Echocardiography for prediction of 6-month and late response to cardiac resynchronization therapy: implementation of stress echocardiography and comparative assessment along with widely used dyssynchrony indices.

Non-response cardiac resynchronization therapy (CRT) remains an issue, despite the refinement of selection criteria. The purpose of this study was to investigate the role of stress echocardiography along with dyssynchrony parameters for identification of CRT responders or late responders. 106 symptomatic heart failure patients were examined before, 6 months and 2-4 years after CRT implementation. Inotropic contractile reserve (ICR) and inferolateral (IL) wall viability were studied by stress echocardiography. Dyssynchrony was assessed by: (1) Septal to posterior wall motion delay (SPWMD) by m-mode. (2) Septal to lateral wall delay (SLD) by TDI. (3) Interventricular mechanical delay (IVMD) by pulsed wave Doppler for (4) difference in time to peak circumferential strain (TmaxCS) by speckle tracking. (5) Apical rocking (ApR) and septal flash (SF) by visual assessment. At 6 months there were 54 responders, with 12 additional late responders. TmaxCS had the greatest predictive value with an area under curve (AUC) of 0.835, followed by the presence of both ICR and viability of IL wall (AUC 0.799), m-mode (AUC = 0.775) and presence of either ApR or SF (AUC = 0.772). Predictive ability of ApR and of ICR is augmented if late responders are also included. Performance of dyssynchrony parameters is enhanced, in patients with both ICR and IL wall viability. Stress echocardiography and dyssynchrony parameters are simple and reliable predictors of 6-month and late CRT response. A stepwise approach with an initial assessment of ICR and viability and, if positive, further dyssynchrony analysis, could assist decision making.

Cardiac tissue characterization and the diagnostic value of cardiovascular magnetic resonance in systemic connective tissue diseases.

OBJECTIVE: Accurate diagnosis of cardiovascular involvement in connective tissue diseases (CTDs) remains challenging. We hypothesized that cardiovascular magnetic resonance (CMR) demonstrates cardiac lesions in symptomatic CTD patients with normal echocardiography. METHODS: CMR from 246 CTD patients with typical cardiac symptoms (TCS; n = 146, group A) or atypical cardiac symptoms (ATCS; n = 100, group B) was retrospectively evaluated. Group A included 9 patients with inflammatory myopathy (IM), 35 with sarcoidosis, 30 with systemic sclerosis (SSc), 14 with systemic lupus erythematosus (SLE), 10 with rheumatoid arthritis (RA), and 48 with small vessel vasculitis. Group B included 25 patients with RA, 20 with SLE, 20 with sarcoidosis, 15 with SSc, 10 with IM, and 10 with small vessel vasculitis. CMR was performed by 1.5T; left ventricular ejection fraction, T2 ratio (edema imaging), and late gadolinium enhancement (LGE; fibrosis imaging) were evaluated. Acute and chronic lesions were characterized as LGE positive plus T2 ratio >2 and T2 ratio ≤2, respectively. According to LGE, lesions were characterized as diffuse subendocardial, subepicardial, and subendocardial/transmural due to vasculitis, myocarditis, and myocardial infarction, respectively. A stress study by dobutamine echocardiography or stress, nuclear, or adenosine CMR was performed in CTD patients with negative rest CMR. RESULTS: Abnormal CMR was identified in 32% (27% chronic) and 15% (12% chronic) of patients with TCS and ATCS, respectively. Lesions due to vasculitis, myocarditis, and myocardial infarction were evident in 27.4%, 62.6%, and 9.6% of CTD patients, respectively. Stress studies in CTD patients with negative CMR revealed coronary artery disease in 20%. CONCLUSION: CMR in symptomatic CTD patients with normal echocardiography can assess disease acuity and identify vasculitis, myocarditis, and myocardial infarction.

Myopericarditis, as the first sign of rheumatoid arthritis relapse, evaluated by cardiac magnetic resonance.

INTRODUCTION: Rheumatoid arthritis (RA) affects many organs, including the heart. Cardiac magnetic resonance (CMR) can assess heart pathophysiology in RA. AIM: To evaluate, using CMR, RA patients under remission with recent onset of cardiac symptoms. PATIENTS AND METHODS: Twenty RA under remission (15F/5M), aged 60±5 yrs, with recent onset of cardiac symptoms (RAH), were prospectively evaluated by CMR. The CMR included left ventricular ejection fraction (LVEF), T2-weighted (T2-W), early (EGE) and late gadolinium enhanced (LGE) images evaluation. Their results were compared with those of 20 RA under remission without cardiac symptoms (RAC) and 18 with systemic lupus erythematosus (SLE) with clinically overt myocarditis. RESULTS: Cardiac enzymes were abnormal in 5/20 RAH. CMR revealed inferior wall myocardial infarction in 2/20 (1M, 1F) and myocarditis in 13/20 (8M/5F) RAH. The T2 ratio of myocardium to skeletal muscle was increased in RAH and SLE compared to RAC (2.5 ± 0.05 and 3.4±0.7 vs 1.8 ± 0.5, p<0.001). EGE was increased in RAH and SLE compared to RAC (15 ± 3 and 12±4.7 vs 2.7±0.8, p<0.001). Epicardial LGEs were identified in 10/13 and pericarditis in 6/13 RAH. Coronary angiography, performed in 5 RAH with increased cardiac enzymes, proved a right coronary artery obstruction in 2/5. In 3/5 with CMR positive for myocarditis, coronary arteries were normal, but endomyocardial biopsy revealed inflammation with normal PCR. An RA relapse was observed after 7-40 days in 10/13 RAH with myopericarditis. The one year follow up showed that a) RAH with myocarditis had more disease relapses and b) CHF was developed in 4 RAH with myocarditis. CONCLUSIONS: Myopericarditis with atypical presentation, diagnosed by CMR in RA under remission, may precede the development of RA relapse. In 1 year follow up, RA patients with history of myocarditis have a higher frequency of disease relapse and may develop CHF.