Inferior Myocardial Wall Research Articles

F-18 FDG PET/CT scan in recurrent prosthetic valve endocarditis without detectable abnormality on echo: a case report

BackgroundInfective endocarditis poses many clinical and diagnostic challenge. The diagnosis of infective endocarditis is made by high index of clinical suspicion based on the American Heart Association modified Duke’s criteria, and the main imaging modality of choice is echocardiography.Case presentationHere, we reported a case of recurrent infective endocarditis revealed by FDG PET/CT study despite completion of antibiotics and negative on echocardiography. A 38-year-old female with history of double-valve replacement for aortic stenosis presented with 1-week history of chest pain, dyspnea and intermittent fever. She was treated with 5 weeks of antibiotic with IV Cephalexin for prosthetic valve endocarditis. The repeated blood culture after IV antibiotic was negative for infection. She represented again with episodes of palpitation. Post-treatment blood investigation showed normal leukocyte level with increasing CRP and Troponin T level. The repeated blood culture and transesophageal echo was negative. The F-18 FDG PET/CT showed a mild hypermetabolic focus at the inferior basal myocardial wall adjacent to the prosthetic valve, however not involving the paraaortic region which is likely secondary to ongoing inflamed myocardium. As the fear of another relapse of endocarditis, oral suppression antibiotic therapy was continued for another 6 months.ConclusionsThis case report illustrates a patient with a prosthetic valve replacement detected by F-18 FDG PET/CT, which one could have overlooked an endocarditis if one had relied on transesophageal echo (TEE) alone. F-18 FDG PET/CT is a promising adjunctive tool in the diagnostic workup of patients with suspected IE, particularly prosthetic device endocarditis where the TEE sensitivity is lower. In our patient, the positive F-18 FDG PET/CT governs the subsequent therapeutic consequences which include adjustment of antibiotic and length of treatment, and it prevents unnecessary intervention.

Inferior myocardial wall ischemia on SPECT-MPI in patients with non dominant right coronary artery and non significant coronary artery disease

BackgroundThe impact of a non-dominant right coronary artery (NDRCA), on single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI)has not been clarified. Methods and resultsWe compared SPECT-MPI results of consecutive patients without significant (diameter stenosis ≥50%)coronary artery disease (CAD) and a NDRCA (Group-1), with those of patients from our database without CAD and a dominant RCA (Group-2). All patients were subjected to SPECT-MPI with I.V. infusion of adenosine, and TC99-tetrofosmin. Group-1 included 69 patients (55 men, 79.7%), mean age 66.8 ± 9.8 years. Group-2 consisted of 79 patients (56 men, 70.9%), mean age 62.7 ± 11.5. There was no difference in demographics and CAD risk factors between the two groups. The SPECT-MPI revealed inferior wall ischemia, in 35 patients (50.7%), in Group-1 and 27 patients (34.1%), in Group-2 (P = 0.041). ConclusionsA relatively high rate of reversible SPECT-MPI perfusion defects may be anticipated in patients with an unobstructed NDRCA compared to patients with a dominant RCA.

A moving liver phantom in an anthropomorphic thorax for SPECT MP imaging

Cranio-caudal respiratory motion and liver activity cause a variety of complex myocardial perfusion (MP) artifacts, especially in the inferior myocardial wall, that may also mask cardiac defects. To assess and characterise such artifacts, an anthropomorphic thorax with moving thoracic phantoms can be utilised in SPECT MP imaging. In this study, a liver phantom was developed and anatomically added into an anthropomorphic phantom that also encloses an ECG beating cardiac phantom and breathing lungs’ phantom. A cranio-caudal respiratory motion was also developed for the liver phantom and it was synchronised with the corresponding ones of the other thoracic phantoms. This continuous motion was further divided into isochronous dynamic respiratory phases, from end-exhalation to end-inspiration, to perform SPECT acquisitions in different respiratory phases. The new motions’ parameters and settings were measured by mechanical means and also validated in a clinical environment by acquiring CT images and by using two imaging software packages. To demonstrate the new imaging capabilities of the phantom assembly, SPECT/CT MP acquisitions were performed and compared to previous phantom and patients studies. All thoracic phantoms can precisely perform physiological motions within the anthropomorphic thorax. The new capabilities of the phantom assembly allow to perform SPECT/CT MP acquisitions for different cardiac-liver activity ratios and cardiac-liver proximities in supine and, for first time, in prone position. Thus, MP artifacts can be characterised and motion correction can be performed due to these new capabilities. The impact of artifacts and motion correction on defect detection can be also investigated.

Hepato-cardiac juxtaposition secondary to right hemi-diaphragmatic eventration on 99mTc-Sestamibi myocardial perfusion scintigraphy

Liver radiotracer activity interfering with the inferior myocardial wall in a patient undergoing myocardial perfusion imaging (MPI) with 99mTc-Sestamibi is a known pitfall. We report a patient with pituitary macroadenoma who was subjected to stress-MPI study for pre-anesthetic clearance. The post-stress raw image showed the liver radiotracer activity in close approximation to the anteroseptal wall of the left ventricular myocardium, secondary to right hemi-diaphragmatic eventration.

Cardiac sympathetic denervation in wild-type transthyretin amyloidosis

Abstract Background Tissue accumulation of misfolded transthyretin (TTR) may occur because of TTR gene mutations (variant amyloid TTR amyloidosis, ATTRv), or as an age-related phenomenon (wild-type ATTR, ATTRwt). Cardiac sympathetic denervation has been reported in ATTRv, but has never been investigated in ATTRwt. Methods Fifteen consecutive patients with ATTRwt cardiomyopathy (81% men, median age 82 years, no one with prior myocardial infarction) underwent Cadmium Zinc Telluride tomographic imaging for amyloid burden (99mTc-hydroxymethylene diphosphonate - 99mTc-HMDP), innervation (123I-metaiodobenzylguanidine – 123I-MIBG), and perfusion (99mTc-tetrofosmin). Results Median summed 99mTc-HMDP score was 60 (58–62), denoting a severe and diffuse amyloid burden. Planar 123I-MIBG examination showed decreased early and late H/M ratios (late H/M ratio: 1.5 [1.3–1.6], range 1.2–1.9, reference value ≥2.0). Summed 123I-MIBG score was 12 (6–22), with the most prominent denervation in the infero-septal, inferior, and infero-lateral regions; summed rest score was 7 (5–11), with lowest degrees of myocardial perfusion in the inferior and infero-septal regions. The correlation between amyloid burden (as relative 99mTc-HMDP uptake) and innervation (as relative 123I-MIBG uptake) did not achieve statistical significance at both segmental (p=0.252) and regional level (p=0.251). Nevertheless, denervation tended to worsen in parallel with the amyloid burden, and 123I-MIBG scores increased with 99mTc-HMDP scores. Segments and regions with more prominent hypoperfusion were those showing the more intense denervation (r=0.500 and 0.591, respectively; both p<0.001). Conclusions Patients with ATTRwt cardiomyopathy display cardiac sympathetic denervation, particularly in the inferior and septal myocardial wall. Myocardial hypoperfusion has a similar regional pattern, while the amyloid burden is more extensive. Funding Acknowledgement Type of funding source: None

Cardiac sympathetic denervation in wild-type transthyretin amyloidosis

Background Tissue accumulation of misfolded transthyretin (TTR) may occur because of TTR gene mutations (variant amyloid TTR amyloidosis, ATTRv), or as an age-related phenomenon (wild-type ATTR, ATTRwt). Cardiac sympathetic denervation has been reported in ATTRv, but has never been investigated in ATTRwt. Methods Fifteen consecutive patients with ATTRwt cardiomyopathy (81% men, median age 82 years, no one with prior myocardial infarction) underwent Cadmium Zinc Telluride tomographic imaging for amyloid burden (99mTc-hydroxymethylene diphosphonate – 99mTc-HMDP), innervation (123I-metaiodobenzylguanidine – 123I-MIBG), and perfusion (99mTc-tetrofosmin). Results Median summed 99mTc-HMDP score was 60 (58–62), denoting a severe and diffuse amyloid burden. Planar 123I-MIBG examination showed decreased early and late H/M ratios (late H/M ratio: 1.5 [1.3–1.6], range 1.2–1.9, reference value ≥2.0). Summed 123I-MIBG score was 12 (6–22), with the most prominent denervation in the infero-septal, inferior, and infero-lateral regions; summed rest score was 7 (5–11), with lowest degrees of myocardial perfusion in the inferior and infero-septal regions. The correlation between amyloid burden (as relative 99mTc-HMDP uptake) and innervation (as relative 123I-MIBG uptake) did not achieve statistical significance at both segmental (p = .252) and regional level (p = .251). Nevertheless, denervation tended to worsen in parallel with the amyloid burden, and 123I-MIBG scores increased with 99mTc-HMDP scores. Segments and regions with prominent hypoperfusion also showed a higher degree of denervation (r = 0.500 and 0.591, respectively; both p < .001). Conclusions Patients with ATTRwt cardiomyopathy display cardiac sympathetic denervation, particularly in the inferior and septal myocardial wall. Myocardial hypoperfusion has a similar regional pattern, while the amyloid burden is more extensive.

PP-441 - Unseen Part of the Iceberg Before Obesity Surgery: Multivessel Coronary Artery Disease

Case report: 47 years old man evaluated for class II exertional dsypnea before obesity surgery as an outpatient. He had a history of hyperlipidemia and smoking with 30 packs a year. Physical examination revealed obesity (body mass index 36.2 kg/m2, 120 kg, 1.82 cm). Electrocardiography demonstrated sinus rhythm, and left anterior hemiblock. Echocardiography demonstrated normal systolic function, and mild mitral regurgitation. Due to the exertional dyspnea, he underwent myocardial perfusion scintigraphy which is showed myocardial ischemia of inferior and anterior myocardial wall. The coronary angiography showed severe stenosis of proximal left anterior descending and circumflex coronary artery. The retrograd collaterals from left coronary system to right coronary artery and total occlusion and antegrad bridge collaterals at proximal right coronary artery were also demonstrated in left and right coronary angiography. Coronary bypass surgery recommended for the complete revascularization but the patient didn't accept the surgery. First, the opening of the chronic total occlusion of right coronary artery, and then left coronary system were planned. 7F JR4 guiding, and 6F JL4 diagnostic catheters used for dual injection. The conus branch was use to anchor with 1,5 × 15 mm semi-compliant balloon. Gaia-3 guidewire was used to advance proximal cap under back-up with Corsair microcatheter and using drilling technique. By using Gaia 3 guidewire we weren't able to enter from distal cap to true lumen. Therefore, microcatheter changed to Twinpass microcatheter and the Fielder FC was used to enter acute margine branch or distal right coronary artery. Fielder FC was penetrated into the acute margine branch, and distal cap was punctured with the Conquest Pro through the side hole of the Twinpass microcatheter by advancing wire into the distal right coronary artery. By using TRAP technique, Twinpass microcatheter was removed and Corsair microcatheter was advanced into distal right coronary artery to protect coronary perforation by Conquest Pro manipulation. Grand Slam guidewire was advanced through Corsair microcatheter. After removing Corsair microcatheter by TRAP technique, multiple balloon dilatations were performed. 3.0 × 48 mm Xience Pro and 3.0 × 38 mm Cre8 DES were implanted mid-distal right coronary artery while 3.5 × 23 mm Xience Pro was implanted proximally. Multiple post-dilatations were performed with 3.5 × 18 mm non-compliant balloon and TIMI III flow was achieved. The revascularization of left coronary system was planned for two weeks later. Firstful, 4.0 × 26 mm Resolute stent was succesfully implanted to circumflex coronary artery. At the same procedure, 4.0 × 38 mm Resolute stent was succesfully implanted to the left anterior descending coronary artery. Control coronary angiography of the right coronary artery also showed that TIMI III flow with no evidence of thrombosis or stenosis. He discharged with the advice of the lifestyle changes, quit smoking, and weight lost. The obesity surgery was postponed until the 6 months from the procedure for reducing stent thrombosis risk.

Troponin and CRP as Indicators of Possible Ventricular Arrhythmias in Myocardial Infarction of the Anterior and Inferior Walls of the Heart.

Introduction:Heart rhythm disorders are quite common in the clinical course of acute myocardial infarction and have a significant influence on the prognosis of the disease.Aim:To investigate the type and frequency of ventricular arrhythmias in patients with acute myocardial infarction (AMI) by sex and age, according to localization of myocardial infarction, and correlated with troponin and C reactive protein (CRP).Material and Methods:A prospective, analytical, comparative clinical study was performed. A total of 100 patients was included who were hospitalized at the Clinic for Heart Disease and Rheumatism at the Clinical Center University of Sarajevo for a period of 6 months, of both sexes, aged from 20 to 90 years. The occurrence of ventricular arrhythmias, CRP and troponin, were observed in relation to the localization (anterior and inferior myocardial wall).Results:It was found that men are more represented in comparison to women and that the largest number of males were in the age group of 51-60 years of life and women in the age group of 71-80 years. It has been established that there is no significant difference between ventricular arrhythmia according to localization of AMI. By determining the mean CRP and troponin levels, a positive correlation was found between CRP and troponin values and recorded ventricular arrhythmias.Conclusion:There is a positive correlation between the troponin and CRP values and ventricular arrhythmias, not related to the localization of AMI, which is important in prevention and planning the treatment of complications of potentially malignant ventricular arrhythmias and fatal outcome at AMI.

Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction

Background— Left ventricular dysfunction is a known predictor of ventricular arrhythmias. We hypothesized that measures of regional longitudinal deformation by speckle-tracking echocardiography predict ventricular tachyarrhythmias and provide incremental prognostic information over clinical and conventional echocardiographic characteristics. Methods and Results— We studied 1064 patients enrolled in the MADIT-CRT trial (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy) with speckle-tracking data available. Peak longitudinal strain was obtained for the septal, lateral, anterior, and inferior myocardial walls at baseline. The end point was the first event of ventricular tachycardia (VT) or fibrillation (VF). During the median follow-up of 2.9 years, 254 (24%) patients developed VT/VF. Patients with VT/VF had significantly lower left ventricular ejection fraction (28.3% versus 29.5%; P &lt;0.001) and longitudinal strain in all myocardial walls compared with patients without VT/VF (anterior-strain, −7.7% versus −8.8%; P &lt;0.001; lateral-strain, −7.3% versus −7.9%; P =0.022; inferior-strain, −8.3% versus −9.9%; P &lt;0.001; septal-strain, −9.1% versus −10.0%; P &lt;0.001). After multivariate adjustment, only anterior and inferior longitudinal strain remained independent predictors of VT/VF (anterior: hazard ratio, 1.08 [1.03–1.13]; P =0.001; inferior: hazard ratio, 1.08 [1.04–1.12]; P &lt;0.001; per 1% absolute decrease for both). When including B-type natriuretic peptide in the model, only a decreasing myocardial function in the inferior myocardial wall predicted VT/VF (hazard ratio, 1.05 [1.00–1.11]; P =0.039). Only strain obtained from the inferior myocardial wall provided incremental prognostic information for VT/VF over clinical and echocardiographic parameters (C statistic 0.71 versus 0.69; P =0.005). Conclusions— Assessment of regional longitudinal myocardial deformation in the inferior region provided incremental prognostic information over clinical and echocardiographic risk factors in predicting ventricular tachyarrhythmias. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00180271.

Aspiracija tromba tokom primarne perkutane koronarne intervencije - gde smo sada?

Introduction. thrombus aspiration is not recommended as a routine procedure considering the results of large randomised trials. It is necessary to define new indications for thrombus aspiration in myocardial infarction and to conduct appropriate trials. The aim of this paper was to report a patient with successful aspiration of large thrombus mass from right coronary artery made after primary balloon angioplasty, and to consider which patients could benefit with this procedure. Case report. a male, 80 years old, has been admitted to a catheterisation laboratory with clinical, biochemical and electrocardiographic signs of acute myocardial infarction with ST segment elevation (STEMI) of inferoposterolateral localisation along with sinus bradycardia and profound arterial hypotension, which all are characteristic for inferior myocardial wall infarction with right ventricular involvement. Two hours after pain onset the patient was admitted to hospital in Bijeljina and sent to catheterisation laboratory straight after. All branches of left coronary artery were well visualized and without significant stenosis. Right coronary artery was occluded in proximal segment. Predilatation was performed with SC Sprinter legend 2,0x20mm balloon. After predilatation thrombus burden is still large, blood flow was slow with significant residual stenosis. Than, BMS Pro-kinetic energy 3,5x20mm stent was implanted. After stent implantation thrombus burden existed and there was no flow in PLV branch. Thrombus mass was 2 cm long and successfully aspirated with Export aspiration catheter. Control coronarography showed no residual stenosis and normal blood flow was restored through branches of right coronary artery. Conclusion. Procedure must be gradual, carefully planned and aspiration of thrombus should be taken only after initial balloon angioplasty with flow evaluation. Large thrombus burden or several smaller thrombi with clear flow obstruction and poor peripheral flow could be the reason for aspiration of thrombus along with possible intracoronary administration of GP IIbIIIa inhibitors. If conducted cautiously, aspiration of thrombus may still be considered as a valuable technique in selected patients with a large angiographic thrombus burden.

Prognostic value of tissue Doppler imaging for predicting ventricular arrhythmias and cardiovascular mortality in ischaemic cardiomyopathy.

Only 30% of patients receiving an implantable cardioverter defibrillator (ICD) for primary prevention receive appropriately therapy. We sought to investigate the value of tissue Doppler imaging (TDI) to predict ventricular tachycardia (VT), ventricular fibrillation (VF), and cardiovascular mortality (CVD) in patients with primary prevention ICD. In total, 151 ICD patients meeting primary prevention criteria and with no history of ventricular arrhythmias were included. All participants were examined by conventional 2D echocardiography and TDI echocardiography. Longitudinal systolic (s'), early diastolic (e'), and late diastolic (a') myocardial velocities were measured using TDI at six mitral annular sites and averaged to provide global estimates. Forty patients experienced the combined endpoint of VT, VF, or CVD during a median follow-up of 2.3 years. Left ventricular ejection fraction, global longitudinal strain, E/e', global s', and global e' were not significantly different in patients who developed VT/VF/CVD compared with those who did not. In contrast, global a' was significantly lower in patients with an unfavourable outcome compared with those without (4.8 ± 2.0 vs. 5.7 ± 1.8 cm/s, P = 0.020). Global a' remained an independent predictor of VT/VF/CVD after multivariable adjustment for age, gender, β-blocker therapy, and deceleration time (HR = 1.25 [1.02, 1.54], P = 0.032). Regional analysis revealed that a depressed a' in the inferior wall drives the predictive capability of a'. Late diastolic velocity by TDI seems to be a superior echocardiographic predictor of VT/VF/CVD in ischaemic cardiomyopathy. Additionally, impaired late diastolic velocity in the inferior myocardial wall seems to be a paramount marker of future VT/VF/CVD.

Discriminant function analysis of the occurrence risk of abnormal electrocardiogram in thyroidectomized differentiated thyroid carcinoma patients with short-term overt hypothyroidism.

The common form and risk factors of electrocardiogram (ECG) abnormality in thyroidectomized differentiated thyroid carcinoma (DTC) patients with short-term overt hypothyroidism were investigated and some discriminant formulas for forecasting the occurrence of abnormal ECG in this specific population were deduced in this study. A total of 260 thyroidectomized DTC patients were retrospectively reviewed, 67 of whom had abnormal ECG and 193 normal ECG after short-term (3 weeks) levothyroxine (L-T4) withdrawal. One-way ANOVA, Spearman's rank correlation analysis and discriminant function analysis were performed using data from these DTC patients. A flat or inverted T wave in inferior myocardial and left ventricular wall leads was the most common abnormal ECG finding in short-term overt hypothyroidism. Statistical analyses showed that age, interval, TSH-end (The serum hormothyrin level at the end of L-T4 withdrawal for 3 weeks), and TSH-vel (The average ascending velocity of serum hormothyrin level during L-T4 withdrawal for 3 weeks) were statistically significant and positively correlated with the occurrence of abnormal ECG. Meanwhile, TSH-vel showed the highest correlation coefficient (r = 0.358, p = 0.000). The formulas, especially deduced from age, interval and TSH-vel, could discriminate patients with abnormal ECG or not as high as 77.6 and 70.5%, respectively (resubstitution accuracy: 72.3%). The thyroidectomized DTC patients undergoing short-term L-T4 withdrawal before their first radioiodine ablative therapy, who had one or more of the above-mentioned risk factors, are likely to show abnormal ECG findings. The formulas from discriminant function analysis may be helpful for predicting patients with abnormal ECG with short-term L-T4 withdrawal and allow appropriate medical intervention beforehand.

Abstract 18269: Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Heart Failure Patients With Reduced Ejection Fraction - A MADIT-CRT Sub-Study

Background: Abnormalities of regional function are known predictors of ventricular arrhythmia. We assessed whether measures of regional longitudinal deformation by speckle tracking echocardiography improve prediction of ventricular tachyarrhythmias over clinical, echocardiography parameters, or biomarkers. Methods: We studied 1064 patients enrolled in MADIT-CRT with speckle-tracking data available. Peak longitudinal strain was obtained for the septal, lateral, anterior and inferior myocardial walls. The endpoint was the first event of ventricular tachycardia (VT) or fibrillation (VF). Results: During the median follow-up of 2.9 years, 254 (24%) patients developed VT/VF. Patients with VT/VF had significantly lower LVEF (28.3% vs 29.5%, p&lt;0.001) and longitudinal strain in all myocardial walls compared to patients without VT/VF (Figure). After multivariate adjustment for clinical and conventional echocardiographic predictors of VT/VF, only longitudinal strain in the anterior and inferior myocardial walls remained independent predictors of VT/VF (anterior: HR 1.08 [1.03; 1.13], p=0.001; inferior: HR 1.08 [1.04; 1.12], p&lt;0.001; per 1% increase for both). After including BNP in the model, only a decreasing myocardial function in the inferior myocardial wall predicted VT/VF (HR 1.05 [1.00; 1.10], p&lt;0.05) (Figure). Additionally, only strain in the inferior myocardial wall provided incremental prognostic information on the risk of VT/VF when added to a model already including clinical parameters and LVEF, determined by a significant increase in the Harrell’s C-statistic (0.70 vs 0.67, p=0.002). Conclusion: In MADIT-CRT, assessment of regional longitudinal myocardial deformation in the inferior myocardial wall provided incremental prognostic information over clinical, conventional echocardiographic risk factors, or biomarkers in predicting ventricular tachyarrhythmias.

Abstract 14898: Prognostic Value of Tissue Doppler Imaging for Predicting Ventricular Arrhythmias and Cardiovascular Mortality in Ischemic Cardiomyopathy

Background: Only 30% of patients receiving an implantable cardioverter defibrillator (ICD) for primary prevention respond appropriately to this therapy. The purpose of this study was to investigate the value of Tissue Doppler Imaging (TDI) Echocardiography at predicting appropriate ICD therapy and cardiovascular mortality (CVD) in patients with primary prevention ICD. Methods: In total, 151 ICD patients meeting primary prevention criteria, with no history of ventricular arrhythmias were included. All participants were examined by conventional 2D echocardiography and TDI echocardiography. Longitudinal systolic (s’), early diastolic (e’), and late diastolic (a’) myocardial velocities were measured using TDI at six mitral annular sites and averaged to provide global estimates. Results: Forty patients experienced the combined endpoint of ventricular tachycardia (VT), fibrillation (VF) or CVD during a median follow-up of 2.3 years. Neither left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), E/e’, global s’ nor global e’ were significantly impaired in patients who developed VT/VF/CVD (LVEF: 31 vs. 28 %, p=0.06; GLS: 9 vs. 9 %, p=0.85; E/e’: 16 vs. 16, p=0.80; s’: 3.8 vs. 3.7 cm/s, p=0.68; e’: 4.5 vs. 4.6 cm/s, p=0.61). In contrast, global a’ was significantly lower in patients with an unfavorable outcome compared to those without (5.7±1.8 vs. 4.8±2.0 cm/s, p=0.020). Global a’ remained an independent predictor of VT/VF/CVD after multivariable adjustment for age, gender, beta blocker therapy and deceleration time (HR=1.25 [1.02; 1.54], p=0.032). Regional analysis revealed that a depressed a’ in the inferior wall drives the predictive capability of a’ (Figure). Conclusion: Late diastolic velocity by TDI seems to be a superior echocardiographic predictor of VT/VF/CVD in ischemic cardiomyopathy. Additionally, impaired late diastolic velocity in the inferior myocardial wall seems to be a paramount marker of future VT/VF/CVD.

Re-initiating professional working activity after myocardial infarction in primary percutaneous coronary intervention networks era.

To investigate the aspects of return to work, socio-economic and quality of life aspects in 145 employed patients under 60 years of age treated with primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. During hospital treatment demographic and clinical data was collected. Data about major adverse cardiovascular events, rehabilitation, sick leave, discharge from job and retirement, salary, major life events and estimation of quality of life after myocardial infarction were obtained after follow-up (mean: 836±242 days). Average sick leave was 126±125 days. Following myocardial infarction, 3.4% of patients were discharged from their jobs while 31.7% retired. Lower salary was reported in 17.9% patients, major life events in 9.7%, while 40.7% estimated quality of life as worse following the event. Longer hospitalization was reported in patients transferred from surrounding counties, those with inferior myocardial wall and right coronary artery affected. Age, hyperlipoproteinemia and lower education degree were connected to permanent working cessation. Significant salary decrease was observed in male patients. Employer type was related to sick leave duration. Impaired quality of life was observed in patients who underwent in-hospital rehabilitation and those from surrounding counties. Longer sick leave was observed in patients with lower income before and after myocardial infarction. These patients reported lower quality of life after myocardial infarction. Inadequate health policy and delayed cardiac rehabilitation after myocardial infarction may lead to prolonged hospitalization and sick leave as well as lower quality of life after the event, regardless of optimal treatment in acute phase of disease.

Utility of left lateral supine position for myocardial perfusion single-photon emission computed tomography compared with other methods of correcting inferior wall attenuation.

Single-photon emission computed tomography (SPECT) myocardial perfusion imaging is an accepted method for reflecting the pathophysiological significance of lesions detected by coronary angiography. However, it has an inherent drawback in terms of false-positive perfusion defects for the inferior myocardial wall. To overcome this problem, different acquisition techniques have been proposed, including the computed tomographic-based attenuation correction method. In this respect, a new imaging technique, left supine lateral position SPECT myocardial perfusion imaging with technetium-99m methoxyisobutylisonitrile (Tc-99m MIBI), has been proposed to eliminate this problem and its value has been investigated in this report. Sixty-two patients were prospectively and randomly enrolled in this study. They underwent Tc-99m MIBI SPECT in the supine, prone, left lateral, and sitting positions after an adequate stress test on the same day.The presence and extent of defects on stress images were noted in the supine image data set for the 11 myocardial segments, which were then labeled as 1 or 0 if a defect was present or absent, respectively. This evaluation sequence was repeated in all other image data sets. When defects persisted in other scan positions it was regarded as true positive, and when they were resolved they were regarded as false positive. By this means, the percentages of resolving perfusion defects by that imaging position were calculated for each observer per positional pair under comparison. From six interpretations carried out by the nuclear medicine physicians, 6×11×3=198 four-fold tables in 11 segments were analyzed for discrepancies between position pairs. In 31 of 33 discrepant interpretations, defects observed in any of the other positions were resolved in the lateral position. Only in two evaluations of one observer were the discrepancies against lateral positioning for the anterior wall. If the inferior wall was considered alone, it was clearly obvious that lateral positioning was more accurate than the other positions.Intraobserver evaluation showed the methodology to be highly reproducible.The SPECT findings were concordant with coronary angiography results in selected patients. Visual and quantitative evaluations of the variation in inferior wall activity lead us to suggest that SPECT imaging with Tc-99m MIBI be performed in the left lateral position to allow better visualization of the inferior and septal walls in those departments not able to utilize computed tomographic attenuation correction.

Loss of Wnt5a disrupts second heart field cell deployment and may contribute to OFT malformations in DiGeorge syndrome.

Outflow tract (OFT) malformation accounts for ∼30% of human congenital heart defects and manifests frequently in TBX1 haplo-insufficiency associated DiGeorge (22q11.2 deletion) syndrome. OFT myocardium originates from second heart field (SHF) progenitors in the pharyngeal and splanchnic mesoderm (SpM), but how these progenitors are deployed to the OFT is unclear. We find that SHF progenitors in the SpM gradually gain epithelial character and are deployed to the OFT as a cohesive sheet. Wnt5a, a non-canonical Wnt, is expressed specifically in the caudal SpM and may regulate oriented cell intercalation to incorporate SHF progenitors into an epithelial-like sheet, thereby generating the pushing force to deploy SHF cells rostrally into the OFT. Using enhancer trap and Cre transgenes, our lineage tracing experiments show that in Wnt5a null mice, SHF progenitors are trapped in the SpM and fail to be deployed to the OFT efficiently, resulting in a reduction in the inferior OFT myocardial wall and its derivative, subpulmonary myocardium. Concomitantly, the superior OFT and subaortic myocardium are expanded. Finally, in chick embryos, blocking the Wnt5a function in the caudal SpM perturbs polarized elongation of SHF progenitors, and compromises their deployment to the OFT. Collectively, our results highlight a critical role for Wnt5a in deploying SHF progenitors from the SpM to the OFT. Given that Wnt5a is a putative transcriptional target of Tbx1, and the similar reduction of subpulmonary myocardium in Tbx1 mutant mice, our results suggest that perturbing Wnt5a-mediated SHF deployment may be an important pathogenic mechanism contributing to OFT malformations in DiGeorge syndrome.

Frequency and Significance of Myocardial Bridging and Recurrent Segment of the Left Anterior Descending Coronary Artery in Patients With Takotsubo Cardiomyopathy

Despite intensive research efforts, the causative mechanisms of takotsubo cardiomyopathy (TC) are still unknown. Recently, morphologic characteristics of the left anterior descending coronary artery (LAD) have been proposed as a potential pathophysiological substrate. Hence, the aim of the present study was to evaluate the prevalence of myocardial bridging and LAD recurrent segments in a large cohort of patients with TC. A total of 161 patients with TC were matched for age and gender with 161 controls without coronary artery or valvular heart disease. Myocardial bridging was diagnosed according to indirect signs in coronary angiography. Furthermore, the LAD was evaluated regarding parts of the vessel outreaching the left ventricular apex (LAD recurrent segment). The prevalence of myocardial bridging was similar in the TC and control groups (11.8% vs 6.8%, p = 0.18). Any part of the LAD outreaching the left ventricular apex was observed in 55.6% of patients with TC compared with 35.4% in the control population (p <0.001). Moreover, the LAD supplied ≥ 25% of the inferior myocardial wall in 21 patients with TC (13.1%), whereas patients in the control group did not show this pattern of coronary circulation at all (p <0.001). Patients with TC with typical apical ballooning compared with those with atypical ballooning patterns demonstrated a higher prevalence of myocardial bridging (p = 0.04) but not LAD recurrent segments (p = 0.28). In conclusion, the prevalence of myocardial bridging in patients with TC is low and comparable with that in a matched control group. In contrast, LAD recurrent segments are significantly more frequent in patients with TC.

A randomized study of the effect of carbonated water prior to myocardial SPECT.

In myocardial perfusion single-photon emission computed tomography (SPECT), abdominal activity often interferes with the evaluation of perfusion in the inferior wall, especially after pharmacological stress. In this randomized study, we examined the effect of carbonated water intake versus still water intake on the quality of images obtained during myocardial perfusion images (MPI) studies. A total of 467 MIBI studies were randomized into a carbonated water group and a water group. The presence of intestinal activity adjacent to the inferior wall was evaluated by two observers. Furthermore, a semi-quantitative analysis was performed in the adenosine subgroup, using a count ratio of the inferior myocardial wall and adjacent abdominal activity. The need for repeated SPECT in the adenosine studies was 5.3% in the carbonated water group versus 19.4% in the still water group (p = 0.019). The inferior wall-to-abdomen count ratio was significantly higher in the carbonated water group compared to the still water group (2.11 ± 1.00 vs. 1.72 ± 0.73, p < 0.001). The effect of carbonated water during rest and after exercise was not significant. This randomized study showed that carbonated water significantly reduced the interference of extra-cardiac activity in adenosine SPECT MPI.

Congenital absence of the pericardium

A 71-year-old male presented with atypical chest pain and dilatation of the right ventricle on echocardiography and was referred for cardiac magnetic resonance imaging (CMR) for suspected arrhythmogenic right ventricular cardiomyopathy. CMR showed marked posterior and leftward displacement of the heart, with the apex extending to the left lateral chest wall. Spin echo imaging showed thin pericardium around the atria and great vessels, but no pericardium was detected around the ventricles (Fig. 1). Lung tissue was interpositioned between the heart and the left hemidiaphragm (Fig. 2). Both ventricles had normal morphology and function. Fig. 1 Spin echo study showing pericardium around the right atrium (black arrow), but lack of pericardium around the right ventricle (white arrow) Fig. 2 Still frames from steady state free precession cine loop showing lung tissue interposition between the inferior myocardial wall and the diaphragm (white arrow). Original cine loops published online (Movie 1) Patients with congenitally absent pericardium may be asymptomatic or may present with chest pain or dyspnoea [1]. Electrocardiography may show right bundle branch block or clockwise rotation. Chest X-ray may show the left lateral position of the heart and the abnormal interposition of lung tissue between the aorta and pulmonary artery or between the inferior myocardial wall and the left hemidiaphragm. On echocardiography, the right ventricle may appear enlarged, as the beam traverses the ventricle closer to the basis of the heart and tangentially [2]. The diagnosis can be confirmed by computed tomography or CMR by showing (partial) absence of the pericardium. CMR may show excessive cardiac mobility. In incomplete defects, a rim of residual pericardium may cause a left ventricular crease, with (fatal) herniation as a rare potential risk, for which preventive closure has been suggested. Complete forms only need intervention in case of symptoms [3, 4].