Right ventricular systolic dysfunction in patients with severe ischemic cardiomyopathy - CMR insights into an interventricular relationship
João L. CavalcanteZoran PopovićRory HachamovitchMilind Y. DesaiScott D. FlammThomas H. MarwickDeborah Kwon
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Background Right ventricular systolic dysfunction is associated with worsened outcomes and poor survival in patients with heart failure. However, it is unclear what mechanisms, other than the presence of RV infarction, contribute to the development of RV dysfunction in patients with severe ischemic cardiomyopathy. We sought to determine the impact of baseline demographic variables, CAD severity, LV diastolic function assessed by echocardiography, ventriculovascular coupling, LV remodeling, aortic biomechanical properties, and RV infarction, assessed by CMR, on RV ejection fraction. Methods Patients were selected if they had undergone TTE and CMR studies within 7 days (median=1 day). 354 patients with LVEF ≤ 40% and ≥ 70% stenosis in ≥1 coronary artery but without prior mitral valve surgery, fused E/A waves, atrial fibrillation or > moderate mitral regurgitation were included. Of those, 30 patients were excluded due to suboptimal CMR image quality for adequate RV volume tracings. A total 324 charts were reviewed for demographic and laboratorial data. Diastolic function assessment was performed as per guidelines. Aortic biomechanics were measured using previously validated software (ARTFUN, INSERM U678, Paris, France) using semi-automated tracing of aortic contours with phasecontrast images and through-plane velocity encoding of the ascending and descending aorta. CMR evaluation also included long and short axis assessment of LV/RV function respectively on balanced steady state free precession images along with assessment of LV/RV myocardial scar (on phase-sensitive inversion recovery DHE-CMR sequence ~ 10-20 minutes). Multivariate linear regression analysis performed to identify the independent predictors of RVEF. ResultsKeywords:
Angiology
Ischemic Cardiomyopathy
Interventricular septum
Cardiac magnetic resonance
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BackgroundCardiac allograft vasculopathy (CAV) continues to limit the long-term survival of heart transplant recipients.CAV affects both the epicardial arteries and the microvessels, however it does so independently, and epicardial and microvascular disease are both independently predictive of prognosis.Despite being associated with considerable limitations, coronary angiography has a class I recommendation for CAV surveillance and annual or biannual surveillance angiography is performed routinely in most centers.The aim of this study was to evaluate the diagnostic performance of multiparametric CMR in CAV, and to compare the performance of CMR to that of invasive coronary angiography, using contemporary invasive epicardial artery and microvascular assessment techniques as reference standards.
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ventricle and 25 patients (96%) in the left ventricle. LGE was more frequent in the inferior and inferolateral walls (17 and 16 patients, 65 and 62%) while the septum was seldom affected (7 patients, 27%). Usually, LGE was subepicardial (12 patients, 46%), but transmural (5 patients, 19%) and intramyocardial (3 patients, 12%) LGE were also observed. Left ventricle systolic dysfunction (LVEF 98ml/m2) in 3 patients, (11%) Conclusions 1. LV involvement is a frequent finding in AC 2. The most frequent abnormality is LGE in the left ventricle and the least, left ventricular dilatation 3. LGE was more frequently subepicardial and located in the inferior and inferolateral walls.
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Introduction: Prophylactic implantation of a cardioverter/ defibrillator (ICD) has been shown to reduce mortality in patients with chronic myocardial infarction (CMI) and an increased risk for life threatening ventricular arrhythmia (VA).The use of ICDs in this large patient population is still limited by high costs and possible adverse events including inappropriate discharges and progression of heart failure.VA is related to infarct size and seems to be related to infarct morphology.Contrast enhanced cardiovascular magnetic resonance imaging (ceCMR) can detect and quantify myocardial fibrosis in the setting of CMI and might therefore be a valuable tool for a more accurate risk stratification in this setting.Hypothesis: ceCMR can identify the subgroup developing VA in patients with prophylactic ICD implantation following MADIT criteria.Methods: We prospectively enrolled 52 patients (49 males, age 69 ± 10 years) with CMI and clinical indication for ICD therapy following MADIT criteria.Prior to implantation (36 ± 78 days) patients were investigated on a 1.5 T clinical scanner (Siemens Avanto © , Germany) to assess left ventricular function (LVEF), LV end-diastolic volume (LVEDV) and LV mass (sequence parameters: GRE SSFP, matrix 256 × 192, short axis stack; full LV coverage, no gap; slice thickness 6 mm).For quantitative assessment of infarct morphology late gadolinium enhancement (LGE) was performed including measurement of total and relative infarct mass (related to LV mass) and the degree of transmurality (DT) as defined by the percentage of transmurality in each scar.(sequence parameters: inversion recovery gradient echo; matrix 256 × 148, imaging 10 min after 0.2 μg/kg gadolinium DTPA; slice orientation equal to SSFP).MRI images were analysed using dedicated software (MASS © , Medis, Netherlands).LGE was defined as myocardial areas with signal intensity above the average plus 5 SD of the remote myocardium.After implantation, patients were followed up including ICD readout after 3 and than every 6 months for a mean of 945 ± 344 days.ICD data were evaluated by an experienced electrophysiologist.Primary endpoint was the occurrence of an appropriate discharge (DC), antitachycard pacing (ATP) or death from cardiac cause.Results: The endpoint occurred in 10 patients (3 DC, 6 ATP, 1 death).These patients had a higher relative infarct mass (28 ± 7% vs. 22 ± 11%, p = 0.03) as well as high degree of transmurality (64 ± 22% vs. 44 ± 25%, p = 0.05).Their LVEF (29 ± 8% vs. 30 ± 4%, p = 0.75), LV mass (148 ± 29 g vs. 154 ± 42 g, p = 0.60), LVEDV (270 ± 133 ml vs. 275 ± 83 ml, p = 0.90) or total infarct mass (43 ± 19 g vs. 37 ± 21 g, p = 0.43) were however not significant from the group with no events.In a cox proportional hazards regression model including LVEF, LVEDV, LV mass, DT and age, only degree of transmurality and relative infarct mass emerged as independent predictors of the primary end point (p = 0.009). Conclusion:In CMI-patients fulfilling MADIT criteria ceCMR could show that the extent and transmurality of myocardial scarring are independent predictors for life threatening ventricular arrhythmia or death.This additional information could lead to more precise risk stratification and might reduce adverse events and cost of ICD therapy in this patient population.Larger trials are needed to confirm this finding.
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