Bioprosthetic Valve Thrombosis and Obstruction Secondary to COVID-19.

Patients with COVID-19 may present a hypercoagulable state, with an important impact on morbidity and mortality. Because of this situation pulmonary embolism is a frequent complication during the course of infection. We present the case of a patient recently discharged, after admission with confirmed COVID-19, who developed a pulmonary embolism and thrombosis of a biological mitral valve prosthesis, producing valve obstruction and stenosis. After 15 days of anticoagulant treatment, resolution of the thrombus and normalisation of prosthetic valve function was observed. This case supports current recommendations of administering full-dose anticoagulation therapy to COVID-19 patients with biological heart valve prosthesis, even after the acute phase of infection.

Prognostic value of mean velocity at the pulmonary artery estimated by cardiovascular magnetic resonance as a prognostic predictor in a cohort of patients with new-onset heart failure with reduced ejection fraction.

BACKGROUND: Pulmonary hypertension (PH) conveys a worse prognosis in heart failure (HF), in particular when right ventricular (RV) dysfunction ensues. Cardiovascular magnetic resonance (CMR) non-invasively estimates pulmonary vascular resistance (PVR), which has shown prognostic value in HF. Importantly, RV to pulmonary artery (PA) coupling is altered early in HF, before significant rise in PV resistance occurs. The aim of this study was to assess the prognostic value of mean velocity at the pulmonary artery (mvPA), a novel non-invasive parameter determined by CMR, in HF with reduced ejection fraction (HFrEF) with and without associated PH. METHODS: Prospective inclusion of 238 patients admitted for new-onset HFrEF. MvPA was measured with CMR during index admission. The primary endpoint was defined as a composite of HF readmissions and all-cause mortality. RESULTS: During a median follow-up of 25 months, 91 patients presented with the primary endpoint. Optimal cut-off value of mvPA calculated by the receiver operator curve for the prediction of the primary endpoint was 9 cm/s. The primary endpoint occurred more frequently in patients with mvPA≤9 cm/s, as indicated by Kaplan-Meier survival curves; Log Rank 16.0, p <  0.001. Importantly, mvPA maintained its prognostic value regardless of RV function and also when considering mortality and HF readmissions separately. On Cox proportional hazard analysis, reduced mvPA≤9 cm/s emerged as an independent prognostic marker, together with NYHA III-IV/IV class, stage 3-4 renal failure and ischemic cardiomyopathy. CONCLUSIONS: In our HFrEF cohort, mvPA emerged as an independent prognostic indicator independent of RV function, allowing identification of a higher-risk population before structural damage onset. Moreover, mvPA emerged as a surrogate marker of the RV-PA unit coupling status.

Síndrome platipnea-ortodeoxia cardiaco: una causa «misteriosa» de hipoxemia / Cardiac platypnea-orthodeoxia syndrome: A «mysterious» cause of hypoxemia

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Prognostic Value of Pulmonary Vascular Resistance by Magnetic Resonance in Systolic Heart Failure / Valor Prognóstico da Resistência Vascular Pulmonar através de Ressonância Magnética em Insuficiência Cardíaca

Abstract Background: Pulmonary hypertension is associated with poor prognosis in heart failure. However, non-invasive diagnosis is still challenging in clinical practice. Objective: We sought to assess the prognostic utility of non-invasive estimation of pulmonary vascular resistances (PVR) by cardiovascular magnetic resonance to predict adverse cardiovascular outcomes in heart failure with reduced ejection fraction (HFrEF). Methods: Prospective registry of patients with left ventricular ejection fraction (LVEF) < 40% and recently admitted for decompensated heart failure during three years. PVRwere calculated based on right ventricular ejection fraction and average velocity of the pulmonary artery estimated during cardiac magnetic resonance. Readmission for heart failure and all-cause mortality were considered as adverse events at follow-up. Results: 105 patients (average LVEF 26.0 ±7.7%, ischemic etiology 43%) were included. Patients with adverse events at long-term follow-up had higher values of PVR (6.93 ± 1.9 vs. 4.6 ± 1.7estimated Wood Units (eWu), p < 0.001). In multivariate Cox regression analysis, PVR ≥ 5 eWu(cutoff value according to ROC curve) was independently associated with increased risk of adverse events at 9 months follow-up (HR2.98; 95% CI 1.12-7.88; p < 0.03). Conclusions: In patients with HFrEF, the presence of PVR ≥ 5.0 Wu is associated with significantly worse clinical outcome at follow-up. Non-invasive estimation of PVR by cardiac magnetic resonance might be useful for risk stratification in HFrEF, irrespective of etiology, presence of late gadolinium enhancement or LVEF.

Resumo Fundamento: A hipertensão pulmonar está associada a mau prognóstico em insuficiência cardíaca. No entanto, o diagnóstico não-invasivo é desafiador na prática clínica. Objetivo: Avaliar a utilidade prognóstica da estimativa não-invasiva das resistências vasculares pulmonares (RVP) medidas através de ressonância magnética cardiovascular na previsão de desfechos cardiovasculares adversos em insuficiência cardíaca com fração de ejeção reduzida (ICFEr). Métodos: Registro prospectivo de pacientes com fração de ejeção do ventrículo esquerdo (FEVE) < 40% internados recentemente por insuficiência cardíaca descompensada, durante três anos. As RVP foram calculadas com base na fração de ejeção do ventrículo esquerdo e velocidade média do fluxo na artéria pulmonar estimada por ressonância magnética cardíaca. Durante a evolução, reinternação por insuficiência cardíaca e mortalidade por todas as causas foram consideradas eventos adversos. Resultados: Foram incluídos 105 pacientes (FEVE média de 26,0 ± 7,7%, etiologia isquêmica em 43%). Os valores de RVP nos pacientes que apresentaram eventos adversos durante o seguimento em longo prazo foram mais altos (6,93 ± 1,9 versus 4,6 ± 1,7 unidades Wood estimadas (uWe), p < 0,001). Na análise de regressão multivariada de Cox, RVP ≥ 5 eWu (valor de corte segundo a curva ROC) mostrou-se independentemente associada a um maior risco de eventos adversos aos 9 meses de seguimento (RR = 2,98; IC 95% = 1,12-7,88; p < 0,03). Conclusões: Em pacientes com ICFEr, a presença de RVP ≥ 5,0 uW está associada a uma evolução clínica significativamente pior. A estimativa não-invasiva da RVP através de ressonância magnética cardíaca pode ser útil na estratificação de risco em ICFEr, independentemente da etiologia, presença de realce tardio pelo gadolínio ou FEVE.

Prognostic Value of Pulmonary Vascular Resistance by Magnetic Resonance in Systolic Heart Failure.

BACKGROUND: Pulmonary hypertension is associated with poor prognosis in heart failure. However, non-invasive diagnosis is still challenging in clinical practice. OBJECTIVE: We sought to assess the prognostic utility of non-invasive estimation of pulmonary vascular resistances (PVR) by cardiovascular magnetic resonance to predict adverse cardiovascular outcomes in heart failure with reduced ejection fraction (HFrEF). METHODS: Prospective registry of patients with left ventricular ejection fraction (LVEF) < 40% and recently admitted for decompensated heart failure during three years. PVR were calculated based on right ventricular ejection fraction and average velocity of the pulmonary artery estimated during cardiac magnetic resonance. Readmission for heart failure and all-cause mortality were considered as adverse events at follow-up. RESULTS: 105 patients (average LVEF 26.0 ± 7.7%, ischemic etiology 43%) were included. Patients with adverse events at long-term follow-up had higher values of PVR (6.93 ± 1.9 vs. 4.6 ± 1.7 estimated Wood Units (eWu), p < 0.001). In multivariate Cox regression analysis, PVR ≥ 5 eWu(cutoff value according to ROC curve) was independently associated with increased risk of adverse events at 9 months follow-up (HR2.98; 95% CI 1.12-7.88; p < 0.03). CONCLUSIONS: In patients with HFrEF, the presence of PVR ≥ 5.0 Wu is associated with significantly worse clinical outcome at follow-up. Non-invasive estimation of PVR by cardiac magnetic resonance might be useful for risk stratification in HFrEF, irrespective of etiology, presence of late gadolinium enhancement or LVEF.

Clinical benefit of cardiac resynchronization therapy with a defibrillator in patients with an ejection fraction > 35% estimated by cardiac magnetic resonance.

INTRODUCTION AND OBJECTIVES: Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35 estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance. METHODS: We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS ≥ to 120 ms, ejection fraction ≤ 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n=103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance. RESULTS: The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function ≤ 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups. CONCLUSIONS: We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction ≤ 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis.

Beneficio clínico de la terapia de resincronización cardiaca con desfibrilador para pacientes con fracción de eyección > 35 por ciento por resonancia magnética / Clinical benefit of cardiac resynchronization therapy with a defibrillator in patients with an ejection fraction > 35 percent estimated by cardiac magnetic resonance

Introducción y objetivos. La terapia de resincronización cardiaca con desfibrilador aumenta la supervivencia y mejora la calidad de vida en insuficiencia cardiaca avanzada. Tradicionalmente, se ha excluido a los pacientes con fracción de eyección > 35% calculada por ecocardiografía. Evaluamos el impacto pronóstico de dicha terapia en un grupo de pacientes con disfunción sistólica grave por ecocardiografía pero con fracción de eyección > 35% por resonancia magnética cardiaca. Métodos. Se analizaron los ingresos por insuficiencia cardiaca entre 2004 y 2011 en clase funcional II - IV , QRS >= 120 ms, fracción de eyección por ecocardiografía <= 35% y estudio de resonancia magnética cardiaca según protocolo local. Se incluyó a los pacientes (n = 103) con implante de dispositivo en prevención primaria. Se registró la incidencia de arritmias ventriculares, reingreso por insuficiencia cardiaca y mortalidad total. La muestra se dividió según la función sistólica por resonancia magnética fuera <= 35% o > 35%. Resultados. Ambos grupos mostraron mejoras comparables en clase funcional y fracción de eyección a los 6 meses. Se encontró una tendencia no significativa hacia mayor mortalidad total entre los pacientes con fracción de eyección <= 35% en el seguimiento a largo plazo. Al dividir la muestra por función sistólica y patrón de realce, encontramos que la presencia de necrosis identificaba a los pacientes con peor pronóstico de arritmias ventriculares y mortalidad total. Conclusiones. La terapia de resincronización cardiaca con desfibrilador proporcionó un beneficio clínico similar a los pacientes con función sistólica por resonancia resonancia magnética cardiaca <=35% y > 35%. El patrón de realce tardío de gadolinio aporta información adicional sobre riesgo arrítmico y pronóstico a largo plazo de estos pacientes (AU)

Introduction and objectives. Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35 estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance. Methods. We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS >= to 120 ms, ejection fraction <= 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n=103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance. Results. The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function <= 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups. Conclusions. We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction <= 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis (AU)

Gerbode-type left ventricular outflow tract to right atrial fistula complicating prosthetic aortic valve replacement identified by cardiac computed tomographic angiography.

Acquired left ventricular-right atrial communication (Gerbode-type defect) is a rare complication of infective endocarditis. Although transesophageal echocardiography remains the technique of choice for the evaluation of complications of endocarditis this case highlights the usefulness of cardiac computed tomography in this scenario, particularly in cases where assessment of coronary anatomy is required before surgery.

Diagnóstico etiológico de la disfunción ventricular izquierda con tomografía computarizada: comparación con coronariografía y cardiorresonancia / Etiological diagnosis of left ventricular dysfunction: computed tomography compared with coronary angiography and cardiac magnetic resonance

Introducción y objetivos. Evaluar la capacidad de la tomografía computarizada con multidetectores en el diagnóstico de la disfunción ventricular izquierda de origen coronario y valorar su exactitud diagnóstica comparándola con la combinación de coronariografía invasiva y resonancia magnética. Métodos. Se estudió a 40 pacientes consecutivos con disfunción ventricular izquierda de origen no filiado mediante coronariografía invasiva y resonancia con contraste. A todos ellos se les realizó además un estudio de tomografía computarizada con multidetectores incluyendo presencia de calcio coronario y su cuantificación, coronariografía y valoración tisular del miocardio. Resultados. La sensibilidad y la especificidad de la presencia de calcio coronario para identificar la disfunción ventricular izquierda de origen coronario fueron del 100 y el 31% respectivamente. Si se considera un score de calcio por Agatston>100, la especificidad sube al 58% manteniendo la sensibilidad del 100%. Los valores de sensibilidad y especificidad de la coronariografía por tomografía computarizada con multidetectores fueron del 100 y el 96% respectivamente; para la identificación de áreas de necrosis en la adquisición precoz, del 57 y el 100% y en la adquisición tardía, del 84 y el 96%. Para identificar a los pacientes coronarios con necrosis, la sensibilidad y la especificidad fueron del 92 y el 100% respectivamente. Conclusiones. De todas las herramientas diagnósticas disponibles en tomografía computarizada con multidetectores, la coronariografía es la que muestra mayor exactitud diagnóstica para determinar el origen coronario de la disfunción ventricular. La combinación del estudio coronariográfico y el estudio tisular del miocardio tras el contraste permite obtener en un solo examen información similar a la de la combinación de cateterismo y resonancia con contraste (AU)

Introduction and objectives. To evaluate the capability of multidetector computed tomography to diagnose the coronary etiology of left ventricular dysfunction compared with using invasive coronary angiography and magnetic resonance. Methods. Forty consecutive patients with left ventricular dysfunction of uncertain etiology underwent invasive coronary angiography and contrast magnetic resonance. All patients were evaluated with multidetector computed tomography including coronary calcium presence and score, noninvasive coronary angiography, and myocardial tissue assessment. Results. The sensitivity and specificity of the presence of coronary calcium to identify left ventricular dysfunction was 100% and 31%, respectively. If an Agatston calcium score of >100 is taken, specificity increases to 58% with sensitivity still 100%. Sensitivity and specificity for coronary angiography by multidetector computed tomography was 100% and 96%, respectively; for identifying necrosis in contrast acquisition it was 57% and 100%, respectively; and in late acquisition, 84% and 96%, respectively. To identify coronary ventricular dysfunction with necrosis, the sensitivity and specificity was 92% and 100%, respectively. Conclusions. Of all the diagnostic tools available in multidetector computed tomography, coronary angiography is the most accurate in determining the coronary origin of left ventricular dysfunction. A combination of coronary angiography and myocardial tissue study after contrast allows a single test to obtain similar information compared with the combination of invasive coronary angiography and contrast magnetic resonance (AU)

Etiological diagnosis of left ventricular dysfunction: computed tomography compared with coronary angiography and cardiac magnetic resonance.

INTRODUCTION AND OBJECTIVES: To evaluate the capability of multidetector computed tomography to diagnose the coronary etiology of left ventricular dysfunction compared with using invasive coronary angiography and magnetic resonance. METHODS: Forty consecutive patients with left ventricular dysfunction of uncertain etiology underwent invasive coronary angiography and contrast magnetic resonance. All patients were evaluated with multidetector computed tomography including coronary calcium presence and score, noninvasive coronary angiography, and myocardial tissue assessment. RESULTS: The sensitivity and specificity of the presence of coronary calcium to identify left ventricular dysfunction was 100% and 31%, respectively. If an Agatston calcium score of >100 is taken, specificity increases to 58% with sensitivity still 100%. Sensitivity and specificity for coronary angiography by multidetector computed tomography was 100% and 96%, respectively; for identifying necrosis in contrast acquisition it was 57% and 100%, respectively; and in late acquisition, 84% and 96%, respectively. To identify coronary ventricular dysfunction with necrosis, the sensitivity and specificity was 92% and 100%, respectively. CONCLUSIONS: Of all the diagnostic tools available in multidetector computed tomography, coronary angiography is the most accurate in determining the coronary origin of left ventricular dysfunction. A combination of coronary angiography and myocardial tissue study after contrast allows a single test to obtain similar information compared with the combination of invasive coronary angiography and contrast magnetic resonance.

Non-invasive assessment of coronary artery bypass grafts and native coronary arteries using 64-slice computed tomography: comparison with invasive coronary angiography.

INTRODUCTION AND OBJECTIVES: Although the diagnostic accuracy of CT in the non-invasive assessment of coronary arteries and grafts is known to be high, only a few studies have investigated the technique's reliability for the combined assessment of native coronary arteries, grafts, and vessels lying distal to anastomoses. The aim of this study was to evaluate the diagnostic accuracy of 64-slice CT for assessing coronary grafts and native coronary arteries. METHODS: In the study, 64-slice CT was used to evaluate 36 patients who had undergone coronary artery bypass graft surgery and had a clinical indication for angiographic graft assessment. The diagnostic accuracy of CT for identifying significant lesions in grafts and native coronary arteries was determined and compared with that of invasive coronary angiography. RESULTS: Of the 103 grafts studied (49 arterial and 54 venous), 96 (93.2%) could be visualized by angiography and 98 (95.1%) by CT. The sensitivity and specificity of CT for detecting significant lesions in grafts were 100% (30/30) and 97% (64/66), respectively, and the positive predictive value (PPV) and negative predictive value (NPV) were 94% and 100%, respectively. For non-revascularized coronary arteries (258 segments), the sensitivity, specificity, PPV and NPV were 94%, 95%, 80%, and 99%, respectively, and for distal vessels, 86%, 97%, 67%, and 99%, respectively. CONCLUSIONS: The diagnostic accuracy of 64-slice CT for evaluating both coronary grafts and native coronary arteries was high.

Valoración no invasiva de injertos aortocoronarios y coronarias nativas con tomografía computarizada de 64 detectores: comparación con la coronariografía invasiva / Non-invasive assessment of coronary artery bypass grafts and native coronary arteries using 64-slice computed tomography: comparison with invasive coronary angiography

Introducción y objetivos. Aunque la tomografía computarizada (TC) multidetector muestra una elevada exactitud diagnóstica en la valoración no invasiva de las arterias coronarias e injertos, son escasos los trabajos que valoren su fiabilidad en el estudio conjunto de vasos nativos, injertos y vasos distales a las anastomosis. El objetivo de este estudio es valorar la exactitud diagnóstica de la TC de 64 detectores en la valoración de injertos coronarios y arterias coronarias nativas. Métodos. Se estudia con TC de 64 detectores a 36 pacientes revascularizados quirúrgicamente e indicación clínica de evaluación angiográfica de sus injertos. Se analizó la exactitud diagnóstica de la TC para la detección de lesiones significativas en los injertos y coronarias nativas comparando sus resultados con los de la coronariografía invasiva. Resultados. De los 103 injertos referidos (49 arteriales y 54 venosos) se visualizaron 96 (93,2%) por coronariografía y 98 (95,1%) por TC. Los valores diagnósticos para los injertos mostraron una sensibilidad del 100% (30/30) y especificidad del 97% (64/66) y valores predictivos positivo (VPP) y negativo (VPN) del 94 y el 100%, respectivamente. Respecto a los vasos nativos no revascularizados (258 segmentos), se obtuvo sensibilidad del 94%, especificidad del 95%, VPP del 80% y VPN del 99%. La sensibilidad y la especificidad de la valoración de vasos distales fueron del 86 y el 97% respectivamente, con VPP del 67% y VPN del 99%. Conclusiones. La TC de 64 detectores presenta una alta exactitud diagnóstica en la valoración de los injertos coronarios y arterias coronarias nativas (AU)

Introduction and objectives. Although the diagnostic accuracy of CT in the non-invasive assessment of coronary arteries and grafts is known to be high, only a few studies have investigated the technique’s reliability for the combined assessment of native coronary arteries, grafts, and vessels lying distal to anastomoses. The aim of this study was to evaluate the diagnostic accuracy of 64-slice CT for assessing coronary grafts and native coronary arteries. Methods. In the study, 64-slice CT was used to evaluate 36 patients who had undergone coronary artery bypass graft surgery and had a clinical indication for angiographic graft assessment. The diagnostic accuracy of CT for identifying significant lesions in grafts and native coronary arteries was determined and compared with that of invasive coronary angiography. Results. Of the 103 grafts studied (49 arterial and 54 venous), 96 (93.2%) could be visualized by angiography and 98 (95.1%) by CT. The sensitivity and specificity of CT for detecting significant lesions in grafts were 100% (30/30) and 97% (64/66), respectively, and the positive predictive value (PPV) and negative predictive value (NPV) were 94% and 100%, respectively. For non-revascularized coronary arteries (258 segments), the sensitivity, specificity, PPV and NPV were 94%, 95%, 80%, and 99%, respectively, and for distal vessels, 86%, 97%, 67%, and 99%, respectively. Conclusions. The diagnostic accuracy of 64-slice CT for evaluating both coronary grafts and native coronary arteries was high (AU)

Late gadolinium enhancement-cardiovascular magnetic resonance identifies coronary artery disease as the aetiology of left ventricular dysfunction in acute new-onset congestive heart failure.

AIMS: We evaluated the ability of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance (CMR) to identify acute new-onset heart failure (HF) with left ventricular systolic dysfunction (LVSD), whether or not in relation to underlying coronary artery disease (CAD), in patients with no clinical evidence of associated ischaemic cardiomyopathy. METHODS AND RESULTS: Hundred consecutive patients admitted with acute new-onset decompensated HF and EF <40%, with no clinical or electrocardiographic data suggestive of CAD. The patients were classified according to the presence or absence of significant CAD (stenosis > or =70% in at least one major vessel). Twenty-one patients (21%) had significant CAD. Seventy-nine (79%) had no lesions. Eighteen of the 21 patients (85%) with CAD had subendocardial/transmural LGE. In the diagnosis of CAD, LGE has a sensitivity of 85.7% (95% CI, 80-91) and specificity of 92.4% (95% CI, 87-96), respectively, with a negative predictive value of 96% (95% CI, 90-99). It has an area under the receiver operating characteristic curve of 0.906 (95% CI, 0.814-0.998). CONCLUSION: In patients with new-onset HF and LVSD for whom there are no clinical and exploratory data suggestive of ischaemic heart disease, CMR with LGE is an excellent means of ruling out significant CAD and is a valid alternative to angiography.