported into an electroanatomic mapping platform to guide successful VT ablation.

Introduction: At present, physicians have a limited ability to predict major cardiovascular complications after non-cardiac surgery and little is known about the anatomy of coronary arteries associated with perioperative myocardial infarction. We have initiated the Coronary CT Angiography (CTA) VISION Study to (1) establish the predictive value of coronary CTA for perioperative myocardial infarction and death and (2) describe the coronary anatomy of patients that have a perioperative myocardial infarction. Methods and analysis: The Coronary CTAVISION Study is prospective observational study. Preoperative coronary CTA will be performed in 1000–1500 patients with a history of vascular disease or at least three cardiovascular risk factors who are undergoing major elective non-cardiac surgery. Serial troponin will be measured 6–12 h after surgery and daily for the first 3 days after surgery. Major vascular outcomes at 30 days and 1 year after surgery will be independently adjudicated. Ethics and dissemination: Coronary CTA results in a measurable radiation exposure that is similar to a nuclear perfusion scan (10–12 mSV). Treating physicians will be blinded to the CTA results until 30 days after surgery in order to provide the most unbiased assessment of its prognostic capabilities. The only exception will be the presence of a left main stenosis >50%. This approach is supported by best available current evidence that, excluding left main disease, prophylatic revascularisation prior to non-cardiac surgery does not improve outcomes. An external safety and monitoring committee is overseeing the study and will review outcome data at regular intervals. Publications describing the results of the study will be submitted to major peer-reviewed journals and presented at international medical conferences.

Cardiovascular magnetic resonance (CMR) imaging is the reference standard for measurement of right ventricular (RV) volumes and function. To date, no study has compared methods of data acquisition and analysis by CMR for adults with a systemic RV. Our objective was to evaluate RV size and function using axial and short axis views in adults post atrial switch (Mustard) surgery. A total of 34 adults (20 male, mean age at CMR 32 ± 6 years) were identified at our centre. Volumes, RV end-diastolic (EDV) and end-systolic (ESV) were measured in short axis and axial orientations by two independent experienced readers, blinded to clinical and CMR data. Intra and interobserver measurements in each view were compared using Bland–Altman plots and intraclass correlation coefficients (ICC). Although mean volumes were larger in the axial as compared with the short axis view [RVEDV 247 ± 67 vs. 233 ± 54 ml (p = 0.002) and RVESV 148 ± 54 vs. 136 ± 50 ml (p = 0.001)], mean RV ejection fractions (EF) were similar [41 ± 9 % vs. 43 ± 12 % (p = 0.13)]. Bland–Altman plots demonstrated better agreement for axial measures of RVEDV and right ventricular ejection fraction (RVEF) within and between observers. Similarly, ICC values were stronger for axial as compared with short axis volumes and function—intraobserver RVEDV 0.99 (0.98–0.99) versus 0.96 (0.92–0.98) and RVEF 0.96 (0.93–0.98) versus 0.90 (0.82–0.95); interobserver RVEDV 0.97 (0.94–0.98) versus 0.90 (0.73–0.95) and RVEF 0.85 (0.53–0.94) versus 0.82 (0.67–0.90). Axially derived measurements of RV volumes and function have better agreement and reproducibility as compared with short axis values; whereas axial volumes tend to be larger, RVEF is not significantly different between the two methods.

Hypertrophic cardiomyopathy (HCM) is the most common, heritable cardiovascular disorder and the most frequent cause of sudden cardiac death (SCD) in young adults. Gender disparities with regards to clinical outcomes among HCM patients are not well-defined. We investigated the relationship between

Background In congenitally corrected transposition of the great arteries (cc-TGA), the morphologic right ventricle acts as the subaortic (systemic) ventricle, and deterioration of the ventricle over time is a well-known complication. The objective of this study was to characterize the right ventricle and explore factors that may be contributing to ventricular dilation and dysfunction and the relationship with exercise capacity. Methods This was a prospective study of adults with cc-TGA. All patients underwent cardiopulmonary stress testing, ventricular volume and fibrosis assessment by cardiac magnetic resonance imaging, and Velocity Vector Imaging strain echocardiography. Results Twenty-six patients were included (mean age, 38 ± 16 years; 54% women). Exercise capacity was significantly reduced in patients with cc-TGA compared with normal subjects (20.9 ± 6.0 vs 30.8 ± 9.2 mL/kg/min, P = .001). The majority of patients (61%) had right ventricular (RV) ejection fractions ≤ 40%. There was no evidence of fibrosis on cardiac magnetic resonance imaging. There was a significant difference in diastolic volumes among those with RV ejection fractions > 40% versus ≤ 40% (173 ± 29mL vs 233 ± 65 mL, P = .02) and moderate or severe versus no or mild tricuspid regurgitation (240 ± 80mL vs 190 ± 38mL, P = .04). RV apical longitudinal and mid free wall circumferential strain was decreased compared with these values in controls. Conclusions In this relatively "well" cc-TGA population, subaortic RV dilation, dysfunction, and exercise intolerance are a common problem. Significant systemic tricuspid atrioventricular valvular regurgitation is an important contributor to the problem. In this study, subaortic RV myocardial deformation parameters were found to be abnormal, suggesting that there is a failure of the ventricle to adapt to systemic pressures, and therapies to reduce afterload should be explored. Recurrent ischemia resulting in fibrosis likely does not contribute to RV dilation or dysfunction as demonstrated by the magnetic resonance imaging findings in this study.

Background Three dimensional echo is a relatively new technique which may offer a rapid alternative for the examination of the right heart. However its role in patients with non-standard ventricular size or anatomy is unclear. This study compared volumetric measurements of the right ventricle in 25 patients with adult congenital heart disease using both cardiovascular magnetic resonance (CMR) and three dimensional echocardiography. Methods Patients were grouped by diagnosis into those expected to have normal or near-normal RV size (patients with repaired coarctation of the aorta) and patients expected to have moderate or worse RV enlargement (patients with repaired tetralogy of Fallot or transposition of the great arteries). Right ventricular end diastolic volume, end systolic volume and ejection fraction were compared using both methods with CMR regarded as the reference standard Results Bland-Altman analysis of the 25 patients demonstrated that for both RV EDV and RV ESV, there was a significant and systematic under-estimation of volume by 3D echo compared to CMR. This bias led to a mean underestimation of RV EDV by -34% (95%CI: -91% to + 23%). The degree of underestimation was more marked for RV ESV with a bias of -42% (95%CI: -117% to + 32%). There was also a tendency to overestimate RV EF by 3D echo with a bias of approximately 13% (95% CI -52% to +27%). Conclusions Statistically significant and clinically meaningful differences in volumetric measurements were observed between the two techniques. Three dimensional echocardiography does not appear ready for routine clinical use in RV assessment in congenital heart disease patients with more than mild RV dilatation at the current time.

[Figure][1] ![Figure][1] [Video 1][2] Cine 4-chamber view showing dilated right ventricle with moderate tricuspid regurgitation. LA = left atrium; LSVC = left superior vena cava; RSVC = right superior vena cava. ![Figure][1] [Video 2][3] High-resolution 3-dimensional

We report 4 cases of left main coronary artery (LMCA) compression after remote repair of conotruncal lesions and their successful surgical management.

This report describes two episodes of significant uvular and oropharyngeal ulceration occurring during routine transoesophageal echocardiographic examination of the heart while intubated under general anaesthesia. Both patients were young and healthy and underwent anaesthesia without compromise, but experienced significant morbidity as a result of the ulceration. Uvular and oropharyngeal ulceration has been described following endoscopy and intubation, but there are few reports of ulceration following transoesophageal echocardiography. Operator skill is often a factor. Physical trauma and local ischaemia may play a role in aetiology. Patients experiencing sore throat following the procedure should be examined and observed in case of potentially fatal complications of airway compromise or uvular necrosis and infection. Particular care is required in patients undergoing day case procedures, as early discharge may lead to complications while the patient is at home.

Up to one third of the population will die as a direct result of cancer. Accurate and timely diagnosis of disease often requires multiple different approaches including the use of modern imaging techniques. Prompt recognition of adverse consequences of some anti-cancer therapies also requires a knowledge of the optimum imaging strategy for the problem at hand. The purpose of this article is to review not only some of the commoner cardiovascular manifestations of malignancy but also to discuss the strengths, weaknesses and appropriate use of cardiovascular imaging modalities.

Background The utility of cardiac magnetic resonance imaging (CMR) for assessment of adults with Ebstein anomaly is not well-defined. We sought to evaluate CMR characteristics in this population and to relate these to exercise parameters. Methods We analyzed CMR studies in adults with unrepaired Ebstein anomaly for measures of severity of Ebstein disease, including atrialized, functional and total right ventricular (RV) volumes, ejection fraction (EF) and severity index (area of atrialized RV+right atrium/functional RV+left ventricle+left atrium). We related these CMR values to cardiopulmonary exercise test measurements. Results Twenty-seven adults (mean age 41±14years, 70% female) were included. Functional RV end-diastolic volume (EDV) was 150±68mL/m 2 and atrialized RVEDV was 25±24mL/m 2 . In 17 patients (63%), the functional RVEDV was enlarged (>114mL/m 2 ). Percent predicted peak VO 2 for the population was 65±20%. On univariable analysis, peak VO 2 was inversely related to atrialized RVEDV (p=0.011), total RVEDV (p=0.041), functional RVEDV/left ventricular EDV ratio (p=0.015) and magnitude of tricuspid valve displacement (p=0.031). In the multivariate model, the only CMR factor to relate to peak VO 2 was atrialized RVEDV (p=0.011, β=−0.48). No significant correlations were found between CMR measures and heart rate response or ventilatory response to exercise. Conclusion In adults with unrepaired Ebstein anomaly, atrialized RV volume was independently related to aerobic capacity. The volume of the atrialized RV is a novel CMR measure which may express severity of disease. Further research is needed to evaluate the prognostic relevance of this exploratory work.

Background MRI is deemed standard of reference for assessment of ventricular volumes and function. However, it remains unclear if the RV can also be adequately assessed in SAO orientation as used for assessment of LV function or requires dedicated axial-Cine imaging. Additional axial-Cine acquisition adds 10-15 min of scan time and thus has a substantial impact on clinical workflow and patient comfort.

Adverse ventricular-ventricular interactions have been recognized in those with repaired tetralogy of Fallot (TOF) and severe pulmonary regurgitation.We aimed to examine the impact of pulmonary valve replacement (PVR) on the left heart late after TOF repair.Left ventricular (LV) volumes and ejection fractions (EF) were analyzed in adults with severe pulmonary regurgitation after TOF repair with cardiac magnetic resonance imaging (CMR) before and after PVR. Thirty-nine patients (median age 33[20-65] years) were reviewed. Post-PVR, LVEF improved significantly in the entire cohort (50 ± 9%→54 ± 7%, p0.001) and in those with moderately impaired (defined as LVEF ≤ 45%) preoperative LVEF (38 ± 5%→47 ± 6%, p0.0001), but was not statistically different in those with relatively preserved (defined as LVEF45%) preoperative LVEF. By multivariate linear regression analysis to evaluate independent CMR predictors of improved LVEF post-PVR for the entire cohort, the only CMR variable to emerge was preoperative LVEF (p=0.012, regression coefficient -0.54, SE 0.13). Whereas PVR resulted in increased LV filling in patients with relatively preserved preoperative LVEF reflected by an increase in LV end-diastolic volumes (77 ± 10→82 ± 16 mL/m(2), p=0.05), LV end-systolic volumes decreased after PVR in patients with impaired preoperative LVEF (65 ± 12→54 ± 10 mL/m(2), p=0.001) but LV end-diastolic volumes were not significantly changed.When LVEF is decreased after TOF repair, PVR appears to have a salutary effect on postoperative LVEF, thereby supporting the concept of recovery of adverse right-left heart interactions. Mechanisms of left heart improvement post-PVR differ depending on degree of preoperative LV systolic dysfunction.

The right ventricular (RV) systolic function is important for decision making in adults with repaired tetralogy of Fallot (rTOF). Our aim was to assess regional RV systolic function and its impact on global RV systolic function by echocardiography.In 101 adults with rTOF, regional RV systolic function on echocardiography was compared to 50 individuals with structurally normal hearts. In patients with rTOF, the impact of echocardiographic measures of regional RV systolic function on global RV-ejection fraction as measured by cardiac magnetic resonance imaging (CMR-RVEF) was determined.Compared to normals, patients with rTOF had impaired systolic function of the RV outflow tract. Patients with rTOF and normal CMR-RVEF compensate this loss of RV outflow tract function with increased contractions of the RV-body, measured as fractional area change on short axis (30±12% versus 19±7%, p0.0001) and on 4-chamber views (42±7% versus 38±8%, p=0.06). In contrast, patients with rTOF and abnormal global CMR-RVEF showed significantly lower systolic function of the RV-body compared to normal controls (fractional area change on 4-chamber view: 31±6% versus 38±8%, p0.0001). A simple regression model, incorporating fractional shortening of RV outflow tract and fractional area change on 4-chamber view allows accurate echocardiographic estimation of the CMR-derived RVEF.Patients with repaired tetralogy of Fallot have markedly different regional systolic RV-function compared to normals, even when the global RV systolic function is preserved. The systolic function of the RV outflow tract and of the RV body are both important determinants of global systolic RV function in these patients. Their prognostic significance needs to be determined.

Background Improved outcomes for normoglycemic patients suffering acute myocardial infarction (AMI) over the last decade have not been matched by similar improvements in mortality for diabetic patients despite similar levels of baseline risk and appropriate medical therapy. Two of the major determinants of poor outcome following AMI are infarct size and left ventricular (LV) dysfunction. Methods Ninety-three patients with first AMI were studied. 22 patients had diabetes mellitus (DM) based on prior history or admission blood glucose ≥11.1 mmol/l. 13 patients had dysglycemia (admission blood glucose ≥7.8 mmol/l but Results Patients with dysglycemia and DM had larger infarct sizes by CMR than normoglycemic patients; at baseline percentage LV scar (mean (SD)) was 23.0% (10.9), 25.6% (12.9) and 15.8% (10.3) respectively (p = 0.001), and at 11 months percentage LV scar was 17.6% (8.9), 19.1% (9.6) and 12.4% (7.8) (p = 0.017). Patients with dysglycemia and DM also had lower event-free survival at 18 months (p = 0.005). Conclusions Patients with dysglycemia or diabetes mellitus sustain larger infarct sizes than normoglycemic patients, as determined by CMR. This may, in part, account for their adverse prognosis following AMI.

A 41-year-old man was admitted with hemoptysis and a 10-year history of progressive exertional decline. He had a patent ductus arteriosus diagnosed in adult life that was unrepaired because of concomitant pulmonary hypertension. On examination, he had a sustained right ventricular impulse with a

Background The aim of this study was to develop a mathematical model using two-dimensional echocardiographic parameters to estimate right ventricular end-diastolic volume (RVEDVi) in adults with repaired tetralogy of Fallot. Methods Linear regression equations were used to examine the relationship between two-dimensional echocardiographic and cardiac magnetic resonance (CMR) imaging measures of RVEDVi. Imaging studies in 101 adults were used to create and validate the model. The ability of the model to detect changes in CMR RVEDVi was tested in 57 adults with serial studies. Results The optimal model to quantitate CMR RVEDVi included two-dimensional echocardiographic right ventricular end-diastolic area measured in the apical four-chamber view, indexed to body surface area (AreaDi) (CMR RVEDVi=11.5 + [7 × AreaDi]). The model reliably allowed the detection of stable and changing CMR RVEDVi (κ = 0.84 and κ = 0.82, respectively, P Conclusion Quantitative assessment of right-ventricular volumes by echocardiography is feasible and may be used for serial follow-up in patients with contraindications for CMR.

Background Conventional coronary angiography (CCA) may be inaccurate to distinguish between interarterial and septal subtypes of anomalous left coronary arteries (CAs). Objective We compared the classification of anomalous left CA arising from the right sinus of Valsalva (RSV) or right CA on the basis of multidetector computed tomography coronary angiography (MDCTCA) with the classification derived from CCA. Methods A retrospective review of 6000 consecutive electrocardiographic-gated MDCTCAs identified 15 cases of anomalous left main or left anterior descending CA arising from the RSV or right CA coursing between the aorta and the main pulmonary artery. On the basis of MDCTCA findings, the proximal course of each vessel was classified into 3 subtypes: 1, interarterial; 2, septal; and 3, mixed. CCA was reviewed in 5 cases (33%) and classified according to traditional criteria. When CCA images were not available, 3-dimensional volume-rendered reconstructions were used to simulate CCA. Results On the basis of MDCTCA, subtypes were distributed as type 1 (n = 2), type 2 (n = 4), and type 3 (n = 8). One case could not be classified into any of these subtypes and was classified as type 4, right ventricular infundibulum (RVI). Applying CCA criteria, 2 cases would have been classified as interarterial and 14 as septal without appreciation of the mixed or RVI subtypes. Conclusions Classification of anomalous left CAs into either septal or interarterial may be too simplistic. There is an anatomic spectrum of anomalous left CAs detected by MDCTCA that challenges the traditional classification based on CCA.

A routine chest X-ray in a 78-year-old female patient suggested a retained vascular catheter in the right ventricle (RV). On transthoracic echocardiography, a prominent linear echo was found in the RV and the patient was referred for cardiac computed tomography and magnetic resonance imaging. Although neither of these tests showed evidence of a retained foreign body in the RV, they could not clarify the nature of the linear structure within the RV cavity. Finally, transesophageal echocardiography, using a matrix array three-dimensional probe solved the mystery: the linear structure in question within the RV was a large papillary muscle with attachments to the anterior leaflet of the tricuspid valve and an unusual origin from the interventricular septum.

Echocardiographic assessment of a 72-year-old woman revealed a posterior mitral valve prolapse with an unusual central regurgitation jet. The use of three-dimensional (3D) transesophageal echocardiography elucidated the mismatch between morphologic and color Doppler echocardiographic findings: There was a cleft in the posterior mitral valve in addition to the posterior mitral valve prolapse. This case illustrates that the use of high-quality real-time 3D transesophageal echocardiography (including 3D color Doppler) facilitates the understanding of the anatomy and the mechanism and severity of regurgitation in complex mitral valve pathology and is clearly superior to two-dimensional transesophageal echocardiography alone.

Methods Prospective consecutive enrollment of adult patients expected to have enlarged right ventricles principally patients with repaired tetralogy and transposition. Patients underwent both CMR and 3D echo within a mean of 12 weeks. Volumetric stacks were contoured by experienced observers for both techniques to determine end diastolic volume and ejection fraction of the RV. Systematic bias was assessed by Bland Altman analysis.

Methods Steady-state free precession cine acquisitions across the aortic root in short axis in patients with a diagnosis of BAV from January 2006 to December 2008 were evaluated at our institution using a 1.5 T magnet. For each aortic root, end-systolic measurements were obtained in duplicate by a single observer from cusp-to-commissure (3 measurements: right, left and non-coronary cusps to opposite commissure respectively) and cusp-to-cusp (3 measurements: right-left, right-non and left-non coronary cusps) using CMR. Using TTE, measures of the aortic root were recorded from the parasternal long axis view. Aortic root asymmetry was defined by comparing the standard deviation (SD) of the average of the 3 measurements of an individual (SDi) to the SD of the entire population (SDp). Two groups were generated: symmetric (SDi SDp) aortic roots.

The technological evolution of computed tomography (CT) in the last decade has placed CT coronary angiography (CTCA) in the spotlight of imaging modalities available to evaluate patients with coronary artery disease. Widespread utilisation of CTCA has generated concern from the medical community regarding potential health issues related to the significant radiation exposure associated with this method, and several modifications of the CTCA technique have been proposed to reduce the radiation exposure without affecting the diagnostic image quality. This review will discuss a practical approach to performing CTCA to ensure that the radiation dose is minimized while maintaining diagnostic image quality.

Background Coronary venous imaging with whole-heart cardiovascular magnetic resonance (CMR) angiography has recently been described using developmental pulse sequences and intravascular contrast agents. However, the practical utility of coronary venous imaging will be for patients with heart failure in whom cardiac resynchronisation therapy (CRT) is being considered. As such complementary information on ventricular function and myocardial viability will be required. The aim of this study was to determine if the coronary venous anatomy could be depicted as part of a comprehensive CMR protocol and using a standard extracellular contrast agent. Methods and Results Thirty-one 3D whole heart CMR studies, performed after intravenous administration of 0.05 mmol/kg gadolinium DTPA, were reviewed. The cardiac venous system was visualized in all patients. The lateral vein of the left ventricle was present in 74%, the anterior interventricular vein in 65%, and the posterior interventricular vein in 74% of patients. The mean maximum distance of demonstrable cardiac vein on the 3D images was 81.5 mm and was dependent on the quality of the 3D data set. Five patients showed evidence of myocardial infarction on late gadolinium enhancement (LGE) images. Conclusion Coronary venous anatomy can be reliably demonstrated using a comprehensive CMR protocol and a standard extracellular contrast agent. The combination of coronary venous imaging, assessment of ventricular function and LGE may be useful in the management of patients with LV dysfunction being considered for CRT.

CT coronary angiography (CTA) with 64 slice multi-detector CT (64-MDCT) has assumed an increasing role in clinical practice; however the high radiation dose associated with retrospective ECG-gated CTA has led to suggestions that a low dose prospectively gated strategy may be more appropriate. This study aims to assess the feasibility of this proposed strategy amongst standard referral for CTA in our centre.We retrospectively analyzed 200 consecutive clinical CTA studies assessing the number of cardiac phases required to allow full diagnostic visualisation of the coronary tree. We assessed whether the pre-test likelihood of coronary disease, heart rate, heart rate variability and range, current beta-blockers use, coronary calcium score, breathing artefact or study quality affected the number of phases required.125/200 patients (62.5%) required only a single phase for full diagnostic visualisation of the coronary tree [most commonly 65% of the R-R interval-109/125 (87.2%)]. A successful diagnostic single cardiac phase was most likely in patients with a low heart rate (Heart rate70 bpm OR = 2.64; p = 0.003 and heart rate60 bpm OR = 4.81; p0.001 respectively) and low likelihood of coronary disease [OR = 1.97 95% CI (1.09, 3.58) p = 0.025].High image quality is possible using single phase analysis in those patients with low likelihood of coronary disease, low heart rates and full cooperation with inspiratory breath hold. In patients with HR of60, prospective ECG-gated acquisitions reduce radiation dose but may be non-diagnostic in as many as one third. Careful patient selection is therefore essential.

Purpose To compare the incidence of respiratory artifact in computed tomography (CT) coronary angiography performed with 64-row and 320-row multidetector scanners and to assess its effect on coronary evaluability. Methods A retrospective review of consecutive coronary angiograms performed on a 64-row multidetector CT from March to April 2007 (group 1: 115 patients, 63 men; mean age [standard deviation] 59.6 ± 12.8 years) and on a 320-row multidetector CT from March to April 2008 (group 2: 169 patients, 89 men; mean [SD] age 57.9 ± 11.6 years). Two cardiac radiologists assessed the occurrence of respiratory artifact and coronary evaluability in studies with respiratory artifacts. Unevaluable coronary segments because of motion at the same anatomical level of the respiratory artifact were considered unevaluable because of this artifact. The association between the occurrence of respiratory artifact and patient biometrics, medication, and scan parameters was examined. Results Respiratory artifacts were detected in 9 of the 115 patients from group 1 (7.8%) and in none of the 169 patients from group 2 ( P < .001). Group 1 had longer scan times (median, 9.3 seconds; range, 7.5−14.4 seconds) compared with group 2 (median, 1.5 seconds; range, 1.1−3.5 seconds; P < .001). In group 1, 4 patients (3.5%) showed unevaluable coronary segments because of respiratory artifacts, and the CT coronary angiography was repeated in 1 patient (0.9%). Conclusions Respiratory artifacts are important in CT coronary angiography performed with 64-row multidetector scanners and impair the diagnostic utility of the examination in up to 3.5% of the studies. These artifacts can be virtually eliminated with a faster scan time provided by 320-row multidetector CT.

Children with congenital heart disease account for one in every 145 live births in the UK. Survival has improved dramatically over the past half century; in the 1950s only 20% of such patients could expect to reach adulthood, but now the number is closer to 80%. However, it is a maxim among congenital specialists that a significant proportion of their patients are “fixed, not cured”. There are currently at least 150 000 adults in the UK with congenital heart disease and this number is expected to rise by 25% by 2010. A smaller subset—roughly 12 000 patients—have complex forms of congenital heart disease and numbers are projected to rise by 50% over the same time period.w1 A vital component to the multidisciplinary management of the congenital heart disease patient is adequate imaging of the heart and circulation. However, simple anatomical delineation alone is not sufficient. Techniques are required which can measure function, flow and pressure as well as resolve anatomical structures with a high degree of detail. Such methods should be directed by a physician with both knowledge and interest in congenital heart disease. The major disadvantage of echocardiography has traditionally been its relatively limited field of view. Assessment of an entire congenital repair, which may include extra anatomic bypasses or systemic shunts, is often suboptimal. While central pulmonary arteries are visible there is no opportunity to evaluate the peripheral pulmonary arterial or venous structures. Similarly the tracheobronchial structures and lung parenchyma remain quite occult by this technique. Cardiac catheterisation remained for many years the reference standard for the investigation of congenital heart disease patients. Radiation dose to this population of children and young adults is a vital consideration, however, given the non-threshold risk of subsequent cancer induction. The European Heart Survey of congenital heart disease, which included over 4000 patients …

OBJECTIVES To assess the acceptability and feasibility of functional tests as a gateway to angiography for management of coronary artery disease (CAD), the ability of diagnostic strategies to identify patients who should undergo revascularisation, patient outcomes in each diagnostic strategy, and the most cost-effective diagnostic strategy for patients with suspected or known CAD. DESIGN A rapid systematic review of economic evaluations of alternative diagnostic strategies for CAD was carried out. A pragmatic and generalisable randomised controlled trial was undertaken to assess the use of the functional cardiac tests: angiography (controls); single photon emission computed tomography (SPECT); magnetic resonance imaging (MRI); stress echocardiography. SETTING The setting was Papworth Hospital NHS Foundation Trust, a tertiary cardiothoracic referral centre. PARTICIPANTS Patients with suspected or known CAD and an exercise test result that required non-urgent angiography. INTERVENTIONS Patients were randomised to one of the four initial diagnostic tests. MAIN OUTCOME MEASURES Eighteen months post-randomisation: exercise time (modified Bruce protocol); cost-effectiveness compared with angiography (diagnosis, treatment and follow-up costs). The aim was to demonstrate equivalence in exercise time between those randomised to functional tests and those randomised to angiography [defined as the confidence interval (CI) for mean difference from angiography within 1 minute]. RESULTS The 898 patients were randomised to angiography (n = 222), SPECT (n = 224), MRI (n = 226) or stress echo (n = 226). Initial diagnostic tests were completed successfully with unequivocal results for 98% of angiography, 94% of SPECT (p = 0.05), 78% of MRI (p < 0.001) and 90% of stress echocardiography patients (p < 0.001). Some 22% of SPECT patients, 20% of MRI patients and 25% of stress echo patients were not subsequently referred for an angiogram. Positive functional tests were confirmed by positive angiography in 83% of SPECT patients, 89% of MRI patients and 84% of stress echo patients. Negative functional tests were followed by positive angiograms in 31% of SPECT patients, 52% of MRI patients and 48% of stress echo patients tested. The proportions that had coronary artery bypass graft surgery were 10% (angiography), 11% (MRI) and 13% (SPECT and stress echo) and percutaneous coronary intervention 25% (angiography), 18% (SPECT) and 23% (MRI and stress echo). At 18 months, comparing SPECT and stress echo with angiography, a clinically significant difference in total exercise time can be ruled out. The MRI group had significantly shorter mean total exercise time of 35 seconds and the upper limit of the CI was 1.14 minutes less than in the angiography group, so a difference of at least 1 minute cannot be ruled out. At 6 months post-treatment, SPECT and angiography had equivalent mean exercise time. Compared with angiography, the MRI and stress echo groups had significantly shorter mean total exercise time of 37 and 38 seconds, respectively, and the upper limit of both CIs was 1.16 minutes, so a difference of at least 1 minute cannot be ruled out. The differences were mainly attributable to revascularised patients. There were significantly more non-fatal adverse events in the stress echo group, mostly admissions for chest pain, but no significant difference in the number of patients reporting events. Mean (95% CI) total additional costs over 18 months, compared with angiography, were 415 pounds (-310 pounds to 1084 pounds) for SPECT, 426 pounds (-247 pounds to 1088 pounds) for MRI and 821 pounds (10 pounds to 1715 pounds) for stress echocardiography, with very little difference in quality-adjusted life-years (QALYs) amongst the groups (less than 0.04 QALYs over 18 months). Cost-effectiveness was mainly influenced by test costs, clinicians' willingness to trust negative functional tests and by a small number of patients who had a particularly difficult clinical course. CONCLUSIONS Between 20 and 25% of patients can avoid invasive testing using functional testing as a gateway to angiography, without substantial effects on outcomes. The SPECT strategy was as useful as angiography in identifying patients who should undergo revascularisation and the additional cost was not significant, in fact it would be reduced further by restricting the rest test to patients who have a positive stress test. MRI had the largest number of test failures and, in this study, had the least practical use in screening patients with suspected CAD, although it had similar outcomes to stress echo and is still an evolving technology. Stress echo patients had a 10% test failure rate, significantly shorter total exercise time and time to angina at 6 months post-treatment, and a greater number of adverse events, leading to significantly higher costs. Given the level of skill required for stress echo, it may be best to reserve this test for those who have a contraindication to SPECT and are unable or unwilling to have MRI. Further research, using blinded reassessment of functional test results and angiograms, is required to formally assess diagnostic accuracy. Longer-term cost-effectiveness analysis, and further studies of MRI and new generation computed tomography are also required.

BACKGROUND: The IMPACT-CABG trial (NCT01033617) is a Canadian multicenter randomized, prospective, doubleblinded study investigating the feasibility, safety and efficacy of intramyocardial injections of autologous CD133+ stem cells in patients with chronic ischemic cardiomyopathy and impaired LV dysfunction (LVEF 25-45%) undergoing isolated CABG surgery. The primary safety endpoint was freedom from major adverse cardiac event (MACE) at time of injection and 6 months follow-up, including freedom from cardiac death, myocardial infarction (MI), repeat revascularization or severe arrhythmias. The secondary efficacy endpoint was regional myocardial perfusion and function assessed by magnetic resonance imaging (MRI). Herein we are reporting the safety results. METHODS: After an initial 5 (Montreal) or 2 (Toronto) openlabel patients who received stem cells, patients were then randomized in a 1:1 (Toronto1⁄418) or 2:1 (Montreal1⁄415) ratio to receive either stem cells or placebo. All forty patients (20 each in Montreal and Toronto) with ischemic cardiomyopathy and clinical indications for CABG provided informed consent and were assessed with preoperative stress echo and perfusion MRI. All patients had 100-150 cc of bone marrow aspirated from the iliac crest under local anaesthesia and light sedation on the morning of surgery. Stem cells were isolated using the CliniMACS CD133+ Reagent System (Miltenyi Biotec), which utilizes superparamagnetic beads composed of iron-dextran particles conjugated to monoclonal antibodies. On the afternoon following cell preparation, patients underwent conventional CABG surgery under cardiopulmonary bypass. Following the completion of the distal coronary anastomoses, the cell preparation containing up to 10 million cells or placebo was injected (10-15 injection sites) into the infarct and border zone as identified by MRI. RESULTS: Patient demographics, intraoperative data and hospital outcomes are presented in Table 1 for all 40 patients. Stem cell isolation procedures yielded cell preparations meeting release criteria in all patients randomized to cell delivery. There was no in-hospital mortality. No patient had a perioperative MI, 4 had renal failure, one had a wound infection and one had a seizure. During the 6-month followup period, one patient died from a pulmonary embolus, and no other MACE. CONCLUSION: This work represents the first Canadian experience with CD133+ stem cells for the treatment of chronic ischemic cardiomyopathy. There were no protocol-related complications, demonstrating that same-day isolation and delivery of stem cells in conjunction with CABG is safe and feasible. Cell therapy may become a valuable adjunct treatment for myocardial repair in heart failure patients in whom conventional therapies for ventricular dysfunction are limited.

Late gadolinium enhancement score (LGE-Score) for prediction of extensive late gadolinium enhancement in hypertrophic cardiomyopathy Raymond H Chan, Barry J Maron, Iacopo Olivotto, Gabriele Egidy Assenza, Tammy S Haas, John R Lesser, Christiane Gruner, Andrew Crean, Harry Rakowski, James E Udelson, Ethan J Rowin, Massimo Lombardi, Franco Cecchi, Benedetta Tomberli, Paolo Spirito, Francesco Formisano, Elena Biagini, Claudio Rapezzi, Carlo Nicola De Cecco, Camillo Autore, Susie N Hong, Michael C Gibson, Warren J Manning, Evan Appelbaum, Martin Maron