Twelve-Lead ECG Optimization of Cardiac Resynchronization Therapy in Patients With and Without Delayed Enhancement on Cardiac Magnetic Resonance Imaging.

Background Delayed enhancement ( DE ) on magnetic resonance imaging is associated with ventricular arrhythmias, adverse events, and worse left ventricular mechanics. We investigated the impact of DE on cardiac resynchronization therapy ( CRT ) outcomes and the effect of CRT optimization. Methods and Results We studied 130 patients with ejection fraction ( EF ) ≤40% and QRS ≥120 ms, contrast cardiac magnetic resonance imaging, and both pre- and 1-year post- CRT echocardiograms. Sixty-three (48%) patients did not have routine optimization of CRT . The remaining patients were optimized for wavefront fusion by 12-lead ECG . The primary end point in this study was change in EF following CRT . To investigate the association between electrical dyssynchrony and EF outcomes, the standard deviation of activation times from body-surface mapping was calculated during native conduction and selected device settings in 52 of the optimized patients. Patients had no DE (n=45), midwall septal stripe (n=30), or scar (n=55). Patients without DE had better ∆ EF (13±10 versus 4±10 units; P<0.01). Optimized patients had greater ∆ EF in midwall stripe (2±9 versus 12±12 units; P=0.01) and scar (0±7 versus 5±10; P=0.04) groups, but not in the no- DE group. Patients without DE had greater native standard deviation of activation times ( P=0.03) and greater ∆standard deviation of activation times with standard programming ( P=0.01). Device optimization reduced standard deviation of activation times only in patients with DE ( P<0.01). Conclusions DE on magnetic resonance imaging is associated with worse EF outcomes following CRT . Device optimization is associated with improved EF and reduced electrical dyssynchrony in patients with DE .

Right atrial thrombus arising from the junction of the right atrium and the inferior vena cava.

BACKGROUND: Cardiac tumors are a rare cause of recurrent syncope which are detected on echocardiography, computed tomographic scan, and/or magnetic resonance imaging. We present echocardiographic, anatomic, and histopathologic images of a cardiac tumor arising from the junction of the right atrium and the inferior vena cava in a young lady. METHODS: Transthoracic echocardiography, transesophageal echocardiography, postmortem examination (autopsy), and histopathology. RESULTS: Transesophageal echocardiogram showed a 7×3-cm mobile multilobulated right atrial mass arising from the right atrial wall near the inferior vena cava. The patient was admitted to hospital to undergo cardiac surgery; however, unfortunately, she went in to cardiorespiratory arrest on the eve before surgery. Autopsy showed embolized mass obstructing the main pulmonary trunk, and pathology revealed an old organizing thrombus. CONCLUSIONS: Cardiac thrombi can mimic appearances of a myxoma on echocardiogram. Delay in thrombus removal surgery can result in increased mortality as seen in our case.

The role of C-reactive protein as a risk predictor of coronary atherosclerosis: implications from the JUPITER trial.

Much controversy surrounds the use of high-sensitivity C-reactive protein (hs-CRP) as a marker of cardiovascular (CV) risk. Although data regarding the association of hs-CRP with CV disease is extensive and consistent, its role in clinical practice remains unclear. The American Heart Association (AHA) recently published a scientific statement regarding criteria for evaluation of novel markers of CV risk. This article provides a comprehensive review of data regarding hs-CRP as a risk marker for CV disease in the context of these AHA criteria. The impact of the JUPITER trial on the utility of hs-CRP as a risk marker is emphasized. The review concludes with an evidence-based statement regarding the current role of hs-CRP in CV risk prediction.

Should we measure C-reactive protein on earth or just on JUPITER?

Evidence for the role of inflammation in the pathogenesis of atherosclerosis is compelling and has generated interest in high-sensitivity C-reactive protein (hs-CRP) as a marker of cardiovascular risk. Data regarding hs-CRP and cardiovascular risk, though largely consistent, is of unclear clinical relevance. Most recently, the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) trial has led to further debate regarding the utility of hs-CRP. This article provides a comprehensive review of the data regarding cardiovascular risk and hs-CRP with an emphasis on the JUPITER trial and concludes with an evidence-based analysis of the current role of hs-CRP in cardiovascular risk assessment.