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International audience; Background: Structural changes and myocardial fibrosis quantification by cardiac imaging have become increasingly important to predict cardiovascular events in patients with mitral valve prolapse (MVP). In this setting, it is likely that an unsupervised approach using machine learning may improve their risk assessment.Objectives: This study used machine learning to improve the risk assessment of patients with MVP by identifying echocardiographic phenotypes and their respective association with myocardial fibrosis and prognosis.Methods: Clusters were constructed using echocardiographic variables in a bicentric cohort of patients with MVP (n = 429 patients, 54 ± 15 years) and subsequently investigated for their association with myocardial fibrosis (assessed by cardiac magnetic resonance) and cardiovascular outcomes.Results: Mitral regurgitation (MR) was severe in 195 (45%) patients. Four clusters were identified: cluster 1 comprised no remodeling with mainly mild MR, cluster 2 was a transitional cluster, cluster 3 included significant left ventricular (LV) and left atrial (LA) remodeling with severe MR, and cluster 4 included remodeling with a drop in LV systolic strain. Clusters 3 and 4 featured more myocardial fibrosis than clusters 1 and 2 (P < 0.0001) and were associated with higher rates of cardiovascular events. Cluster analysis significantly improved diagnostic accuracy over conventional analysis. The decision tree identified the severity of MR along with LV systolic strain 42 mL/m2 as the 3 most relevant variables to correctly classify participants into 1 of the echocardiographic profiles.Conclusions: Clustering enabled the identification of 4 clusters with distinct echocardiographic LV and LA remodeling profiles associated with myocardial fibrosis and clinical outcomes. Our findings suggest that a simple algorithm based on only 3 key variables (severity of MR, LV systolic strain, and indexed LA volume) may help risk stratification and decision making in patients with MVP. (Genetic and Phenotypic Characteristics of Mitral Valve Prolapse; NCT03884426 and Myocardial Characterization of Arrhythmogenic Mitral Valve Prolapse [MVP STAMP]; NCT02879825).

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[18F]fluorodeoxyglucose-positron emission tomography/computed tomography ([18F]FDG-PET/CT) is used to diagnose large vessel vasculitis in giant cell arteritis (GCA). We aimed to define a semi-quantitative threshold for identifying GCA aortitis from aortic atheroma or the control. Contrast enhanced computed tomography (CECT) was used as the reference imaging for aortic evaluation and to define aortitis, aortic atheroma and control aortas. [18F]FDG-PET/CT was performed on 35 GCA patients and in two different control groups (aortic atheroma (n = 70) and normal control (n = 35)). Aortic semi-quantitative features were compared between the three groups. GCA patients without aortitis on CECT were excluded. Of the GCA patients, 19 (54.3%) were not on glucocorticoids (GC) prior to [18F]FDG-PET/CT. The SUVmax, TBRblood and TBRliver aortic values were significantly higher in the GCA aortitis group than in the aortic atheroma and control groups (p < 0.001). Receiver operating characteristic curve analyses brought to light quantitative cut-off values allowing GCA aortitis diagnosis with optimal sensitivity and specificity versus control or aortic atheroma patients for each PET-based feature analyzed. Considering the overall aorta, a SUVmax threshold of 3.25 and a TBRblood threshold of 1.75 had a specificity of 83% and 75%, respectively, a sensitivity of 81% and 81%, respectively, and the area under the ROC curve (AUC) was 0.86 and 0.83, respectively, for aortitis detection compared to control groups in GCA cases with GC. A SUVmax threshold of 3.45 and a TBRblood threshold of 1.97 had a specificity of 90% and 93%, respectively, a sensitivity of 89% and 89%, respectively, with an AUC of 0.89 and 0.96, respectively, for aortitis detection compared to the control in GC-free GCA cases. Discriminative thresholds of SUVmax and TBRblood for the diagnosis of GCA aortitis were established using CECT as the reference imaging.

Outcomes research; Risk factors Investigación de resultados; Factores de riesgo Recerca dels resultats; Factors de risc Bioprosthetic heart valves (BHVs) are commonly used to replace severely diseased heart valves but their susceptibility to structural valve degeneration (SVD) limits their use in young patients. We hypothesized that antibodies against immunogenic glycans present on BHVs, particularly antibodies against the xenoantigens galactose-α1,3-galactose (αGal) and N-glycolylneuraminic acid (Neu5Gc), could mediate their deterioration through calcification. We established a large longitudinal prospective international cohort of patients (n = 1668, 34 ± 43 months of follow-up (0.1–182); 4,998 blood samples) to investigate the hemodynamics and immune responses associated with BHVs up to 15 years after aortic valve replacement. Early signs of SVD appeared in

Background Mitral valve prolapse (MVP) is a frequent pathology that can be complicated by mitral regurgitation, heart failure, rhythm disorders, arterial embolism and death. The aim of this study was to evaluate the prognostic interest of ventricular volumes, right ventricular ejection fraction (RVEF) and late gadolinium enhancement (LGE) assessed by cardiac magnetic resonance (CMR) imaging on cardiovascular morbi-mortality in a cohort of patients with MVP Methods We examined the prognostic value of CMR imaging in 237 patients with MVP (no to severe mitral regurgitation) included between 2010 and 2019. All patients underwent a comprehensive echocardiography. The main endpoint was a composite endpoint of cardiovascular death, heart failure, new onset atrial fibrillation, arterial embolism. Results Among the 237 patients (63% male), 97 (41%) had LGE (75 myocardial wall, 10 papillary muscle tip and 12 both locations). Factors associated with LGE in multivariable analysis were age (OR 1.02, P = 0.037), left ventricular (LV) mass (OR 1.01, P = 0.008) and pulmonary artery systolic pressure (PAPS, OR 1.02, P = 0.069). Follow-up was censored at the time of surgery or percutaneous repair. In univariate analysis NYHA class, LV mass, left atrial volume, PAPS, LV end-diastolic and end-systolic volumes, chordal rupture and MR degree were associated with outcome. RVEF and biventricular dysfunction (LV EF < 60% and RV EF < 40%) were also associated with impaired event-free survival (36.0 ± 17.0% vs 65.4± 5.8%, P = 0.019). Finally, LGE was associated with a decreased event-free survival (55.6 ± 9.9% vs 70.7± 6.9%, P = 0.002). In multivariablee analysis, moderate to severe mitral regurgitation (HR : 2.14 [1.44-3.19], P Conclusion CMR imaging provides additional prognostic information to echocardiography in the study of MVP. Myocardial fibrosis of the left ventricle and right ventricular function as assessed by CMR imaging are predictors of cardiovascular morbidity and mortality in MVP.

SummaryPurpose To assess the potential of platelet-rich plasma (PRP) subcutaneous injection of to treat alopecia and to evaluate local toxicity. Materials-Methods Twelve Hairless rats were used. At D0, we performed systematic clinical examination and divided the rat back into four quadrants (Q). We initiated subcutaneous injection using either PRP in PRPQ+, platelet-poor plasma (PPP) in PPPQ+, physiological serum (PS) in PSQ+, or no treatment (Q4). At D7, D14, D21, and D28 but also second month (M2), M3, M4, M5, rats had exactly the same injection procedure. Follow-up with PRP efficacy and toxicity at D28 and M6 using clinical and histological evaluation was performed. Results Hair density was significantly improved at D28 and at M6 for PRPQ+ vs PSQ+ (respectively, P = .0156 and P = .0313), PPPQ+ (respectively, P = .042 and P = .046). Significant histological improvement was observed between D28 and M6, for PRPQ+ vs PPPQ+ and PSQ+ for vessels (respectively, P = .0160 and P = .021), collagen (respectively, P = .0036 and P = .032), and epithelium (respectively, P = .0138 and P = .022) with no local toxicity. Conclusion Our study suggests that subcutaneous PRP injections using controlled concentration of platelets and leukocytes improve hair growth.

BACKGROUND AND PURPOSE The susceptibility vessel sign (SVS) on magnetic resonance imaging (MRI) is related to thrombus location, composition, and size in acute stroke. No previous study has determined its inter-MRI scanner variability. We aimed to compare the diagnostic accuracy in-vitro of four different MRI scanners for the characterization of histologic thrombus composition. METHODS Thirty-five manufactured thrombi analogs of different composition that were histologically categorized as fibrin-dominant, mixed, or red blood cell (RBC)-dominant were scanned on four different MRI units with T2* sequence. Nine radiologists, blinded to thrombus composition and MRI scanner model, classified twice, in a 2-week interval, the SVS of each thrombus as absent, questionable, or present. We calculated the weighted kappa with 95% confidence interval (CI), sensitivity, specificity and accuracy of the SVS on each MRI scanner to detect RBC-dominant thrombi. RESULTS The SVS was present in 42%, absent in 33%, and questionable in 25% of thrombi. The interscanner agreement was moderate to good, ranging from .45 (CI: .37-.52) to .67 (CI: .61-.74). The correlation between the SVS and the thrombus composition was moderate (κ: .50 [CI: .44-.55]) to good κ: .76 ([CI: .72-.80]). Sensitivity, specificity, and accuracy to identify RBC-dominant clots were significantly different between MRI scanners (P < .001). CONCLUSION The diagnostic accuracy of SVS to determine thrombus composition varies significantly among MRI scanners. Normalization of T2*sequences between scanners may be needed to better predict thrombus composition in multicenter studies.

Aims Several data suggest that acute myocarditis could be related to genetic variants involved in familial cardiomyopathies, particularly arrhythmogenic cardiomyopathy, but the management of patients with acute myocarditis and their families regarding their risk for having an associated inherited cardiomyopathy is unclear. Methods and results Families with at least one individual with a documented episode of acute myocarditis and at least one individual with a cardiomyopathy or a history of sudden death were included in the study. Comprehensive pedigree, including genetic testing, and history of these families were analysed. Six families were included. Genetic analysis revealed a variant in desmosomal proteins genes in all the probands [five in desmoplakin (DSP) gene and one in desmoglein 2 gene]. In the five families identified with a DSP variant, genetic testing was triggered by the association of an acute myocarditis with a single case of apparently isolated dilated cardiomyopathy or sudden death. Familial screening identified 28 DSP variant carriers; 39% had an arrhythmogenic left ventricular (LV) cardiomyopathy phenotype. Familial histories of sudden death were frequent, and a remarkable phenotype of isolated LV late gadolinium enhancement on contrast‐enhanced cardiac magnetic resonance without any other structural abnormality was found in 38% of asymptomatic mutation carriers. None of the DSP variant carriers had imaging characteristics of right ventricle involvement meeting current Task Force criteria for arrhythmogenic right ventricular cardiomyopathy. Conclusions Comprehensive familial screening including genetic testing in case of acute myocarditis associated with a family history of cardiomyopathy or sudden death revealed unknown or misdiagnosed arrhythmogenic variant carriers with left‐dominant phenotypes that frequently evade arrhythmogenic right ventricular cardiomyopathy Task Force criteria. In view of our results, acute myocarditis should be considered as an additional criterion for arrhythmogenic cardiomyopathy, and genetic testing should be advised in patients who experience acute myocarditis and have a family history of cardiomyopathy or sudden death.

Background Structural valve degeneration (SVD) remains a major complication of aortic bioprostheses. Purpose We aimed to assess the mode of SVD leading to bioprosthetic aortic valve failure (BVF) in a large series of patients. Methods Between 2010 and 2017, we prospectively enrolled 261 consecutive patients with BVF related to SVD. All patients underwent a clinical work-up. Explanted bioprostheses were analysed for assessing the mechanism of SVD. Results The delay from surgery to SVD diagnosis was 8.5±3.3 (1.7 to 21.4) years, 10 years after exclusion of a specific type of bioprosthesis. Of the 261 SVD patients, 150 (57%) had mainly a stenotic type, and 111 (43%) a regurgitant type. In regurgitant SVD bioprosthesis was more frequently porcine (19 vs 7%, P=0.002), prosthesis diameter was larger (23.2±2.5 vs 21.6±1.9 mm; P Conclusion Structural valve degeneration remains a matter of concern in current practice with a mean delay of 8 to 10 years after surgery. Beside classical SVD with extensive calcification process other types of SVD can be observed with minimal calcification.

International audience

International audience

Background No-reflow in ST-segment elevation acute myocardial infarction (STEMI) is associated with a poor clinical prognosis. Its pathophysiological mechanisms are not fully elucidated yet but enhanced vascular permeability plays a key role in this phenomenon. Angiopoietin-like 4 (ANGPTL4) has been implicated in vascular permeability in experimental models of acute myocardial infarction (AMI). We therefore sought to investigate whether baseline ANGPTL4 serum levels are associated with no-reflow after primary percutaneous coronary intervention (PPCI). Methods We studied a group of 41 patients presenting with a first STEMI within 12h of onset of symptoms and who underwent successful PPCI. Blood samples were obtained from all patients on admission before the start of the procedure, for ANGPTL4 level measurement. No-reflow was assessed by cardiac magnetic resonance imaging (MRI), the reference method. Results MRI-detected no-reflow was observed in 20 patients (48.8%). Variables independently associated with no-reflow on multivariate logistic regression analysis were: lower ANGPTL4 serum levels (odds ratio 0.82, 95% CI 0.70–0.98, P =0.02), higher troponin T peak (odds ratio 1.03, 95% CI 1.00–1.05, P =0.03), higher incidence of left anterior descending coronary artery (LAD) as culprit artery (odds ratio 14.61, 95% CI 1.24–172.49, P =0.03), and higher C-reactive protein levels (odds ratio 1.18, 95% CI 1.00–1.39, P =0.05). Conclusion ANGPTL4 serum levels predict MRI-detected no-reflow after successful PPCI in STEMI patients. Given the recently demonstrated therapeutic role of ANGPTL4 in diminishing no-reflow and limiting infarct size in pre-clinical animal models, these findings in humans may open up new possibilities in the field of research.

Aim: We have designed ultrasmall superparamagnetic iron oxide (USPIO) nanoparticles associated with fucoidan (USPOI-FUCO), a natural sulfated polysaccharide with high affinity for activated platelets, to visualize by MRI arterial thrombi. Materials & methods: USPIOs were prepared and sizes, zeta-potentials and relaxivities were measured. Elastase perfusion in the infrarenal aorta of Wistar rats induced intraluminal thrombus. They were scanned on 4.7 T MRI before and after injection of USPIO-FUCO or USPIO coated with anionic dextran. Results: Surface plasmon resonance evidenced that fucoidan and USPIO-FUCO bind in vitro to immobilized P-selectin. All intraluminal hyposignals detected by MRI after injection of USPIO-FUCO on animals (13 out of 13) were correlated by histology with thrombi, whereas none could be identified with control USPIOs (0 out of 7). No signal was seen in absence of thrombus. Thrombi by MRI were correlated with P-selectin immunostaining and USPIO detection by electron microscopy. Conclusion: In vivo thrombi can thus be evidenced by MRI with USPIO-FUCO. Original submitted 8 July 2013; Revised submitted 4 March 2014

International audience; In anterior acute ischemic stroke (AAIS) treated with endovascular treatment (EVT), the susceptibility vessel sign (SVS+ or SVS-) is related to recanalization results (TICI 2b/3) and clinical outcome. However, a binary qualitative assessment of thrombus using SVS does not reflect its complex composition. Our aim was to assess whether a quantitative MRI marker, Thrombus-T2* relaxation time, may be assessable in clinical routine and may to predict early successful recanalization after EVT, defined as a TICI 2b/3 recanalization obtained in 2 attempts or less. MATERIAL AND METHODS: Thrombus-T2* relaxation time was prospectively obtained from consecutive AAIS patients treated by EVT (concomitant aspiration and stent retriever). Quantitative values were compared between early recanalization and late or unsuccessful recanalization. RESULTS: Thirty patients with AAIS were included and Thrombus-T2* relaxation time was obtained in all patients. Earlier TICI 2b/3 recanalization were obtained in 22 patients (73%) and was significantly associated with SVS+ (1/8 vs. 16/22, P=0.01) and a shorter Thombus-T2* relaxation time (mean SD, range: 257, 18-50ms vs. 45 9, 35-60ms, P\textless0.001). CONCLUSION: A new quantitative MRI biomarker, the Thrombus-T2* relaxation time is assessable in clinical routine. In a preliminary study of 30 patients, a shorter Thombus-T2* relaxation time is related to earlier recanalization after EVT using combination of stent retriever and aspiration.

The susceptibility vessel sign (SVS) on magnetic resonance imaging (MRI) is related to thrombus location, composition, and size in acute stroke. No previous study has determined its inter-MRI scanner variability. We aimed to compare the diagnostic accuracy in-vitro of four different MRI scanners for the characterization of histologic thrombus composition.Thirty-five manufactured thrombi analogs of different composition that were histologically categorized as fibrin-dominant, mixed, or red blood cell (RBC)-dominant were scanned on four different MRI units with T2* sequence. Nine radiologists, blinded to thrombus composition and MRI scanner model, classified twice, in a 2-week interval, the SVS of each thrombus as absent, questionable, or present. We calculated the weighted kappa with 95% confidence interval (CI), sensitivity, specificity and accuracy of the SVS on each MRI scanner to detect RBC-dominant thrombi.The SVS was present in 42%, absent in 33%, and questionable in 25% of thrombi. The interscanner agreement was moderate to good, ranging from .45 (CI: .37-.52) to .67 (CI: .61-.74). The correlation between the SVS and the thrombus composition was moderate (κ: .50 [CI: .44-.55]) to good κ: .76 ([CI: .72-.80]). Sensitivity, specificity, and accuracy to identify RBC-dominant clots were significantly different between MRI scanners (P.001).The diagnostic accuracy of SVS to determine thrombus composition varies significantly among MRI scanners. Normalization of T2*sequences between scanners may be needed to better predict thrombus composition in multicenter studies.

Background— Structural valve deterioration (SVD) is a major flaw of bioprostheses. Early SVD has been suspected in the last models of Mitroflow bioprosthesis. We sought to assess the incidence, mode, and impact of SVD on outcome in a large series of Mitroflow aortic valve replacement. Methods and Results— Six hundred seventeen consecutive patients (aged 76.1±6.3 years) underwent aortic valve replacement with a Mitroflow prosthesis (models 12A/LX) between 2002 and 2007. By echocardiography, 39 patients developed early SVD (1.66% per patient-year), with stenosis as the main mode (n=36). Mean delay to SVD was only 3.8±1.4 years, and 5-year SVD-free survival was 91.6% (95% confidence interval [CI], 88.7–94.7) for the whole cohort and 79.8% (95% CI, 71.2–89.4) and 94.0% (95% CI, 90.3–97.8) for 19- and 21-mm sizes, respectively. Among the 39 patients with SVD, 13 patients (33%) had an accelerated SVD once the mean gradient exceeded 30 mm Hg. Valve-related death was 46.2% in this SVD subgroup. Five-year overall survival was 69.6% (95% CI, 65.7–73.9). In multivariable analysis, SVD was the strongest correlate of overall mortality (hazard ratio=7.7; 95% CI, 4.4–13.6). Conclusions— Early SVD is frequent in Mitroflow bioprosthesis (models 12A/LX), especially for small sizes (19 and 21 mm), and reduces overall survival. An unpredictable accelerated pattern of SVD constitutes a life-threatening condition. In view of the large number of Mitroflow valves implanted worldwide, one can expect an epidemic of SVD and valve-related deaths, which represents a major public health issue, especially in the elderly. Hence, a close follow-up with yearly echocardiography after Mitroflow implantation is advisable. An urgent reoperation should be discussed in patients with severe SVD even though they are still asymptomatic.

Resume Objectif La tendinopathie est une pathologie frequente et ubiquitaire, caracterisee par une desorganisation precoce des fibres de collagene et s’accompagnant histologiquement d’une neo-angiogenese. Malgre l’absence de reaction inflammatoire, la strategie therapeutique de reference consiste en une injection peritendineuse de corticosteroides. Le plasma enrichi en plaquettes (PRP) pourrait s’averer utile pour accelerer la guerison, mais il n’existe pas de consensus sur la quantite de PRP a injecter et sur l’opportunite d’une deuxieme injection en cas de soulagement initial partiel de la douleur. Notre etude avait pour objectif d’evaluer, en cas d’efficacite partielle de la premiere injection de PRP avec douleur persistante, l’effet therapeutique potentiel d’une deuxieme injection rapprochee intratendineuse de PRP dans le traitement des ruptures tendineuses et des tendinoses, dans le cadre d’un suivi echographique et clinique a long terme. Patients et methodes Nous avons inclus de facon retrospective une serie de 24 patients adresses pour la prise en charge echographique d’une rupture tendineuse ou d’une tendinose (T+). Tous les patients avaient deja recu une mono-injection intratendineuse de PRP sous guidage echographique (PRPT+) et ont beneficie d’une deuxieme injection de PRP (PRPT2+) sous guidage echographique afin de traiter le tableau douloureux persistant. Les donnees echographiques et cliniques concernant chaque compartiment anatomique des membres inferieurs et superieurs ont ete recueillies avant le traitement (j0), six semaines (S6) puis six semaines (S12) apres la deuxieme injection et a 32 mois de suivi. Nous avons utilise le test de Mc Nemar et un modele de regression pour comparer les donnees echographiques et cliniques. Resultats Nous n’avons pas observe de reduction significative de la taille residuelle des lesions a l’echographie a S12 apres PRPT2+ par rapport a S6 ( p = 0,86 dans le membre superieur et p = NS dans le membre inferieur), independamment de l’âge ( p = 0,22), du sexe ( p = 0,97) et du type de tendinopathie ( p = NS). Les scores Quick DASH et WOMAC n’etaient pas significativement plus faibles pour PRPT2+ a S12 (moyenne : 21,5 mois) par rapport a S6 ( p > 0,66) et au suivi a long terme ( p > 0,75), independamment de l’âge ( p = 0,39), du sexe ( p = 0,63) et du type de tendinopathie ( p = NS). Cependant, la comparaison des scores fonctionnels cliniques a D0 et sur le long terme sont tous significatifs ( p Conclusion Notre etude clinique indique que la seconde injection precoce de PRP ne permet pas une diminution rapide de la douleur clinique du patient et ne permet pas une diminution rapide du score fonctionnel et de la zone de tendinopathie lors de l’evaluation quantitative echographique a S12. En revanche, ces resultats demontrent qu’un traitement associant deux injections de PRP entraine une diminution des douleurs et une amelioration du score fonctionnel sur le long terme.

Purpose To investigate the clinical feasibility of diffusion-weighted imaging (DWI) to detect recent myocardial infarction (MI) and to differentiate it from subacute and chronic MI, with late-gadolinium enhancement (LGE) sequence as reference. Furthermore, to measure variation of the myocardial apparent diffusion coefficient (ADC) according to the age of MI. Materials and Methods Seventy-four MI patients were separated in 3 groups. Group A included 34 recent ( 90 days) MI patients; a fourth group (group D) included 24 controls. DWI and LGE images were acquired on a 1.5T system. DWI and LGE matched images were assessed visually by two blinded observers for hyperintense areas in corresponding segments. Results Qualitative assessment of DWI compared with LGE images yielded a sensitivity of 97% and a specificity of 61%/14% to differentiate recent from chronic/subacute MI, respectively. The absolute ADCs (recent 0.00632 ± 0.00037 mm2/s, subacute 0.00639 ± 0.00035 mm2/s, chronic 0.00743 ± 0.00056 mm2/s, remote or normal 0.00895 ± 0.00019 mm2/s) and relative ADCs were significantly different between groups (P

International audience; Objectives: The aim of the study was to compare clinical/imaging findings and outcome in patients with idiopathic (isolated aortitis, IA) and with giant cell arteritis (GCA)-related aortitis.Methods: Patients from 11 French internal medicine departments were retrospectively included. Aortitis was defined by aortic wall thickening > 2 mm and/or an aortic aneurysm on CT-scan, associated to inflammatory syndrome. Patients with GCA had at least 3 ACR criteria. Aortic events (aneurysm, dissection, aortic surgeries) were reported, and free of aortic events-survival were compared.Results: Among 191 patients with non-infectious aortitis, 73 with GCA and 44 with IA were included. Patients with IA were younger (65 vs 70y, p = 0.003) and comprised more past/current smokers (43 vs 15%, p = 0.0007). Aortic aneurisms were more frequent (38% vs 20%, p = 0.03) and aortic wall thickening was more pronounced in IA. During follow-up (median = 34 months), subsequent development of aortic aneurysm was significantly lower in GCA when compared to IA (p = 0.009). GCA patients required significantly less aortic surgery during follow-up than IA patients (p = 0.02). Mean age, sex-ratio, inflammatory parameters and free of aortic aneurism-survival were equivalent in patients with IA ≥ 60y when compared to patients with GCA-related aortitis.Conclusions: IA is more severe than aortitis related to GCA, with higher proportions of aortic aneurism at diagnosis and during follow-up. IA is a heterogeneous disease and its prognosis is worse in younger patients < 60y. Most patients with IA ≥ 60y share many features with GCA-related aortitis.

Iatrogenic aortic dissection is an uncommon but potentially fatal complication. We present a case of iatrogenic coronary dissection following percutaneous coronary intervention to the right coronary artery. Aortography initially suggested coronary dissection complicated by type A aortic dissection, however, 64-slice computed tomography excluded classical aortic dissection and instead demonstrated widespread pericardial extravasation secondary to coronary perforation/rupture. This article reviews the pathophysiology, diagnosis and management of aorto-coronary dissection.

The presence of aortic valve calcifications has been known for many years, but knowledge of their development and relationship with aortic valve stenosis is relatively recent and has been studied extensively with the use of multislice CT (MSCT). The calcium burden shown with MSCT is well correlated with the degree of hemodynamic severity and anatomic surface of aortic stenosis. MSCT is also useful for monitoring valvular calcifications, by evaluating the progression of the disease and the effect of treatments. In parallel, simultaneous MSCT assessment of coronary artery and mitral valve calcifications can help achieve a better overview of the risks of cardiovascular events in these patients.

Background and Purpose— Recanalization is a powerful predictor of stroke outcome in patients with arterial occlusion. Intravenous recombinant tissue plasminogen activator is limited by its recanalization rate, which may be improved with mechanical endovascular therapy (MET). However, the benefit and safety of MET remain to be determined. The aim of this study was to give reliable estimates of efficacy and safety outcomes of MET. Methods— We analyzed data from our prospective clinical registry and conducted a systematic review of all previous studies using MET published between January 1966 and November 2009. Results— From April 2007 to November 2009, 47 patients with acute stroke were treated with MET at Bichat Hospital. The literature search identified 31 previous studies involving a total of 1066 subjects. In the meta-analysis, including our registry data, the overall recanalization rate was 79% (95% CI, 73–84). Meta-analysis of clinical outcomes showed a pooled estimate of 40% (95% CI, 34–46; 27 studies) for favorable outcome, 28% (95% CI, 23–33; 28 studies) for mortality, and 8% (95% CI, 6–10; 27 studies) for symptomatic intracranial hemorrhage. The likelihood of a favorable outcome increased with the use of thrombolysis (OR, 1.99; 95% CI, 1.23–3.22) and with proportion of patients with isolated middle cerebral artery occlusion (OR per 10% increase, 1.14; 95% CI, 1.04–1.25). Conclusions— MET is associated with acceptable safety and efficacy in stroke patients, and it may be a therapeutic option in those presenting with isolated middle cerebral artery occlusion.

Objective: Abdominal aortic aneurysm (AAA) rupture is a devastating event, and development of noninvasive methods to detect AAA at risk is needed. Matrix metalloproteinases (MMPs) play a major role in AAA growth and their subsequent rupture. This study was aimed to evaluate the ability of P947, a recently developed magnetic resonance imaging (MRI) contrast agent, to target MMPs in vivo in expanding experimental AAAs. Materials and Methods: AAAs were induced in Wistar rats (n = 18) by perfusion of a segment of the abdominal aorta with porcine elastase. After 5 or 6 days of elastase perfusion, when the aortic segment was expanding and showed inflammation with high MMP levels, rats were injected either with P947 (n = 6), P1135, a scramble form of P947 (n = 6), or with the reference contrast agent Gadolinium-DOTA (Gd-DOTA) (n = 3). Sham-operated rats (n = 3) were injected with P947 as controls. Imaging was performed on the animals using a 1.5T MRI scanner before and at different times after injection of contrast agents (100 μmol/kg). Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) gelatin zymography of culture media conditioned by incubation with perfused aortic segment or control TA from elastase-perfused rats (n = 3) was performed to determine levels of MMP2 and MMP9. In addition, in situ gelatin zymography was used to localize these active MMPs on frozen histologic sections. Results: The normalized signal enhancement determined on MRI images was higher in the perfused aortic segment of rats injected with P947 (162%) than in rats injected with P1135 (100%) or Gd-DOTA (117%) (P < 0.01 using the Friedman test) from 5 to 125 minutes after injection. The area of contrast enhancement on MRI images colocalized with the fluorescence generated by MMPs in the AAA inflammatory area, as detected by in situ zymography on histologic sections. Conclusion: Our data showed that MRI using P947 allows detection of MMP activity within the inflammatory wall of experimental AAAs, thus representing a potential noninvasive method to detect AAAs with a high risk of rupture.

Measurement of the degree of aortic valve calcification (AVC) using electron beam computed tomography (EBCT) is an accurate and complementary method to transthoracic echocardiography (TTE) for assessment of the severity of aortic stenosis (AS). Whether threshold values of AVC obtained with EBCT could be extrapolated to multislice computed tomography (MSCT) was unclear and AVC diagnostic value in patients with low ejection fraction (EF) has never been specifically evaluated.Patients with mild to severe AS underwent prospectively within 1 week MSCT and TTE. Severe AS was defined as an aortic valve area (AVA) of less than 1 cm(2). In 179 patients with EF greater than 40% (validation set), the relationship between AVC and AVA was evaluated. The best threshold of AVC for the diagnosis of severe AS was then evaluated in a second subset (testing set) of 49 patients with low EF (≤40%). In this subgroup, AS severity was defined based on mean gradient, natural history or dobutamine stress echocardiography.Correlation between AVC and AVA was good (r=-0.63, p0.0001). A threshold of 1651 arbitrary units (AU) provided 82% sensitivity, 80% specificity, 88% negative-predictive value and 70% positive-predictive value. In the testing set (patients with low EF), this threshold correctly differentiated patients with severe AS from non-severe AS in all but three cases. These three patients had an AVC score close to the threshold (1206, 1436 and 1797 AU).In this large series of patients with a wide range of AS, AVC was shown to be well correlated to AVA and may be a useful adjunct for the evaluation of AS severity especially in difficult cases such as patients with low EF.

Delayed myocardial enhancement and diagnosis of acute coronary syndrome with normal coronarography Cardiac MRI in patients with acute coronary syndrome with elevated troponin levels but normal coronarography can now routinely be performed on most MR units. MRI plays an important role in this clinical setting by its ability to detect myocardial infarction in patients with normal coronarography or suggest a different, potentially severe, alternate diagnosis such as myocarditis or takotsubo cardiomyopathy.

A third of cerebrovascular accidents are a complication from carotid artery plaque. In addition to the degree of stenosis, plaque composition and morphology are key elements in determining the probability of complication from the atherosclerotic plaque. High resolution MRI can characterize plaque composition and morphology and therefore help identify unstable plaque. The purpose of this review is to summarize recent concepts on unstable plaque and underlying inflammation. The signal characteristics of the different components of plaque on high resolution MRI then be reviewed. Finally, current morphological and functional criteria for unstable plaque will be discussed.

Objectives We sought to compare 3 methods of measurements of the aortic annulus, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multislice computed tomography (MSCT), and to evaluate their potential clinical impact on transcatheter aortic valve implantation (TAVI) strategy. Background Exact measurement of the aortic annulus is critical for a patient9s selection and successful implantation. Methods Annulus diameter was measured using TTE, TEE, and MSCT in 45 consecutive patients with severe aortic stenosis referred for TAVI. The TAVI strategy (decision to implant and choice of the prosthesis9 size) was based on manufacturer9s recommendations (Edwards-Sapien prosthesis, Edwards Lifesciences, Inc., Irvine, California). Results Correlations between methods were good but the difference between MSCT and TTE (1.22 ± 1.3 mm) or TEE (1.52 ± 1.1 mm) was larger than the difference between TTE and TEE (0.6 ± 0.8 mm; p = 0.03 and p Conclusions In patients referred for TAVI, measurements of the aortic annulus using TTE, TEE, and MSCT were close but not identical, and the method used has important potential clinical implications on TAVI strategy. In the absence of a gold standard, a strategy based on TEE measurements provided good clinical results.

Summary Background The efficacy of intravenous (IV) alteplase is restricted by the speed of recanalisation and the site of the occlusion. The aim of this study was to ascertain the effect of a combined IV–endovascular approach (intra-arterial alteplase and, if required, additional thrombectomy) in patients with stroke due to arterial occlusion. Methods We compared recanalisation rates, neurological improvement at 24 h, and functional outcome at 3 months between two periods (February, 2002, to March, 2007, vs April, 2007, to October, 2008) in patients in a prospective registry who were treated with different regimens of alteplase within 3 h of symptom onset. Patients with confirmed occlusion who were treated before April, 2007, were treated with IV alteplase; after April, 2007, patients were treated with a systematic IV–endovascular approach. Analysis was by intention to treat. Findings 46 (87%) of 53 patients treated with the IV–endovascular approach achieved recanalisation versus 56 (52%) of 107 patients in the IV group (adjusted relative risk [RR] 1·49, 95% CI 1·21–1·84; p=0·0002). Early neurological improvement (NIHSS score of 0 or 1 or an improvement of 4 points or more at 24 h) occurred in 32 (60%) patients in the IV–endovascular group and 42 (39%) patients in the IV group (adjusted RR 1·36, 0·97–1·91; p=0·07). Favourable outcome (mRS of 0–2 at 90 days) occurred in 30 (57%) patients in the IV–endovascular group and 47 (44%) patients in the IV group (adjusted RR 1·16, 0·85–1·58; p=0·35). The mortality rate at 90 days was 17% in both groups, and symptomatic intracranial haemorrhage was reported in five (9%) patients in the IV–endovascular group and in 12 (11%) patients in the IV group. Better clinical outcome was associated with recanalisation in both groups and with time to recanalisation in the IV–endovascular group. Interpretation An IV–endovascular approach is associated with higher recanalisation rates than is IV alteplase in patients with stroke and confirmed arterial occlusion. In patients treated with an IV–endovascular approach, a shorter time from symptom onset to recanalisation is associated with better clinical outcomes. Funding SOS-ATTAQUE CEREBRALE.

Cardiac diffusion MRI of recent and chronic myocardial infarction: preliminary results Purpose. To use diffusion weighted MR imaging (DWI), a technique routinely used in patients with stroke, for diagnosis of myocardial infarction (MI). Materials and methods. A breath hold ECG gated DWI sequence (b=300 sec/mm 2 ) was developped and applied to 7 patients with recent MI (3-15 days), 3 patients with chronic MI (> 6 months) and 4 patients with valvular heart disease without MI (control cases). DWI data were correlated to T2W, first pass perfusion and delayed enhancement data. Results. In all patients with recent MI, DWI showed an area of increased signal with reduction of ADC relative to normal myocardium. Hyperintense lesion on DWI corresponded to areas of delayed enhancement. The diffusion images were normal in patients with chronic MI or no MI. Conclusion. Even though no animal model or other reference method is available, these preliminary results indicate that DWI could assist clinicians in detecting recent MI.

Percutaneous mitral valve commissurotomy (PMC) is the treatment of choice for patients with mitral stenosis (MS) and favorable anatomy. Evaluation of MS should answer two questions: is MS severe? And is the valve suitable for PMC? Evaluation of MS severity relies on accurate echocardiographic assessment of the mitral valve area (MVA). Several methods can be used, often in combination. The planimetry is the reference method but must be precisely performed at the tips of the leaflets in a well-oriented plane and thus requires experienced operators. New imaging technologies, such as 3D-echocardiography, MRI or computed tomography may reduce planimetry's operator dependence. The pressure half-time method (PHT) has the merit of simplicity but should be used cautiously in elderly patients or those in atrial fibrillation. It is invalid immediately after PMC but can still be used as a semi-quantitative method: a PHT less than 130 msec is associated with a good valve opening with an excellent specificity and positive predictive value whereas a PHT 130 msec does not allow any conclusion. The continuity equation, easy to perform, may be invalidated by the commonly associated aortic or mitral regurgitation or in case of atrial fibrillation. The PISA method, is reputed technically challenging and requires a direct measurement of angle between the mitral leaflets, although the use of a fixed value of 100 degrees provides an accurate MVA estimation. The main indication of transesophageal echocardiography is the exclusion of left atrial thrombus, which is a contra-indication to PMC as well as a 2/4 or greater mitral regurgitation grade. Two-dimensional-echocardiography allows detailed evaluation of valve morphology, including leaflet thickness and mobility, degree and localization of calcifications, extent of the subvalvular involvement. Unfavorable valve anatomy is associated with a lower rate of PMC success and lower event-free survival. However, given the low predictive value of all anatomic scores, the decision to perform or not the procedure should be based on a global approach taking into account not only the valve anatomy but also individual patients characteristics such as age, rhythm, NYHA class, MVA and the predicted operative mortality based on associated comorbidities.

Points essentiels L’augmentation du nombre de detecteurs en tomodensitometrie (ou scanner) a conduit a une meilleure resolution spatiale qui se rapproche de celle de la coronarographie. Simultanement, les constructeurs investissent beaucoup dans l’amelioration de la resolution temporelle. De ces ameliorations resulte une disparition des coroscanners incompletement interpretables. Mais le coroscanner, dont les indications primaires s’orientent plutot vers l’exclusion de la maladie coronaire chez des patients a faible risque cardiovasculaire, doit etre egalement une tomodensitometrie cardiaque et thoracique. Le controle des pontages, l’analyse de la fonction ventriculaire, les maladies myocardiques ischemiques ou non, les pathologies valvulaires, le diagnostic des douleurs thoraciques aux urgences sont parfaitement etudiees avec cette technique. L’avenir proche se tourne egalement vers l’analyse de la composition de la plaque coronaire, et de son suivi avec des traitements medicamenteux notamment par statines.

Purpose: It is essential to evaluate new stent designs before in vivo testing. The purpose of this study was to develop and validate a controlled and reproducible patient-derived process to produce a life-size in vitro model of aortic arch aneurysm for endovascular procedure simulation. Methods: A three-dimensional magnetic resonance angiography (3D MRA) image derived from a 60-year-old patient with aortic arch aneurysm was segmented using a home-made software package which allows one-click automatic segmentation of the aorta, meshing, and conversion to standard tessellation language (STL) format. A rapid prototyping technique established a stereolithographic model to produce a replica of the whole aorta, including the arch aneurysm and supra-aortic arteries. Results: The final model was made by pouring silicone rubber to obtain a sturdy, life-size, soft, transparent, plastic cast, accurately reproducing both the internal and external anatomy of the aortic aneurysm. This model was used under perfusion by an extracorporeal circulation pump, to test ex vivo stent deployment. Conclusion: The combination of easy segmentation and conversion to the STL format with industrial stereolithography techniques enabled a realistic silicon vascular phantom to be created for endovascular procedure simulation, image modality calibration, and new stent design. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

A new functionalized macromolecular magnetic resonance (MR) contrast agent has been developed from a carboxymethyldextran-Gd(DOTA) devoid of biospecificity. The functionalized contrast agent was synthesized in order to mimic PSGL-1, the main ligand of P-selectin, a glycoprotein mainly expressed on the surface of activated platelets. The starting compound, CM1, was first carboxymethylated by monochloroacetic acid leading to a series of 10 derivatives varying in their carboxymethyl content. CM8 derivative, with a degree of substitution in carboxymethyl of 0.84, was chosen for subsequent fluorolabeling and sulfation to give CM8FS. CM8FS has an average number molecular weight of 27 000 +/- 500 g/mol, a hydrodynamic radius of 5.7 +/- 0.2 nm and a high relaxivity (r(1) = 11.2/mM (Gd)/s at 60 MHz). Flow cytometry experiments on whole human blood or on isolated platelets evidenced in vitro a preferential binding of CM8FS on TRAP-activated human platelets. Interestingly, CM8FS did not bind to other blood cells or to resting platelets. Pellets of TRAP-activated human platelets have also been imaged in tubes with a 1.5 T MR imager. A MR signal was observed for activated platelets incubated with CM8FS. Altogether, these in vitro results evidenced the recognition of activated human platelets by a fluorescent paramagnetic contrast agent grafted with carboxyl and sulfate groups. This biomimetic approach associated with the versatile macromolecular platform appears promising for the development of new contrast agents for molecular imaging of activated platelets in cardiovascular diseases such as atherosclerosis and aneurysms.

Wave scattering provides profound insight into the structure of matter. Typically, the ability to sense microstructure is determined by the ratio of scatterer size to probing wavelength. Here, we address the question of whether macroscopic waves can report back the presence and distribution of microscopic scatterers despite several orders of magnitude difference in scale between wavelength and scatterer size. In our analysis, monosized hard scatterers 5 μm in radius are immersed in lossless gelatin phantoms to investigate the effect of multiple reflections on the propagation of shear waves with millimeter wavelength. Steady-state monochromatic waves are imaged in situ via magnetic resonance imaging, enabling quantification of the phase velocity at a voxel size big enough to contain thousands of individual scatterers, but small enough to resolve the wavelength. We show in theory, experiments, and simulations that the resulting coherent superposition of multiple reflections gives rise to power-law dispersion at the macroscopic scale if the scatterer distribution exhibits apparent fractality over an effective length scale that is comparable to the probing wavelength. Since apparent fractality is naturally present in any random medium, microstructure can thereby leave its fingerprint on the macroscopically quantifiable power-law exponent. Our results are generic to wave phenomena and carry great potential for sensing microstructure that exhibits intrinsic fractality, such as, for instance, vasculature.

PURPOSE: the aim of our study was thus to quantify the effect of Platelet Rich Plasma (PRP) injection on systemic and local growth factors and to identify molecular markers in a rat model of patellar and Achilles tendinosis treated with PRP. MATERIAL AND METHOD: twenty two rats were used for the study. Two healthy rats were used as control (T-). We induced tendinosis (T+) in 20 rats (80 tendons by injecting under ultrasonography (US) guidance Collagenase 1® (day 0 = D0, patellar=40 and Achilles=40). At D3, these 20 rats with tendinosis were separated in treatment by either PRP (PRPT+, n=28), physiological serum (PST+, n=28, control) US-guided intratendinous injection, or without no PRP or PS (T+, n=24, control of natural evolution of tendinopathy). Follow-up at D7, D13, D18 and D25 using serum sample and local tendon removal with ELISA technics and comparison between the 3 groups were performed. RESULTS: during biological follow up, comparison of all serum samples of PRPT+, PST+ and T+ groups showed no significant modification of their biological markers at D7, D13, D18 and D25 (p>0.22). Comparison of immunological sample tendon markers of PRPT+, PST+ and T+ groups also showed no significant modification of markers at D7, D13, D18 and D25 (p>0.16) considering each biological marker and also all subgroups confounded. CONCLUSION: our study strongly suggests that a single intratendinous US-guided injection of PRP in Achilles and patellar T+ doesn't increase biological markers such as growth factors compared to a control group in mid-term and long-term follow-up.

Object: To assess the accuracy and reproducibility of semi-automatic vessel axis extraction and stenosis quantification in 3D contrast-enhanced Magnetic Resonance Angiography (CE-MRA) of the carotid arteries (CA). Materials and methods: A total of 25 MRA datasets was used: 5 phantoms with known stenoses, and 20 patients (40 CAs) drawn from a multicenter trial database. Maracas software extracted vessel centerlines and quantified the stenoses, based on boundary detection in planes perpendicular to the centerline. Centerline accuracy was visually scored. Semi-automatic measurements were compared with: (1) theoretical phantom morphometric values, and (2) stenosis degrees evaluated by two independent radiologists. Results: Exploitable centerlines were obtained in 97% of CA and in all phantoms. In phantoms, the software achieved a better agreement with theoretic stenosis degrees (weighted kappa κ w = 0.91) than the radiologists (κ w = 0.69). In patients, agreement between software and radiologists varied from κ w =0.67 to 0.90. In both, Maracas was substantially more reproducible than the readers. Mean operating time was within 1 min/ CA. Conclusion: Maracas software generates accurate 3D centerlines of vascular segments with minimum user intervention. Semi-automatic quantification of CA stenosis is also accurate, except in very severe stenoses that cannot be segmented. It substantially reduces the inter-observer variability.

The aim of the study was to determine the potential diagnostic value of contrast-enhanced echocardiogram (ECG)-gated multidetector computed tomography (MDCT) in the setting of suspected acute myocarditis compared with contrast-enhanced magnetic resonance imaging (MRI). The study group consisted of 12 consecutive patients admitted for suspected acute myocarditis less than 10 days after onset of symptoms. All patients had clinical, electrocardiographic signs, and laboratory findings consistent with the diagnosis. All patients but one (severe claustrophobia) underwent cardiac MRI using T1-weighted delayed-enhancement images after injection of gadolinium. ECG-gated MDCT was performed in all patients and included a first-pass contrast-enhanced acquisition and a delayed acquisition. MRI revealed abnormal focal or multifocal myocardial enhancement and confirmed the diagnosis in 11 patients. The first-pass MDCT acquisition showed homogenous left-ventricle contrast enhancement and absence of coronary stenosis in all patients. Delayed MDCT acquisition, performed 5 min later without reinjection of contrast medium revealed multiple areas of myocardial hyperenhancement in a focal or a multifocal pattern (six and six patients, respectively). Extent and location of hyperenhancement at MDCT correlated well with that observed at MR examination for all 11 patients evaluated by both techniques (r=0.9167, p=0.0004). These preliminary results show that ECG-gated MDCT could be a useful alternative noninvasive diagnostic test in the early phase of acute myocarditis.

Summary There is a growing consensus to recognize the role of cardiac magnetic resonance (MR) imaging in the diagnosis of myocarditis. The most characteristic finding is the presence of subepicardial enhancing areas in the inferior and lateral walls in delayed-enhanced MR sequences. Segmental wall motion abnormality may be present in the myocardial segments that can be different from those exhibiting the myocardial damage in delayed enhancement sequence. These MR features provide accurate information on the type of myocardial involvement, and probably are able to assess the severity of the disease. Moreover, these MR patterns as well as others may distinguish acute myocarditis from acute myocardial infarct, both on first-pass perfusion images and on delayed-enhancement images. Recent improvements of computerized tomography (CT) make it a challenging method for cardiac MR to assess myocarditis. By providing similar results in terms of myocardial involvement, and by adding information on coronary arteries, ECG-gated MDCT could be a useful alternative non-invasive diagnostic test in the early phase of acute myocarditis.