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Magnetic resonance has become a first-line imaging modality in various clinical scenarios. The number of patients with different cardiovascular devices, including cardiac implantable electronic devices, has increased exponentially. Although there have been reports of risks associated with exposure to magnetic resonance in these patients, the clinical evidence now supports the safety of performing these studies under specific conditions and following recommendations to minimize possible risks. This document was written by the Working Group on Cardiac Magnetic Resonance Imaging and Cardiac Computed Tomography of the Spanish Society of Cardiology (SEC-GT CRMTC), the Heart Rhythm Association of the Spanish Society of Cardiology (SEC-Heart Rhythm Association), the Spanish Society of Medical Radiology (SERAM), and the Spanish Society of Cardiothoracic Imaging (SEICAT). The document reviews the clinical evidence available in this field and establishes a series of recommendations so that patients with cardiovascular devices can safely access this diagnostic tool. Full English text available from: www.revespcardiol.org/en.

[EN] Introduction and objectives The cardiac sequelae of SARS-CoV-2 infection are still poorly documented. We conducted a cross-sectional study in healthcare workers to report evidence of pericardial and myocardial involvement after SARS-CoV-2 infection. Methods We studied 139 healthcare workers with confirmed past SARS-CoV-2 infection. Participants underwent clinical assessment, electrocardiography, and laboratory tests, including immune cell profiling and cardiac magnetic resonance (CMR). Clinically suspected pericarditis was diagnosed when classic criteria were present and clinically suspected myocarditis was based on the combination of at least 2 CMR criteria. Results Median age was 52 (41-57) years, 71.9% were women, and 16.5% were previously hospitalized for COVID-19 pneumonia. On examination (10.4 [9.3-11.0] weeks after infection-like symptoms), participants showed hemodynamic stability. Chest pain, dyspnea or palpitations were present in 41.7% participants, electrocardiographic abnormalities in 49.6%, NT-proBNP elevation in 7.9%, troponin in 0.7%, and CMR abnormalities in 60.4%. A total of 30.9% participants met criteria for either pericarditis and/or myocarditis: isolated pericarditis was diagnosed in 5.8%, myopericarditis in 7.9%, and isolated myocarditis in 17.3%. Most participants (73.2%) showed altered immune cell counts in blood, particularly decreased eosinophil (27.3%; P < .001) and increased cytotoxic T cell numbers (17.3%; P < .001). Clinically suspected pericarditis was associated (P < .005) with particularly elevated cytotoxic T cells and decreased eosinophil counts, while participants diagnosed with clinically suspected myopericarditis or myocarditis had lower (P < .05) neutrophil counts, natural killer-cells, and plasma cells. Conclusions Pericardial and myocardial involvement with clinical stability are frequent after SARS-CoV-2 infection and are associated with specific immune cell profiles., [ES] Introducción y objetivos Las secuelas cardiacas tras la infección por SARS-CoV-2 todavía están poco documentadas. Se realizó un estudio transversal en trabajadores sanitarios para estudiar la prevalencia de afección pericárdica y miocárdica tras la infección por SARS-CoV-2. Métodos Se estudió a 139 trabajadores sanitarios con infección previa confirmada por SARS-CoV-2. Los participantes se sometieron a evaluación clínica, electrocardiograma, laboratorio, incluido el perfil de células inmunitarias, y resonancia magnética cardiaca (RMC). El diagnóstico clínico de pericarditis se realizó ante la presencia de los criterios clásicos y el diagnóstico clínico de miocarditis ante la presencia de al menos 2 criterios de RMC. Resultados La mediana de edad fue de 52 (41–57) años, el 71,9% eran mujeres, y el 16.5% había sido hospitalizado previamente por neumonía por COVID-19. En la evaluación (10,4 [9,3–11,0] semanas después de los síntomas de infección), todos los participantes presentaban estabilidad hemodinámica. El 41,7% presentaba dolor torácico, disnea o palpitaciones; el 49,6%, alteraciones electrocardiográficas; el 7,9%, elevación de NT-proBNP; el 0,7%, elevación de troponina; y el 60,4%, alteraciones en la RMC. Un total de 30,9% de participantes cumplieron los criterios clínicos establecidos de pericarditis o miocarditis: pericarditis aislada en el 5,8%, miopericarditis en el 7,9% y miocarditis aislada en el 17,3%. La mayoría de los participantes (73,2%) mostraron recuentos de células inmunitarias alterados en sangre; en particular diminución de eosinófilos (27,3%; p < 0,001) y aumento del número de células T citotóxicas (17,3%; p < 0,001). La sospecha clínica de pericarditis se asoció (p < 0,005) particularmente con un elevado número de células T citotóxicas y recuento de eosinófilos disminuidos; mientras que los participantes con sospecha clínica de miopericarditis o miocarditis tenían recuentos de neutrófilos, células natural killer y células plasmáticas más bajos (p < 0,05). Conclusiones La afección pericárdica y miocárdica con estabilidad hemodinámica es frecuente después de la infección por SARS-CoV-2 y se asocia con perfiles de células inmunitarias específicas., This study was supported by CIBERCV (CB16/11/00374), CIBERONC (CB16/12/00400) and the COV20/00386 grant from the Instituto de Salud Carlos III and FEDER, Ministerio de Ciencia e Innovación, Madrid, Spain, and by GRS COVID 26/A/20 from the Gerencia Regional de Salud, Junta de Castilla y León, Spain.

Background: The timing and selection of optimal candidates for mitral transcatheter edge-to-edge valve repair remains to be fully determined, especially in cases with severely depressed left ventricular ejection fraction (LVEF). The objective of this study is to evaluate the prognostic value of myocardial strain (LVGLS) in this setting. Methods: Retrospectively, 172 consecutive patients with LVEF ≤40% and severe MR treated with MitraClip were included. Four groups were generated according to the LVEF (

El implante de TAVI se ha convertido en la primera opción de tratamiento en pacientes con estenosis aórtica severa de alto riesgo. Muchas veces el factor limitante es la ruta de acceso para llevar la prótesis a su lugar. Con este caso clínico breve mostramos cómo el implante transcava es una opción que puede resolver estos casos complejos.

Resumen Introduccion y objetivos Se han descrito previamente variantes geneticas del gen HCN4 con el fenotipo combinado de sindrome del seno enfermo (SSE) y miocardiopatia no compactada del ventriculo izquierdo (MCNC). Actualmente hay pocos casos en los que se haya probado esta relacion y ningun caso previo se ha relacionado con dilatacion de la auricula izquierda (DAi). El objetivo es estudiar un trastorno familiar caracterizado por SSE, DAi e hipertrabeculacion/fenotipo de MCNC para identificar las bases geneticas y electrofisiologicas subyacentes. Metodos Se realizo una evaluacion clinica, genetica y electrofisiologica de una familia con SSE y MCNC. Se practicaron electrocardiograma, Holter, ecocardiografia y ergometria, asi como resonancia magnetica en los casos patologicos. Se realizaron pruebas geneticas con tecnicas next-generation-sequencing (NGS) y un estudio funcional de la variante genetica candidata en celulas de ovario de hamster chino. Resultados Se observo bradicardia sinusal en 12 familiares, asociada con criterios diagnosticos de MCNC en 4, hipertrabeculacion en 6 y DAi en 9. Se detecto la variante genetica HCN4 c.1123C > T (p.Arg375Cys) en heterocigosis en todos los pacientes afectados y ausente en individuos normales. Los analisis electrofisiologicos mostraron que la amplitud y las densidades de las corrientes de HCN4 (IHCN4) generadas por canales HCN4 con la variante genetica p.R375C eran significativamente menores que las generadas por canales no mutados. Conclusiones El fenotipo combinado de SSE, DAi y fenotipo de MCNC esta asociado con la variante genetica de HCN4 c.1123C > T (p.Arg375Cys). El gen HCN4 deberia incluirse en el diagnostico genetico de la MCNC y en formas familiares de SSE, pero tambien en individuos con bradicardia sinusal y DAi.

Introduction and objectives HCN4 variants have been reported to cause combined sick sinus syndrome (SSS) and left ventricular noncompaction (LVNC) cardiomyopathy. This relationship has been proven in few cases and no previous patients have associated left atrial dilatation (LAD). Our objective was to study a familial disorder characterized by SSS, LAD, and hypertrabeculation/LVNC and to identify the underlying genetic and electrophysiological characteristics. Methods A family with SSS and LVNC underwent a clinical, genetic, and electrophysiological assessment. They were studied via electrocardiography, Holter recording, echocardiography , and exercise stress tests; cardiac magnetic resonance imaging was additionally performed in affected individuals. Genetic testing was undertaken with targeted next-generation sequencing , as well as a functional study of the candidate variant in Chinese hamster ovary cells . Results Twelve members of the family had sinus bradycardia , associated with complete criteria of LVNC in 4 members and hypertrabeculation in 6 others, as well as LAD in 9 members. A HCN4 c.1123C >T;(p.R375C) variant was present in heterozygosis in all affected patients and absent in unaffected individuals. Electrophysiological analyses showed that the amplitude and densities of the HCN4 currents (I HCN4) generated by mutant p.R375C HCN4 channels were significantly lower than those generated by wild-type channels. Conclusions The combined phenotype of SSS, LAD, and LVNC is associated with the heritable HCN4 c.1123C >T;(p.R375C) variant. HCN4 variants should be included in the genetic diagnosis of LVNC cardiomyopathy and of patients with familial forms of SSS, as well as of individuals with sinus bradycardia and LAD.

Resumen La imagen cardiovascular es fundamental para el diagnostico y el tratamiento de las diferentes cardiopatias. Ha habido multiples publicaciones a lo largo del presente ano, por lo que es dificil seleccionar las que representan los avances mas relevantes. Hemos realizado una pequena seleccion de aquello que consideramos mas destacado en cada uno de los campos de la imagen cardiovascular, englobando las enfermedades mas relevantes.

A 56-year-old male presented with angina pectoris despite optimal medical treatment. A coronary computed tomography angiography revealed a chronic total occlusion of the proximal right coronary artery with a moderately calcified long path, and a chronic total occlusion of the distal circumflex. In selected cases with long occlusions and the need for a hybrid approach, the use of computed tomography angiography fusion could help to identify the right wire position, prevent perforations, reduce the use of contrast and fluoroscopy time, improve patient safety, and increase success rate.

Resumen La imagen cardiovascular es uno de los grandes pilares en el diagnostico y el seguimiento de la cardiologia moderna. Los diferentes avances tecnicos ofrecen una mejora en este proceso, aunque con una exactitud y una eficacia dependientes de multiples factores, incluidos la disponibilidad y la experiencia acumulada. Resulta dificil seleccionar «lo mejor del 2019» por la cantidad de publicaciones donde participa la imagen cardiovascular. Hemos realizado un pequeno muestreo de articulos destacados en las diferentes tecnicas diagnosticas (ecocardiografia, resonancia cardiaca, tomografia computarizada y cardiologia nuclear) con un foco especial en tres campos de mayor interes actual: la inteligencia artificial, la cardio-onco-hematologia y el campo del intervencionismo en patologia estructural.

Background: Right ventricular (RV) to pulmonary circulation (PC) coupling can stratify prognosis in heart failure (HF). In this study, we assessed the prognostic role of the mean velocity of the pulmonary artery (mvPA) determined by cardiac magnetic resonance (CMR) in HF with preserved ejection fraction (HFpEF). Methods: Inclusion of 58 HFpEF outpatients that underwent CMR with measurement of RV–PC coupling parameters including mvPA between 2016 and 2019. The primary combined endpoint was a composite of HF readmissions and all-cause mortality. Results: Optimal cut-off value of mvPA calculated by receiver operating curve for the prediction of the primary endpoint was 9 cm/s. Over a median follow-up of 23 months (interquartile range: 24), 21 patients met the primary endpoint. The primary endpoint was more frequent in patients with mvPA ≤ 9 cm/s, as indicated by Kaplan–Meier survival curves; Log-Rank: 9.193, p = 0.02, regardless of RV dysfunction. On Cox multivariate analysis, mvPA ≤ 9 cm/s emerged as an independent prognostic predictor of the primary endpoint (HR: 4.11, 95% CI: 1.28–13.19, p = 0.017), together with left atrial area by CMR (HR: 1.08, 95% CI: 1.01–1.24, p = 0.034). Conclusions: In our HFpEF cohort, mvPA was associated with a higher rate of the primary endpoint, regardless of RV function, thus enabling identification of patients at higher risk of cardiovascular events before structural damage onset.

Mujer de 83 años con insuficiencia mitral (IM) grave asintomática hospitalizada para ser intervenida de cierre percutáneo de la orejuela izquierda tras haber sufrido una hemorragia gastrointestinal grave mientras estaba bajo tratamiento anticoagulante. La ecocardiografía transesofágica (ETE) realizada previa a la intervención confirmó la presencia de IM grave por flail en segmento P2 y con un chorro regurgitante que se deslizaba por la pared auricular hacia la orejuela. El cierre de la orejuela se llevó a cabo desplegando con éxito el sistema LAmbre (Lifetech Scientific). Una primera valoración confirmó la presencia de una fuga de IM sobre el lóbulo externo del dispositivo (figura 1A; AI: aurícula izquierda; VI: ventrículo izquierdo), si bien un examen mas detallado detectó una vía de fuga de insuficiencia mitral debajo del dispositivo utilizado para el cierre de la orejuela (figura 1B,C). La ETE en 3D del festón P2 de la válvula mitral (*) se muestra en la figura 1D-F (RAo: raíz aórtica; dispositivo de cierre de la orejuela (#); el volumen en 3D está recortado según la línea roja para crear la figura E). La imagen fluoroscópica previa al dispositivo LAmbre se muestra en la figura G. Los pasos de esta intervención pueden seguirse en...

An 83-year-old female with severe asymptomatic mitral regurgitation (MR) was admitted for an elective percutaneous left atrial appendage occlusion (LAAO) due to severe gastrointestinal bleeding under anticoagulant treatment. The transesophageal echocardiography (TEE) conducted before the procedure confirmed the presence of severe MR due to a flail P2 segment with a jet lesion on the sliding atrial wall adjacent to the appendage. An LAAO procedure was performed and the LAmbre system (Lifetech Scientific) was successfully deployed. A first assessment confirmed the presence of MR jet over the external lobe of the device (figure 1A; LA, left atrium; LV, left ventricle), but detailed scanning detected one MR jet pathway below the LAAO device (figure 1B,C). The 3D-TEE of the mitral valve P2 scallop (*) is shown on figure 1D-F (Ao, aortic root; LAAO device (#); the 3D-volume is cropped according to red line to create figure E). The pre-LAmbre device fluoroscopy image is shown on figure G. The steps of this procedure are available at video 1 of the supplementary data. Device change or relocation were not considered. We thought that a LAmbre device was the best option for a cone-shaped appendage since the external disc is far enough from the mitral...

We present the case of an 80-year-old man who presented with symptomatic severe aortic stenosis and coronary artery disease (proximal left anterior descending artery, proximal circumflex artery, and first marginal branch). Surgical risk was considered high (Society of Thoracic Surgeons score 8.3%)

Background: Paravalvular leak occurs in 5–17% of patients following surgical valve replacement, more often in mitral position. The prognosis without treatment is poor. Percutaneous device closure represents an alternative to repeat surgery. The objective of this work is to evaluate the medium and long-term results in the percutaneous closure of PVL in mitral prosthesis. Methods: This observational study is based on a retrospective registry including consecutive mitral PVL cases undergoing percutaneous closure at a single tertiary-care center from April 2010 to December 2020. The safety and efficacy results of the procedure, at 90 days and in the long term, were analyzed. Also, predictors of procedure failure and long-term events were identified. Results: A total of 128 consecutive mitral paravalvular leak closure procedures were included. Technical success was achieved in 115 (89.8%) procedures. The presence of multiple PVLs was the sole factor that independently predicted procedural failure. Median follow-up of our sample was 41.8 months (mean 47.7 ± 35.7 months). Underlying hemolytic anemia as the indication for PVL closure, a recent admission for decompensated HF, and lack of improvement in functional class emerged as consistent predictors of MACE and death during long-term follow-up, while lack of procedural success during the first PVL procedure and chronic kidney disease were also associated with MACE during follow-up. Conclusions: Percutaneous mitral PVL closure displayed high technical and procedural success rates, with an acceptable safety profile, in a high-risk population. Percutaneous mitral PVL closure achieved an improvement in short- and long-term functional class and a reduction of hemolysis in the vast majority of patients. In addition, long-term survival in our study was good, in particular for patients undergoing successful PVL closure procedures.

A correct label classification of data allows improving healthcare processes and research. However, labeling is a difficult and expensive process, which limits its use and quality. We propose a proof of concept based on Natural Language Processing and active learning, in order to automatically structure information from a text in Spanish in the field of echocardiography.

BACKGROUND Myocardial deformation with echocardiography allows early detection of systolic dysfunction and is related to myocardial iron overload (MIO) determined by T2* in hereditary anemias under transfusion support. Our aim was to analyze the diagnostic and prognostic usefulness of magnetic resonance feature tracking (MR-FT) myocardial strain in low-risk myelodysplastic syndromes (LR-MDS) patients. METHODS Prospective study in transfusion-dependent LR-MDS patients and healthy controls who underwent a cardiac MR-FT. We analyzed the relationships between strain MR-FT and iron overload parameters and its prognostic impact in cardiovascular events and/or death. RESULTS Thirty-one patients and thirteen controls were included. MIO (T2* < 20 ms) was detected in 9.7% of patients. Left ventricular global longitudinal strain (LV-GLS) by MR-FT was pathological (> −19.3%) in 32.3% of patients. Less negative strain values correlated with lower T2* (R = −0.37, p = 0.033) and native myocardial T1 (R = −0.39, p = 0.031) times. LV-GLS by MR-FT was significantly associated with higher incidence of the combined cardiovascular events and/or all-cause death (p = 0.047), with a cut-off value of −17.7% for predicting them (63% sensitivity and 81% specificity, area under the curve = 0.69). After adjusting analysis including demographic, biomarkers and imaging variables, a higher LV-GLS value by MR-FT remained as predictor of combined event in transfusion-dependent LR-MDS patients (hazard ratio, 0.4; confidence interval, 0.15–0.98; p = 0.045). CONCLUSIONS Longitudinal myocardial strain by MR-FT in LR-MDS patients is associated to MIO and correlates with adverse events in the follow-up, what could serve as a prognostic tool.

Case series Patients: Male, 60-year-old • Male, 58-year-old • Female, 28-year-old Final Diagnosis: Late-onset Anderson Fabry disease Symptoms: Left ventricular hypertrophy Medication: — Clinical Procedure: Cardiac magnetic resonance imaging Specialty: Cardiology Objective: Unusual clinical course Background: Cardiac magnetic resonance imaging (CMR) is the only noninvasive test capable of differentiating between hypertrophic cardiomyopathy (HCM) and late-onset Anderson-Fabry disease (AFD). The purpose of this report is to show how CMR led to diagnosis of AFD in 3 family members, 1 of whom previously was misdiagnosed with HCM, and how late-onset AFD can present with different cardiac phenotypes, even in a family with the same pathogenic mutation. Case Report: A 60-year-old man was referred because of evidence of left ventricular hypertrophy (LVH) on an electrocardiogram (ECG) that was performed to screen for cardiomyopathy. One of his siblings previously had been diagnosed with HCM and atrial fibrillation. The patient’s ECG and echocardiographic findings were suspicious for HCM. CMR showed severe symmetrical LVH but tissue characterization sequences were highly suggestive of AFD cardiomyopathy. Enzymatic and genetic testing confirmed the diagnosis of late-onset AFD (presence of the GLA p.F113.L mutation). The brother of the index patient then was re-evaluated and also diagnosed with late-onset AFD. He was found to have the same pathogenic mutation but with a presentation of asymmetrical septal LVH. The daughter of the index patient was positive for the same mutation but did not have LVH. Conclusions: The fact that patients with late-onset AFD can present with different LVH and fibrosis patterns, even in the presence of the same pathogenic mutation, underscores the importance of including AFD in the differential diagnosis of HCM. CMR is fundamental for differentiating between those 2 entities and defining the pathological phase of AFD. A correct diagnosis can have a substantial impact on patient management, and more so on thier families.