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We aimed to describe the natural history of left ventricular assist device (LVAD)-supported patients with preimplantation significant tricuspid regurgitation (TR) in a single-center retrospective analysis of LVAD-implanted patients (2008-2019). TR severity was assessed semiqualitatively using color-Doppler flow: insignificant TR (iTR) was defined as none/mild TR and significant TR (sTR) as ≥moderate TR. Included were 121 LVAD-supported patients of which 53% (n = 64) demonstrated sTR preimplantation. Among patients with pre-LVAD implantation sTR and available echocardiographic data, 55% (n = 26) ameliorated their TR severity grade to iTR during the first-year postsurgery and 55% (n = 17) had iTR at 2-year follow-up. On univariate analysis, predictors for TR severity improvement post-LVAD implantation were preimplant lack of atrial fibrillation, reduced inferior vena cavae diameter, and elevated pulmonary vascular resistance. In patients who failed to improve their TR severity grade, we observed a deterioration in right ventricular (RV) function (pulmonary artery pressure index 2.0 [1.7, 2.9], a decline in RV work index 242 [150, 471] mm Hg·L/m2) and higher loop-diuretics dose requirement. At a median of 21 (IQR 8, 40) months follow-up, clinical LVAD-related complications, heart failure-hospitalizations, and overall survival were similar among patients who improved versus failed to improve their TR severity-grade post-LVAD implantation. In conclusion, LVAD implantation is accompanied by a reduction in TR severity in approximately 50% of patients. In patients who failed to improve their TR severity grade, progressive RV dysfunction was observed. Overall, an isolated LVAD implantation in patients with sTR does not adversely affect survival.

AIMS: To assess the short-term immunogenicity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine in a population of heart transplant (HTx) recipients. A prospective single-centre cohort study of HTx recipients who received a two-dose SARS-CoV-2 mRNA vaccine (BNT162b2, Pfizer-BioNTech). METHODS AND RESULTS: Whole blood for anti-spike IgG (S-IgG) antibodies was drawn at days 21-26 and at days 35-40 after the first vaccine dose. Geometric mean titres (GMT) ≥50 AU/mL were interpreted positive. Included were 42 HTx recipients at a median age of 61 [interquartile range (IQR) 44-69] years. Median time from HTx to the first vaccine dose was 9.1 (IQR 2.6-14) years. Only 15% of HTx recipients demonstrated the presence of positive S-IgG antibody titres in response to the first vaccine dose [GMT 90 (IQR 54-229) AU/mL]. Overall, 49% of HTx recipients induced S-IgG antibodies in response to either the first or the full two-dose vaccine schedule [GMT 426 (IQR 106-884) AU/mL]. Older age [68 (IQR 59-70) years vs. 46 (IQR 34-63) years, P = 0.034] and anti-metabolite-based immunosuppression protocols (89% vs. 44%, P = 0.011) were associated with low immunogenicity. Importantly, 36% of HTx recipients who were non-responders to the first vaccine dose became S-IgG seropositive in response to the second vaccine dose. Approximately a half of HTx recipients did not generate S-IgG antibodies following SARS-CoV-2 two-dose vaccine. CONCLUSIONS: The generally achieved protection from SARS-CoV-2 mRNA vaccination should be regarded with caution in the population of HTx recipients. The possible benefit of additive vaccine should be further studied.

OBJECTIVES The immunogenicity of two-dose severe acute respiratory syndrome coronavirus 2 vaccine is lower among heart transplant (HTx) recipients, compared with the general population. Our aim was to assess the immunogenicity of a third-dose vaccine in HTx recipients. METHODS This is a prospective cohort study of HTx recipients who received a third dose of the BNT162b2 vaccine. Immunogenicity was assessed by serum levels of anti-spike immunoglobulin G (S-IgG), taken at baseline and 14–28 days after the third dose. Titres above 50 U/ml were interpreted positive. RESULTS We Included 42 HTx recipients at a median age of 65 years [interquartile range (IQR) 58–70]. At baseline, the median of 27 days (IQR 13–42) before the third dose and the median titre of the whole group was 18 U/ml (IQR 4–130). Only 14 patients (33%) were S-IgG seropositive. After the third dose, the proportion of seropositive patients increased significantly to 57% (P = 0.05) and the median titre increased significantly to 633 U/ml (IQR 7–6104, P < 0.0001). Younger age at HTx (OR per 1-year decrease 1.07, P = 0.05), low tacrolimus serum level (OR per 1-unit decrease 2.28, P = 0.02), mammalian target of rapamycin use (OR 13.3, P = 0.003), lack of oral steroids use (OR 4.17, P = 0.04) and lack of calcineurin inhibitor use (71% of responders vs 100% non-responders received calcineurin inhibitors, P = 0.01) were predictors of seropositive result after the third dose. However, no significant association was detected following adjustment for baseline S-IgG titre. CONCLUSIONS Third-dose booster of BNT162b2 vaccine significantly increased immunogenicity among HTx recipients who previously received a two-dose vaccine.

Circulating endothelial progenitor cells have an important role in the process of vascular repair. Impaired recruitment and function of endothelial progenitor cells is related to the pathophysiology of congestive heart failure. Endothelial progenitor cells have been shown to express the mineralocorticoid receptor.To investigate the effect of mineralocorticoid receptor antagonists on endothelial progenitor cells in patients with heart failure.Twenty-four patients with compensated heart failure, who were not under mineralocorticoid receptor antagonist therapy, were recruited. Either eplerenone (n=8) or spironolactone (n=16) therapy was initiated. Circulating endothelial progenitor cell level, identified as the proportion of mononuclear cells expressing vascular endothelial growth factor receptor 2 (VEGFR-2), CD133, and CD34, was evaluated by flow cytometry at baseline and after 8 weeks. Following 7 days of culture, colonies were counted by microscopy and MTT assay was performed on randomly selected patients (n=12) to estimate viability.Both median CD34+/VEGFR2+ and median CD133+/VEGFR2+ increased significantly (P = 0.04 and 0.02, respectively). However, the number of colonies and viability of the cells after therapy (as assessed by the MTT assay) was not significantly different compared with the baseline.These preliminary results suggest that mineralocorticoid receptor blockade may enhance endothelial progenitor cells recruitment in patients with compensated heart failure.

Left ventricular (LV) dyssynchrony by phase analysis has been studied by myocardial perfusion imaging (MPI)-gated SPECT in patients with LV dysfunction in various clinical settings. We aimed to investigate the routine use of phase analysis with gated SPECT for predicting cardiac outcome. Patients referred to a tertiary medical center in 2010-2011 prospectively underwent a gated SPECT and phase analysis, and follow-up for cardiac events. The values of clinical variables, MPI, LV function, and LV dyssynchrony in predicting cardiac events were tested by univariate and multivariate analyses. The study group included 787 patients (66.5 ± 11 years, 81% men) followed for a mean duration of 18.3 ± 6.2 months. There were 45 (6%) cardiac events defined as composite endpoint; cardiac death occurred in 26 patients, and the rest had new-onset or worsening heart failure and life-threatening arrhythmias. In multivariate analysis, it was shown that NYHA class, diabetes mellitus, and LVEF

We previously described the feasibility of performing myocardial perfusion imaging (MPI) with half the technetium (Tc-99m) activity using ordered-subset expectation maximization with resolution recovery (OSEM-RR) processing. This study sought to assess the accuracy of this technique by correlating the findings with coronary angiography. Of 290 patients who underwent MPI-gated SPECT using a half dose of Tc-99m sestamibi and OSEM-RR software in 2010-2012 at a tertiary medical center, 62 were referred for invasive coronary angiography within 90 days and formed the study group. Ischemia was defined as a summed difference score (SDS) of >3 on the MPI scan. Luminal stenosis of ≥70% on invasive coronary angiography served as the reference. Mean Tc-99m activity per study was 23.9 ± 11.5 mCi and mean effective radiation dose was 7.2 ± 3.4 mSv. MPI revealed no abnormalities in 10 patients (16.2%), myocardial infarction only in 8 patients (12.9%), and ischemia in 44 patients (71.1%). Overall sensitivity, specificity, and positive and negative predictive values for MPI compared to invasive angiography were 89.1%, 75.0%, 91.1%, and 70.5%, respectively. MPI SPECT performed with a half dose of Tc-99m and OSEM-RR image processing correlates well with invasive angiography. (J Nucl Cardiol 2013)

Stress-only single-photon emission computed tomography myocardial perfusion imaging (SO SPECT MPI) is associated with similarly benign prognosis as stress-rest SPECT MPI. However, previous studies have used attenuation correction rather than prone imaging to increase the rate of SO studies. To assess the prognosis of SO SPECT MPI performed with prone imaging. We performed a retrospective cohort analysis of all patients who underwent a Tc-99m gated SPECT MPI over a 58-month period. Two thousand four hundred and sixty five patients were followed up. Of them, 1114 (45.2%) patients had a SO supine test, 388 (15.7%) underwent a SO supine and prone test, and the remaining 963 (39.1%) patients underwent a full stress-rest SPECT MPI. There was a similar annual mortality rate between the SO supine/prone group (1.3%), the SO supine (1.5%), and the stress-rest (1.5%) group (P = 0.47). Patients in the stress-rest group were significantly more likely to suffer from myocardial infarction (MI) as compared to the other two groups with an annual rate of 0.7% as compared to 0.4% (P = 0.049). Normal supine-prone SO SPECT MPI is associated with a similarly benign prognosis as stress-rest SPECT MPI. The adjunction of prone imaging to the stress supine significantly increases the rate of SO SPECT MPI

This study sought to assess the feasibility of performing myocardial perfusion imaging (MPI) with half the technetium activity using ordered-subset expectation maximization with resolution recovery (OSEM-RR), an iterative reconstruction software developed to improve count statistics and acquisition time.Two hundred eighteen patients referred for MPI were randomly allocated to undergo stress-rest or rest-stress protocols with standard full-dose (FD) injections of technetium (Tc)-99m sestamibi or half-dose (HD) injections and OSEM-RR processing. Dose activities were adjusted individually by weight. The groups were compared for image quality and clinical results.The groups were similar for mean patient age, weight, and body mass index, sex distribution, pre-test probability of CAD and CAD prevalence. Mean Tc-99m activities for the low-dose and high-dose stages were as follows: FD group: 429 ± 85 MBq and 1132 ± 200 MBq; HD group: 263 ± 129 MBq and 629 ± 85 MBq (P.0001 for both). Mean effective dose per study was 13.6 ± 1.4 mSv in the FD group and 7.7 ± 1.0 mSv in the HD group (P.001). Over all image quality was good-to-excellent in 98% and 95% of the groups, respectively. However, when we analyzed the low-dose stage separately, image quality was slightly worse in the HD than the FD, though still within the good-to excellent range.MPI with nearly half the radiation dose is feasible with good image quality.

To examine the yield of an ultra-low-dose computed tomography (CT) transmission module for attenuation-correction (AC) on a dedicated cardiac camera in evaluation of SPECT-myocardial perfusion imaging (MPI) in the diagnosis of CAD and for additional chest abnormalities. The study group included 150 patients with known or suspected CAD referred for technetium sestamibi SPECT MPI. CT transmission scanning (effective radiation 0.17 mSv) was performed after each gated SPECT scan. AC and non-corrected (NC) SPECT scans were evaluated on a 5-point scale using a 17-segment model, and the sum stress score (SSS) and sum rest score (SRS) were calculated for each condition. Overall image quality, sensitivity and normalcy rate (51 patients) and processing of 28 CT slices were screened for chest findings. CT-based AC significantly improved image quality (P = .01). Mean SSS was 3.8 ± 5.8 with AC and 6.1 ± 7.1 with NC (P

BACKGROUND Myocardial perfusion imaging with single-photon emission tomography (SPECT) is associated with reduced specificity due to tissue attenuation. This can be corrected by prone imaging while necessitating additional imaging time. Image processing with iterative reconstruction allows for a half-time (HT) acquisition. OBJECTIVE To assess the feasibility of myocardial perfusion with SPECT using prone imaging with HT acquisition. METHODS Ninety-one patients referred for SPECT myocardial perfusion imaging and weighing up to 90 kg were enrolled for HT supine and prone SPECT protocol. Patients with known myocardial infarction were excluded. HT prone imaging was performed when supine imaging was visually equivocal or abnormal. Image quality was compared for each patient between supine and prone imaging. RESULTS Acquisition time was 17.9 ± 2.9 min in the HT group compared with 31.8 ± 5.8 min in patients imaged with full-time acquisition. Image quality was good or excellent in 85.7% of studies in a supine position and in 81.3% of studies in the prone position (P = 0.25). No study was considered as nondiagnostic. Prone imaging reduced the rate of equivocal scans from 40.7 to 15.4% and of ischemic studies from 34.1 to 7.7%. In the study population, 80% of inferior and septal defects were corrected by the prone position. CONCLUSION In a selected population, HT prone and supine imaging is feasible and is associated with a good image quality in most studies whereas acquisition time is reduced almost by half.

Mechanical left ventricular dyssynchrony (MLVD) might contribute in the therapeutic decision-making in patients with heart failure (HF) prior to cardiac resynchronization therapy (CRT). Our aim was to assess MLVD in patients with HF prior to implantable cardioverter-defibrillator (ICD) compared to patients with CRT-D. In a prospective study, patients with LVEF ≤ 35% who were scheduled for ICD or CRT-D, underwent gated SPECT myocardial perfusion imaging with technetium 99m sestamibi within 3 months prior procedure. MLVD was measured by phase analysis. The study cohort consisted of 143 patients, 71 with ICD and 72 with CRT-D. Age 68.3 ± 11 and LVEF 24 ± 6%. Phase standard deviation (SD) was 62.5 ± 18 and 59.7 ± 20 (P = NS), respectively. During follow-up of 23.7 ± 12.1 months, there were 10 vs 14 cardiac death in ICD and CRT-D, respectively (P = NS), hospitalization for HF, in 34 vs 53 (P

Most patients with Primary Pulmonary Hypertension (PPH) have severe exertional limitation which ultimately leads to right heart failure and death. The purpose of the study was to assess the correlation between right ventricular (RV) systolic and diastolic noninvasive variables and exercise tolerance, as well as the predictors of adverse outcome in treated patients.We prospectively studied 29 patients, 17 with PPH and 12 with PPH due to collagen disease. RV parameters were assessed by echocardiography and Radionuclide ventriculography. Pulmonary function and clinical profile were assessed by 6 min walk test and NYHA class. The patients were followed-up during 2 years for cardiac death and cardiac deterioration.Mean age was 51 +/- 15 years, 22 (78%) women. NYHA class1 in 2 pts, class 2 in 17, class 3 in 8 and class 4 in 2 pts. Pulmonary function (DLCO) was low in 25 (86%) pts, mean 22 +/- 48%. Six minutes walk distance was 358 +/- 132 m, RVEF was 34 +/- 11% (range 16-51%). Among RV variables, RVEF, RA area and TR were independently correlated to 6 min walk. Within follow up of 2 years, there were 10 patients with adverse outcome (4 deaths and 6 deteriorated to NYHA class 3 and 4). Among all clinical and noninvasive variables, RVEF only was correlated to adverse outcome.The noninvasive tests of RVEF, RA size and TR were closely correlated to exercise tolerance. However, among the various clinical, functional and RV variables, RVEF was the only variable correlated with adverse outcome in pts with PPH.

The aim of this study was to evaluate the value of myocardial perfusion imaging (MPI) in predicting major adverse cardiovascular events (MACE) in symptomatic and asymptomatic patients after percutaneous coronary intervention (PCI). We revised retrospectively patients after PCI that underwent MPI and were followed for a year for the presence of MACE. We found no differences in the incidence of MACE between symptomatic and asymptomatic patients. On multivariate analysis, the presence of ischemia by MPI was the most important independent predictor of MACE (OR 5.09, CI 95% 2.15–12.05, p < 0.001). The presence of myocardial ischemia by MPI performed after PCI, and no symptom status, predicts a worse outcome during 1 year of follow-up.

Left internal mammary artery (LIMA) grafting to the left anterior descending artery (LAD) is known to have long-term patency. However, myocardial ischemia in the territories supplied by LIMA to LAD is still demonstrated. The aim of this study is to examine the relationships between the extent, location, and clinical outcome of myocardial ischemia in LAD territories (ILAD) by use of myocardial perfusion imaging (MPI) and angiographic characteristics of such a bypass conduit.We studied 38 consecutive patients with prior coronary artery bypass grafting who showed stress-induced ischemia in LIMA to LAD territories by MPI single photon emission computed tomography between the years 1996-2000. All patients underwent quantitative coronary angiography within 6 months of the nuclear study. Single photon emission computed tomography parameters of ILAD were assessed by location (septum, apex, anterior, and anterolateral) and included extension score (1-4 per patient), severity score (0-3 per territory), and total sum score. LIMA to LAD quantitative coronary angiography parameters included minimal lumen diameter, lesion length, reference diameter, and diameter stenosis (percentage). LAD and LIMA diameters and ratio (in normal segments) were determined within 10 mm proximal and distal to the anastomotic site. The study group was compared with 18 control subjects without ischemia or stenosis treated with LIMA to LAD. The patients were followed up for cardiac death at an interval of 3.2 +/- 1.5 years from the time of MPI testing. The patients' mean age was 66 +/- 12 years (31 men and 7 women); the mean period after surgery was 6.2 +/- 1.5 years. The ILAD distribution was as follows: septum, 12 (32%); apex, 20 (52%); anterior, 24 (63%); and anterolateral, 18 (47%). The mean extension score was 1.9 +/- 1.0, and the mean total sum score was 3.4 +/- 2.3. Of 38 patients with ILAD, only 17 (45%) had greater than 50% luminal stenosis (2 LIMA and 15 anastomosis or distal). Among clinical variables during stress testing, the prevalence of angina was significantly higher in the luminal stenotic patients versus patients without stenosis (P =.04). A significant correlation was found between anterior wall ischemia and reference diameter (r = -0.7, P =.002) and between total sum score and minimal lumen diameter (r = -0.48, P =.05). Of note, the LAD-to-LIMA ratio was significantly lower in patients with ILAD and without luminal stenosis compared with the control group (0.73 +/- 0.16 vs 0.87 +/- 0.15, P =.004). Cardiac death occurred in 8 patients (21%), 5 patients with luminal stenosis versus 3 patients without stenosis (P = not significant).In patients with LIMA to LAD anastomosis, myocardial ischemia could occur even without angiographic luminal stenosis and apparently reflects a mismatch between LAD and LIMA diameters at distal anastomotic sites. Regarding the similar prevalence of cardiacdeath, invasive evaluation and aggressive treatment are recommended in all patients with ischemia in LIMA/LAD territories.

We previously described the feasibility of myocardial perfusion imaging (MPI) with nearly half the radiation dose using ordered-subset expectation maximization with resolution recovery (OSEM-RR) processing. This study sought to determine if the findings can be expanded to obese patients. Fifty obese patients (>100 kg) referred for MPI underwent stress-rest or rest-stress studies with a half dose of Tc-99m sestamibi in a 1-day protocol using OSEM-RR processing. Image quality and clinical results were compared with matched patients (by age, sex, weight, presence/probability of coronary artery disease) evaluated with standard “full-dose” Tc-99m sestamibi, mostly in a 2-day protocol. Dose activities were adjusted individually by weight. Mean Tc-99m activity was 33.4 ± 13.9 mCi in the half-dose group and 60 ± 10 mCi in the full-dose group (P

Background More and more young people are being referred for evaluation or screening for coronary artery disease (CAD). However, the value of myocardial perfusion imaging (MPI) in this population is unclear, especially in the absence of symptoms. Methods The study sample included 1765 consecutive patients less than 51 years old who were referred to a major medical center for stress/rest MPI study. Clinical and MPI variables were compared between patients with and without known CAD, by gender. Results There were 1346 (76%) men and 419 (24%) women of mean age 44 ± 6 years; 461 (26%) had known CAD. Stress-induced ischemia was detected in 321 patients (18.2%) and significant ischemia in 131 (7.4%); there was no difference in the rate or severity of ischemia by presence of symptoms. Among those without known CAD, the rate of stress-induced ischemia by MPI was significantly lower in women than men. On logistic regression analysis, the independent predictors of ischemia in men were high cholesterol, diabetes, angina during stress testing, ST depression, and smoking (P

Background: Octogenarian patients referred for stress myocardial perfusion imaging (MPI) differ from younger (non-octogenarian) patients in that they have lower prevalence of risk factors for CAD, but more frequent ischemic events and higher cardiac mortality. Hypothesis: The purpose of this study was to investigate the efficacy of MPI in octogenarian men and women compared with that in the younger population, and to compare the prognostic value of stress MPI in both populations. Methods: We studied 162 consecutive patients aged ≥ 80 years who were referred for stress MPI, and compared them with 253 consecutive patients aged < 80 years. Patients completed a questionnaire encompassing information about the existence of coronary risk factors, cardiac symptoms, coronary artery disease (CAD), myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and results of stress MPI. The patients were followed up for cardiac mortality for a mean of 45 ± 12 months. Results: There were 61 women and 101 men (17% of all referrals) with a mean age of 83 ± 3 (range 80-90). Parameters of octogenarian patients demonstrated a significantly lower prevalence of non-insulin-dependent diabetes mellitus (p < 0.02), hypercholestrolemia (p < 0.001), and smoking (p = 0.001) compared with non-octogenarian patients. The prevalence of known CAD was similar, but the prevalence of abnormal resting electrocardiogram, left ventricular (LV) dilatation, and stress-induced ischemia was significantly higher in octogenarians (p < 0.002). Cardiac mortality rate peryear was 4.3%in octogenarians versus 1.3%in the younger population (p < 0.0001). The independent predictors according to MPI of cardiac death were LV dilatation and presence of ischemia in octogenarians, and severity of ischemia in non-octogenarians. Conclusions: The octogenarian population referred for stress single-photon emission computed tomography differed from the non-octogenarian group in that it had a lower prevalence of risk factors for CAD, but more frequent ischemic events and higher cardiac mortality; however, MPI variables predict adverse outcome in both populations.

The prognostic value of myocardial perfusion imaging (MPI) in the very elderly population has not been addressed specifically. The aim of this study was to examine the characteristics of the octogenarian population referred for MPI and the prognostic value of the procedure in terms of patient gender.The study sample consisted of 162 consecutive patients (61 women, 101 men) of mean age 83 +/- 3 years (range, 80-90) who underwent stress MPI. The duration of follow-up was 45+/-12 months. Outcome measures were cardiac-related death, and nonfatal myocardial infarction (MI).Thirty-one major cardiac events (19%) were recorded, including 26 cardiac deaths and 5 MI events, in 6 of the 61 women (10%) and 25 of the 101 men (25%) (p0.03). The univariate predictors of cardiac death or MI, except of known coronary artery disease (CAD), were MPI variables: left ventricular (LV) dilatation, increased lung uptake, abnormal scan, and the presence and extent of myocardial ischemia. However, the only predictors for major cardiac events were: LV dilatation (OR = 6.9, 95% CI 2.7-17.4, p0.0001) and ischemia by scan (OR = 2.75, 95% CI 1.09-6.96, p0.03). The Kaplan Meier curve demonstrated significant differences in survival between patients with or without LV dilatation and patients with or without ischemia.LV dilatation and myocardial ischemia were useful predictors of cardiac death and MI in octogenarian patients with CAD or with suspicion of CAD.