Scar Percentage Research Articles

Post-surgical scar assessment in rehabilitation: a systematic review

Abstract Manual therapies are frequently recommended to improve post-surgical scar pliability, e.g., its elasticity and glide capacity with respect to the underlying tissue. A significant percentage of scars are pathological, causing

Climate and land-use effects on wildfire in northern Mexico, 1650–2010

Characterizing climate controls on fire regimes, and disentangling the effects of human relative to climate influences, has been difficult in forests of the western U.S. due to the nearly ubiquitous legacy of fire exclusion that began in the middle to late 19th century. However, the Sierra San Luis of northern Mexico, just across the border from Arizona and New Mexico, offers an opportunity to examine the influence of climate and land-use on fire history largely without the effects of modern fire exclusion. Pine forests in portions of the Sierra San Luis remain ungrazed and unlogged to this day, while other portions of the Sierra were not logged until ca. 1952–1954 or grazed until the early 1930s. Historical and modern fire regimes closely reflect these differences in land-use through time. Fires were relatively frequent in all sites until 1932, but continued at high frequency only in the sites without grazing or logging. Notably, the influence of drought and antecedent conditions for fires changed over time. From 1650 to 1886 (early period), fires occurred during drought years, with little influence of climate in antecedent years. However, from 1887 to 2003 (modern period), drought in the year of fire became generally unimportant and fires instead occurred following wet years. Above-average precipitation promotes accumulation of fine fuels, which apparently has been the primary constraint on fire ignition and spread in this semi-arid ecosystem during the modern period. Percentage of scarring aligned with multi-year fluctuations in Palmer Drought Severity Index (PDSI), with higher percent scarring in wet periods (X‾=19.371) and lower scarring in dry periods (X‾=13.778). Native American burning was not an important driver of past fire frequency, even though the study area lies within the historical homeland of the Chiricahua Apache people. We found no change in frequency of fires when Apaches were effectively removed in 1886. Climatic controls, rather than Apache wartime and peacetime periods, more easily explain changes in frequency over time. Projected increases in climate variability in the Southwest highlight the need to understand antecedent climate conditions conducive to fire occurrence in fuel-limited systems, including comparisons of historical to current climate–fire relationships. The relict forests of the Sierra San Luis, where fires continue to burn today with only minimal human interference, provide a rare look at these relationships.

PT406 Incidental findings are common in CT scans performed prior to atrial fibrillation ablation

Introduction: Left ventricular (LV) ejection fraction (EF), LV end systolic volume (LVESV) and scar size are well described predictors of adverse cardiovascular events post myocardial infarction (MI). Objectives: The purpose of this study was to evaluate the relationship between early reduction in LVEF, scar size and altered diastolic function. Methods: Acute STEMI patients (n1⁄4101), treated with percutaneous coronary intervention, were prospectively enrolled (May 2012 to February 2013). Transthoracic echocardiograms (TTE) were performed at 5 3 days (baseline) and 60 14 days (follow up) post STEMI. LVESV, LVEF, and LV diastolic parameters: (diastolic function grade: 01⁄4normal; 11⁄4impaired relaxation; 21⁄4pseudonormal; and 31⁄4restrictive filling, E/E’ ratio, E/A ratio, and deceleration time) were measured from TTE. CMRI with delayed gadolinium enhancement images was used to assess scar size at follow-up. Results: 101 consecutive patients (mean age 56 10 years; 90% males) were recruited. 15.8% had diabetes mellitus; 85% were first presentation of MI. Mean LVEF was 45.3 9.1% (baseline) and 49.2 10.8% (follow up). Twenty-one patients underwent negative remodelling (had a reduction in LVEF from baseline: Group 1). This group had significantly lower E’ (p1⁄40.014), larger E/E’ ratio (p1⁄40.010) and LVESV (p1⁄40.012) at follow-up compared with the group in whom LVEF remained unchanged or improved (Group 2). Negative remodelling was also associated with worse diastolic function grade, and a higher percentage with restrictive filling {Group 1 9/21 (42.8%) vs. Group 2 6/79 (7.5%)} at follow-up. Furthermore, change in LVEF correlated with CMRI scar percentage (R1⁄4 -0.264, P1⁄40.008) and scar volume (R1⁄4 -0.219, P1⁄40.028) at follow-up, such that reduction in LVEF from baseline was present in those with greater scar size. Conclusion: Early LV remodelling changes post STEMI, demonstrated by a reduction in LVEF from baseline, is a predictor for worsening diastolic dysfunction, and is associated with larger scar size. Early LV remodelling changes may contribute useful clinical information to help identify patients at higher risk post-MI. Longer term outcome data will help to further elucidate its prognostic value. Disclosure of Interest: None Declared CT average S-C 4.26 0.001 0.89

Scar extent as a predictive factor of ventricular tachycardia cycle length after myocardial infarction: implications for implantable cardioverter-defibrillator programming optimization

After an old myocardial infarction (MI), patients are at risk for reentrant ventricular tachycardia (VT) due to scar tissue that can be accurately identified by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Although the ability of LGE-CMR to predict sustained VT in implantable cardioverter-defibrillator (ICD) recipients has been well established, its use to predict monomorphic VT (sustained or not) cycle length (CL) and so, optimize ICD programming has never been investigated. We included retrospectively 49 consecutive patients with an old MI who had undergone LGE-CMR before ICD implantation over a 4-year period (2006-09). Patients with amiodarone used were excluded. Scar extent was assessed by measuring scar mass, percent scar, and transmural scar extent. The endpoint was the occurrence of monomorphic VT, requiring an ICD therapy or not. The endpoint occurred in 26 patients. The median follow-up duration was 31 months. Scar extent parameters were significantly correlated with the study endpoint. With univariate regression analysis, the scar mass had the highest correlation with the VT CL (R = 0.671, P = 0.0002). Receiver-operating characteristic curve showed that scar mass can predict VT CL (area under the curve = 0.977, P < 0.0001). For a cut-off value of scar mass at 17.6 g, there is 100% specificity and 94.4% sensitivity. In this observational and retrospective study, scar mass studied by LGE-CMR was specific and sensitive to predict VT CL and so could be a promising option to improve ICD post-implantation programming and decrease appropriate and inappropriate shocks. These conclusions must now be confirmed in a large and prospective study.

Comparison of Three-Dimensional Echocardiographic Findings to Those of Magnetic Resonance Imaging for Determination of Left Ventricular Mass in Patients With Ischemic and Non-Ischemic Cardiomyopathy

The standard echocardiographic evaluation of left ventricular (LV) mass, particularly in ischemic cardiomyopathy (IC) is challenging because it is based on geometric assumptions. The aim of this study was to assess the accuracy of LV mass calculation using echocardiographic modalities compared with cardiac magnetic resonance (CMR) in IC and in nonischemic cardiomyopathy (non-IC). Echocardiography was performed in 104 patients (mean age 55 ± 15 years) referred for CMR: 63 with IC and 41 with non-IC. CMR, M-mode echocardiography, 2-dimensional echocardiography, and 3-dimensional echocardiography (3DE) were analyzed using standard commercial tools to obtain LV mass. LV mass on 3DE showed a higher correlation with CMR than 2-dimensional echocardiography (r = 0.87 vs r = 0.70, p <0.001). M-mode echocardiography overestimated LV mass (bias +30%) and 2-dimensional echocardiography underestimated LV mass (bias -11%), whereas measurements on 3DE showed only minimal bias (-2%). LV mass on 3DE in non-IC showed a significantly higher correlation with CMR than in IC (r = 0.92 vs r = 0.84, z = 2.3, p <0.05). In non-IC, the mean difference was -2 g (-1% of the mean), with 95% limits of agreement of ±33 g (±19% of the mean). In IC, the mean difference was -7 g (-4% of the mean), with limits of agreement of ±56 g (±31% of the mean). There was a correlation between the absolute LV mass differences (3DE derived and CMR derived) and scar percentage (infarcted mass/total LV mass) using delayed-hyperenhancement images (r = 0.40, p <0.05). The net reclassification index with 3DE was +16% for concentric LV hypertrophy. In conclusion, the most accurate and reliable echocardiographic measurement of LV mass is 3DE, but underestimation and variability remain challenges in IC.

Validation of sub‐segmental visual scoring for the quantification of ischemic and nonischemic myocardial fibrosis using late gadolinium enhancement MRI

To determine the accuracy and reproducibility of late gadolinium enhancement (LGE) MRI scar quantification using visual sub-segmental analysis (VSSA) versus signal threshold-based analysis in ischemic and nonischemic cardiomyopathy. One-hundred sixty-one patients with abnormal LGE imaging underwent VSSA and signal threshold-based analysis. VSSA was performed using a 68 sub-segmental model. Signal threshold-based analysis was performed using cutoffs of ≥2, ≥3, and ≥5 standard deviations (SD) above the mean signal of normal myocardium. Comparison of VSSA and signal threshold-based analysis was performed by linear regression and Bland Altman plots. Seventy (44%) patients had ischemic scar, 76 (47%) had nonischemic scar, and 15 (9%) had a combined pattern. Correlation coefficients for VSSA versus signal threshold-based analysis at ≥2, ≥3, and ≥5SD thresholds were r = 0.63, r = 0.79, r = 0.81 (P < 0.001) for all patients, r = 0.74, r = 0.81, r = 0.81 (P < 0.001) in those with ischemic scar, and r = 0.46, r = 0.69, r = 0.72 (P < 0.001) in those with nonischemic scar. Bland Altman analysis revealed no significant bias in total scar volume among all patients (-4.3 ± 7.9%), those with ischemic scar (-4.8 ± 7.8%), or those with nonischemic scar (-2.6 ± 7.6%). Intra-observer and inter-observer variability of the VSSA technique was excellent with a mean difference in total percent scar of 0.3% (-8.3-8.9%) and -0.4% (-9.5-8.5%), respectively. A VSSA-based model of myocardial scar quantification is accurate and reproducible in ischemic and nonischemic cardiomyopathy.

Scar extent evaluated by late gadolinium enhancement CMR: a powerful predictor of long term appropriate ICD therapy in patients with coronary artery disease.

BackgroundCoronary artery disease (CAD) patients are at risk for life-threatening ventricular arrhythmias (VA) related to scar tissue. Late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) can accurately identify myocardial scar extent. It has been shown that scar extent, particularly scar transmurality, percent scar and scar mass, are associated with the occurrence of appropriate implantable cardioverter-defibrillator (ICD) therapy. However, quantification of transmurality extent has never been studied. The purpose of our study was to evaluate whether different methods quantifying scar transmurality, percent scar and scar mass (assessed with LGE-CMR) can predict appropriate ICD therapy in CAD patients with a long term follow-up period.Methods and resultsWe enrolled retrospectively 66 patients with chronic CAD referred for primary or secondary preventive ICD implantation and LGE-CMR before ICD implantation. Using LGE-CMR, scar extent was assessed by measuring scar mass, percent scar and transmural scar extent using four different methods. The median follow-up duration was 41.5 months (interquartile range 22–52). The endpoint was the occurrence of appropriate device therapy and occurred in 14 patients. Pre-ICD revascularization and transmural scar extent were significantly associated with the study endpoint but the latter was especially highly dependent on the method used. Patients with appropriate device therapy had also larger scar mass (29.6 ± 14.5 g vs 17.1 ± 8.8 g, p = 0.004), and larger percent scar (15.1 ± 8.2% vs 9.9 ± 5.6%, p = 0.03) than patients without appropriate device therapy. In multivariate analysis, scar extent variables remained significantly associated with the study end-point.ConclusionsIn this study of CAD patients implanted for primary or secondary preventive ICD, pre-ICD revascularization and scar extent studied by LGE-CMR were significantly associated with appropriate device therapy and can identify a subgroup of CAD patients with an increased risk of life-threatening VA. Depending of the method used, transmural scar extent may vary significantly and needs further studies to obtain a validated and consensual study method.

Apical ventricular tachycardia morphology in left ventricular nonischemic cardiomyopathy predicts poor transplant-free survival

The scar of patients with left ventricular (LV) nonischemic cardiomyopathy (NICM) and ventricular tachycardia (VT) typically originates at or near the mitral annulus and extends a variable distance toward the apex. To determine whether electrocardiograms of VT with LV apical exit sites would identify patients with larger scars extending a greater distance from the base toward the apex and decreased heart transplant/left ventricular assist device (LVAD)-free survival. Consecutive patients with LV NICM undergoing VT ablation between May 2008 and April 2011 were studied. All electrocardiograms of spontaneous and induced VT were analyzed. Apical VT was defined as left bundle branch morphology with precordial transition ≥ V5 or right bundle branch morphology with precordial transition ≤ V3. Scar percentage was defined as the area of low voltage divided by the total surface area. Thirty-two of 76 patients had 1 or more apical VTs. Those with apical VTs had larger percentage of endocardial and epicardial bipolar scars (14.9% vs 8.1%, P = .01, and 15.5% vs 5.5%, P = .03, respectively), scar that, although originating from the periannular region (94.7% of the patients), was more likely to extend apically beyond the basal half (48.3% vs 24.4%, P = .05 endocardial, and 85.7% vs 25.9%, P = .07 epicardial), and worse transplant/LVAD-free survival during a mean follow-up of 332 days (P = .006). Patients with NICM and apical VTs have larger voltage abnormality extending as contiguous or patchy "scar" from the base further toward the apex and worse transplant/LVAD-free survival. Particular attention should be paid to optimal heart failure management in these patients, with more guarded prognosis.

Left Ventricular Scar Burden Specifies the Potential for Ventricular Arrhythmogenesis: An LGE‐CMR Study

The extent of left ventricular (LV) scar, characterized by late gadolinium enhancement cardiac MRI (LGE-CMR), has been shown to predict the occurrence of ventricular arrhythmias in implantable cardioverter defibrillator (ICD) recipients. However, the specificity of LGE-CMR for sudden cardiac death (SCD) versus non-SCD is unclear. The aim of this retrospective, observational study was to evaluate this relationship in a cohort of ICD recipients. We included consecutive patients who had undergone LGE-CMR before ICD implantation over a 4-year period (2006-2009). Scar (defined as myocardium with a signal intensity ≥50% of the maximum in scar tissue) was characterized in terms of percent scar and number of transmural LV scar segments in a 17-segment model. The endpoints were appropriate ICD therapy and all-cause mortality. Sixty-four patients (average age 66 ± 11 years, 51 male, median LVEF 30%) were included. During 42 ± 13 months follow-up, appropriate ICD therapy occurred in 28 patients (44%), and 14 patients (22%) died. Number of transmural scar segments (P = 0.005) and percentage LV scar (P = 0.03) were both significantly associated with appropriate ICD therapy. However, neither number of transmural scar segments (P = 0.32) or percent LV scar (P = 0.59) was significantly associated with all-cause mortality. In this observational study, in medium-term follow-up, the extent of LV scar characterized by LGE-CMR was strongly associated with the occurrence of spontaneous ventricular arrhythmias but not all-cause mortality. We hypothesize that scar quantification by LGE-CMR may be more specific for SCD than non-SCD, and may prove a valuable tool for the selection of patients for ICD therapy.

Survival in Patients With Severe Ischemic Cardiomyopathy Undergoing Revascularization Versus Medical Therapy

The value of assessment of viability as a predictor of surgical revascularization benefit in ischemic cardiomyopathy has recently been questioned in a large trial. We sought to determine whether the contribution of viability as myocardial scar burden (SB) to predict revascularization outcomes could be modulated by end-systolic volume index (ESVi). Delayed hyperenhancement-MRI was obtained in 450 patients with ≥70% stenosis in ≥1 epicardial coronary artery (75% men; median age, 62.8 ± 10.7 years; mean left ventricular ejection fraction, 23 ± 9%; mean ESVi, 115 ± 50 mL) from 2002 to 2006. SB was quantified as scar percentage (infarcted mass/total left ventricular mass). Subsequent surgical revascularization was performed in 245 (54%) patients and subsequent percutaneous coronary interventions were performed in 28 (6%) patients. A propensity score was developed for revascularization. Cox proportional hazards models of all-cause mortality were used for risk adjustment. Over a mean follow-up of 5.8 ± 2.7 years, 186 (41%) deaths occurred. After adjusting for prior revascularization, sex, diabetes, age, use of cardiac resynchronization therapy, implantable cardioverter defibrillator, mitral regurgitation, and mitral valve procedures; an interaction between scar percentage and ESVi (P=0.016) and an interaction between post-MRI revascularization and ESVi (P=0.0017) were independently associated with mortality. ESVi demonstrated a significant interaction with revascularization and female sex, such that enhanced survival was associated with ESVi. ESVi also showed an interaction with SB; better survival was associated with lower volumes and less scar. ESVi and SB provide independent, incremental prognostic value in patients with severe ischemic cardiomyopathy. The risk associated with SB should not be assessed in isolation.

Relationship between myocardial scar and hypertrophy by LGE CMR in hypertrophic cardiomyopathy patients with and without clinical events

Summary The purpose of this study was to investigate the relationship between the extent of hyperenhancement and left ventricle maximal wall thickness (mWT) detected by LGE CMR and clinical events of nonsustained ventricular tachycardia (NSVT), implantation of cardioverter defibrillator (ICD) or diastolic heart failure in HCM patients that underwent LGE CMR. Background Late gadolinium enhancement cardiac magnetic resonance (LGE CMR) imaging has been used to detect myocardial hypertrophy and scar/fibrosis in Hypertrophic cardiomyopathy (HCM) patients. The presence of hyperenhancement has been associated with progressive ventricular dilation, ventricular arrhythmias and clinical risk factors for sudden cardiac death. Methods Under IRB approved protocol a total of 82 HCM patients underwent LGE CMR images using a 2D PSIR TurboFLASH protocol after administration of 0.2 mmol of gadopentetate dimeglumine per kilogram of body weight. The presence of LGE was assessed using automated software: percentage of scar and maximal wall thickness were calculated. Percentage of scar was compared between patients with mWT <2.5 cm and ≥2.5cm The mean values of percentage scar and mean maximal wall thickness between patients with/ without clinical events (presence of NSVT, placement of ICD or development of diastolic heart failure) were compared. Results

Myocardial deformation (strain) measured by DENSE reliably detects myocardial scar

Summary The purpose of this study was to explore the differences in myocardial deformation by DENSE determined in healthy myocardium and in segments variously affected by myocardial infarction. There was a significant difference in both radial and circumferential strain between normal and infarcted myocardium. Background The purpose of this study was to explore the differences in myocardial deformation by DENSE determined in healthy myocardium and in segments variously affected by myocardial infarction. There was a significant difference in both radial and circumferential strain between normal and infarcted myocardium. Methods By using a 1.5T scanner have 68 patients with a high likelihood of coronary artery disease been included. The following MRI protocol was used: cine SSFP, single slice multiphase Displacement ENcoding with Stimulated Echoes (DENSE) during breath holding, perfusion during adenosine stress and at rest and late gadolinium enhancement. Ejection fraction was calculated from the short axis cine and wall motion was assessed in terms of normal, hypokinetic, akinetic and dyskinetic according to guidelines. Perfusion was assessed as normal or reduced in parts of the thickness of the wall. Late gadolinium enhancement was also graded in terms of transmurality (scar percentage of the wall thickness). All measurements were applied to segments of the AHA seventeen segment model, excluding the apical cap. DENSE post processing was performed with an in-house developed software calculating radial strain and circumferential strain. Healthy myocardium was determined if scar was absent and, wall motion and perfusion were normal (n=11). Significant myocardial infarction was defined as positive gadolinium enhancement in excess of fifty percent wall thickness (n=27). Segments were aggregated according to the coronary perfusion territories. Results Data are shown for healthy/scared areas (p<0.0005). LCX area: radial strain 23% / 15%, circumferential strain was -11%/ -4% RCA area: radial strain 24% / 18%, circumferential strain -10% / -6%. LAD area: radial strain 20% / 10% and circumferential strain -10% / -4%. The means and the standard deviation is shown in fig.1. The standard deviation in the strain values for the infarcted vessel areas depend on the added segments and the 50% cut-off value for transmurality. Conclusions Myocardial infarction more than 50% transmurality can be identified by strain measurements using DENSE.

Highlights of Thirty-Year Experience of Laser Use at the Florence (Italy) Department of Dermatology

The CO2 laser has been used extensively in dermatological surgery over the past 30 years and is now recognised as the gold standard for soft tissue vaporization. Considering that the continuous wave CO2 laser delivery system and the newer “superpulsed” and scanned CO2 systems have progressively changed our practice and patient satisfaction, a long range documentation can be useful. Our experience has demonstrated that the use of CO2 laser involves a reduced healing time, an infrequent need for anaesthesia, reduced thermal damage, less bleeding, less inflammation, the possibility of intra-operative histologic and/or cytologic examination, and easy access to anatomically difficult areas. Immediate side effects have been pain, erythema, edema, typically see with older methods, using higher power. The percentage of after-treatment keloids and hypertrophic scars observed was very low (~1%) especially upon the usage of lower parameters. The recurrence of viral lesions (condylomas and warts) have been not more frequent than those due to other techniques. Tumor recurrence is minor compared with radiotherapy or surgery. This method is a valid alternative to surgery and/or diathermocoagulation for microsurgery of soft tissues. Our results are at times not consistent with those published in the literature, stressing the concept that multicentric studies that harmonization methodology and the patient selection are vital.

Sustainable effect of skin stretching for burn scar excision: Long-term results of a multicenter randomized controlled trial

Purpose Primary wound closure of large defects after burn scar excision may be facilitated by intraoperative stretching of the adjacent skin. In a randomized controlled trial (RCT), the effect of skin stretching for wound closure after scar excision (SS) was compared to scar excision without additional techniques (SE). Short-term results already showed that in the SS group larger scars could be excised in a one-step procedure. In this paper, the long-term scar outcome using reliable and valid measurement tools was evaluated. Basic procedures The percentage of total remaining scar area (i.e. remaining scar compared to preoperative scar), the percentage of linear scarring (i.e. surface area of linear scar compared to excised scar) and scar hypertrophy was measured at 3 and 12 months postoperatively. Main findings At 12 months postoperatively, the percentage of total remaining scar area was significantly lower in the SS group (26%) compared to the SE group (43%). The percentage of linear scarring (SS: 21%, SE: 25%) and the incidence of hypertrophy (SS: 29%, SE: 40%) were not significantly different between the treatment groups. Conclusions This RCT demonstrates the long-term beneficial and sustainable effect skin stretching for wound closure after scar excision without leading to wider linear scars or more scar hypertrophy.

Burn scar pleomorphic sarcoma—case report

Malignant transformation in burn scars was formally described by Jean-Nicholas Marjolin in 1828, although there are reports that this phenomenon had been first noted by Celsus in the first century A.D. The term Marjolin’s ulcer (MU) is used to denote the malignancies, predominantly squamous cell carcinomas, which develop in scars and chronic wounds [1–3]. The burned area, especially those which healed by secondary intention, is at risk of injury by daily activities because their coverage differs from normal skin, with reduced elasticity and hydration. The main factors that predispose to malignant transformation are: time of evolution, injury and constant irritation, chronic infection, poor hygiene habits, and environmental factors [1–3]. The percentage of scars that progress to malignancy is estimated at 2%, where squamous cell carcinoma is the most common histological type, followed by basal cell carcinoma and melanoma. Sarcomas, however, are rarely described [4–8]. The aim of this paper is to report a case of undifferentiated pleomorphic sarcoma in a burn scar treated at our service.

Scarring, disfigurement, and quality of life in long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study.

9038 Background: Survivors of childhood cancer are at risk for a host of chronic and often debilitating medical conditions. Less studied and understood late effects are treatment-related scarring, disfigurement and persistent hair loss, and their impact on the survivor’s health related quality of life. Methods: The prevalence of bodily scarring and persistent hair loss was examined in 14,358 survivors (63.5% ≥ 20 yrs old; 53.7% male) and 4,023 siblings from the Childhood Cancer Survivor Study cohort. Multivariable models were used to examine associations with demographic and cancer treatment variables. A subset of 7,178 survivors who completed a subsequent survey was used to evaluate the impact of disfigurement and hair loss on quality of life and emotional distress. Results: The percentage of self-reported scarring and disfigurement was significantly higher for survivors compared to siblings across all sites (all p-values <0.001) including head/neck (25.1% vs. 8.4%), arms/legs (18.3% vs. 10.2%), chest/abdomen (38.1% vs. 9.2%) and persistent hair loss (14.0% vs. 6.3%). In age-, sex-, and race-adjusted models, cranial radiation exposure ≥ 36 Gy increased the risk for head/neck disfigurement (RR 2.50; 95% CI 2.29-2.73) and persistent hair loss (RR 4.81; 95% CI 4.12-5.63). In survivors, persistent hair loss increased risk of depression (RR 1.38; 95% CI 1.12-1.70), anxiety (RR 1.63; 95% CI 1.26-2.12) and somatization (RR 1.42; 95% CI 1.18-1.71). Head/Neck disfigurement increased risk for somatization (RR 1.24; 95% CI 1.07-1.44). Reported limitations in daily functioning due to emotional symptoms was associated with head/neck disfigurement (p<0.001), arm/leg disfigurement (p=0.003) and persistent hair loss (p=0.001), controlling for sex, age, and cranial radiation therapy. Conclusions: Survivors of childhood cancer are at increased risk for disfigurement and persistent hair loss, which is associated with future emotional distress and reduced quality of life. Interventions facilitating coping skills and emotional adjustment, and management strategies for these sequelae may be warranted for survivors with these physical symptoms.

The Extent of Left Ventricular Scar Quantified by Late Gadolinium Enhancement MRI Is Associated With Spontaneous Ventricular Arrhythmias in Patients With Coronary Artery Disease and Implantable Cardioverter-Defibrillators

Characterization of sudden cardiac death (SCD) risk remains a challenge in the application of implantable cardioverter-defibrillator (ICD) therapy. Late gadolinium enhancement cardiac MRI (LGE-CMR) can accurately identify myocardial scar. We performed a retrospective, single-center observational study to evaluate the association between the extent and distribution of left ventricular scar, quantified using LGE-CMR, and the burden of ventricular arrhythmias in patients with coronary artery disease and ICDs. All patients included (2006 to 2009) had undergone LGE-CMR before ICD implantation. Scar (defined as myocardium with a signal intensity ≥50% of the maximum in scar tissue) was characterized in terms of percent scar, scar surface area, and number of transmural left ventricular scar segments. The end point was appropriate ICD therapy. Sixty-four patients (mean age, 66±11 years; male sex, 51) were included. During 19±10 months follow-up, appropriate ICD therapy occurred in 19 (30%) patients. In Cox regression analyses, both percent scar (hazard ratio per 10%, 1.75; 95% CI, 1.09 to 2.81; P=0.02) and number of transmural scar segments (hazard ratio per segment, 1.40; 95% CI, 1.15 to 1.70; P=0.001) were significantly associated with the occurrence of appropriate ICD therapy. In this pilot study, the extent of myocardial scar characterized by LGE-CMR was significantly associated with the occurrence of spontaneous ventricular arrhythmias. We hypothesize that scar quantification by LGE-CMR may prove a valuable risk stratification tool for the occurrence of ventricular arrhythmias, which may have implications for patient selection for ICD therapy.

ASSESSMENT OF GLOBAL AND REGIONAL STRAIN IN RELATION TO INFARCT SIZE AND LOCATION USING FEATURE TRACKING MAGNETIC RESONANCE IMAGING IN PATIENTS WITH MYOCARDIAL INFARCTION

Background: Feature tracking (FT-MRI) is a novel method for assessment of myocardial strain that provides multi-planar strain data without the need for tagged images. The goal of our study was to characterize left ventricular (LV) global and regional strains in patients with prior myocardial infarction (MI) using FT-MRI. Methods: Eighty patients with prior MI were grouped by infarct location {left anterior descending (LAD), left circumlex (LCx), right coronary (RCA)}. Scar quantiication was done by computer-assisted planimetry (Medis Qmass v7.2) of gadolinium enhanced delayed images and scar percentage was determined. Global and regional circumferential endocardial (Ecc endo) and epicardial (Ecc epi) and longitudinal (Ell) strains were derived from long and short axis planes. Semi-automated tracing of endocardial and epicardial borders using FT-MRI (Diogenes MRI, Tomtec Systems) was performed and strains were mapped to a 17 segment AHA model. Repeated measures ANOVA was used to compare normal strain values from 60 healthy subjects to MI patients controlling for scar percentage. Results: The mean age was 64.4(12) years, mean ejection fraction (EF) 42(11)% and mean scar percentage 17(9)%. Peak global Ecc strains were decreased in LAD (endo: -13.7 (5)%, epi: -8.4 (3)%) and RCA infarcts (endo: -16.1(6)%, epi: -9.6%) compared to normals (Ecc endo= -24 (4)%, Ecc epi= -16.1 (3)%, all with p<0.001). However, only peak global Ecc epi was decreased in LCX infarcts (LCx= -10.6 (3)%, p=0.01) compared to normals . Peak global Ell strain was reduced in LAD infarcts (-9.4 (3)% vs -16.2(5)% in normals, p=0.04) but was not signiicantly reduced in other infarcts {LCx MI: -10.2 (5)%, RCA MI: -14.7 (5)%, p=NS}. The best correlate of reduced LVEF in MI patients was reduced global Ecc Endo (r =0.82, p<0.0001), followed by global Ecc Epi (r=0.64, p <0.0001), scar territory percent (r=0.53, p<0.0001) and global Ell (r=0.43, p< 0.0001). Conclusion: FT-MRI permits detailed assessment of global and regional strains in patients with MI. Global Ecc was decreased in all MI patients, while Ell was reduced only in LAD infarcts. The best correlate of reduced LV EF was reduced global Ecc endo strain, which was superior to infarct size.

Myocardial scar sizing and characterization predicts ventricular arrhythmia in cardiac resynchronization therapy candidates

Methods A standard Contrast-enhanced Cardiac Magnetic Resonance (ce-CMR) was performed pre-implantation of CRT device in 78 cardiac heart failure patients (64±11 years) with ischemic and non-ischemic dilated cardiomyopathy. Systolic function was assessed by cine imaging. Myocardial scar was characterized by a standard 2D segmented gradient echo inversion-recovery sequence applied in sequential short axis slices. Total scar was expressed as percentage of LV mass and the core and border zone as percentage of total scar). Patients were followed every 6 months to look for appropriate ICD therapy episodes. Results During a mean follow up of 25 months (percentile 25 th 75 th =15-34 months), appropriate therapy of ICD devices occurred in 11.5% of patients. The analysis showed that the percentage of total scar was a strong predictor of VA (ventricular fibrillation or ventricular tachycardia) needing ICD therapy (HR 1.096 [1.053 to 1.143], p <0.001). In a Cox regression model adjusted for systolic function, etiology and type of prevention, the predictive value of the size of the scar remained unchanged (HR 1.156 [1.063 to 1.257], p = 0.001). The percentage of border zone of the scar was also associated with the occurrence of VA (HR 1.063 [1.022 to 1.101], p <0.001). However, the proportion of core was not significant (p = 0.662). The area under the ROC curve of total scar to predict VA was 0.94, and a cut-off value of <16% of LV mass had a 100% negative predictive value to exclude VA during follow-up. Conclusions In TRC candidates with dilated cardiomyopathy of any etiology the extent of myocardial scar and the proportion of border zone predict the occurrence of VA. Assessment of scar burden and scar characterization using ce-CMR may be helpful to decide when combined ICD/CRT devices are indicated among CRT candidates.

Effects of Endolithic Boring on the Muscle Scar and Growth of PinkHaliotis corrugata(Gray 1828)

ABSTRACT In Baja California, Mexico, pink abalone (Haliotis corrugala) banks have been found to be heavily infested by endolithic (boring) organisms, which damage the shell, reduce individual growth, and, in many cases, prevent the abalone from reaching the minimum legal size of capture (140 mm). Thus, the accumulation of endolithic borings has a negative impact on the fishery. Infested shells have a different appearance from healthy shells, decreasing their ornamental value. As the size of the muscle scar of pink abalone increases with age, we assume that endolithic infestation affects individual growth and produces adults of a smaller size than normal. The correlation among the degree of muscle scar development, shell length, and percent coverage by endolithic borings was determined. We identified five stages of muscle scar development and found a significant correlation between scar stages and percentage of endolithic boring coverage and shell length. This correlation may be an indication of the profou...