Feasibility of MRI in patients with non-Pacemaker/Defibrillator metallic devices and abandoned leads.

OBJECTIVE: To evaluate feasibility of MRI in patients with non-pacemaker (PM)/ Implantable cardioverter defibrillator (ICD) metallic devices and abandoned leads. BACKGROUND: Relative safety of MRI performed using specified protocol has been established in MR non-conditional PM/ICDs. With limited safety data, many non-PM/ICD metallic devices and abandoned leads continue to be a contraindication for MRI. METHODS: We retrospectively analyzed consecutive patients with extra-cardiac devices, non-programmable cardiac devices, and abandoned leads, who underwent MRI (GE 1.5 Tesla, WI) at a single tertiary care center over a span of 13 years. Scan protocol was designed to maintain specific absorption rate (SAR) < 4.0 W/kg and scan time < 60 minutes. RESULTS: The cohort comprised 127 MRI exams representing 94 patients, with 13 patients having two or more scans. The devices consisted of: 23 vagal nerve stimulators (VNS), 22 implantable loop recorders, 16 spinal stimulators, 5 peripheral nerve stimulators, 3 bladder stimulators, 2 deep brain stimulators, 1 gastric stimulator, 1 bone stimulator, 1 WATCHMAN device, 22 abandoned PM/lCD leads and 1 VNS lead. There was no immediate (peri-MRI exam) morbidity or mortality. Patients did not report any discomfort, palpitations, heating, or sensation of device migration during the exam. Local follow-up data was available in 65% (100% for thoracic imaging) with a mean of 190±475 days (median 13 days). No device malfunction reported during follow-up. CONCLUSIONS: With appropriate precautions, MRI is feasible in patients with extracardiac devices, nonprogrammable cardiac devices, and abandoned leads.

Impact of the 2016 ASE/EACVI Guidelines on diastolic function reporting in routine clinical practice.

OBJECTIVE: To evaluate the impact of 2016 ASE/EACVI guidelines on Diastolic Function (DF) reporting during routine clinical practice. METHODS: Transthoracic echos performed 9 months before and 18 months after the 2016 guidelines (DF2016) were retrospectively analyzed. RESULTS: Twenty thousand eight hundred forty three echos performed between July 1, 2015, and September 30, 2017, were analyzed. Quarterly trends showed a stable proportion of normal DF (nDF), diastolic dysfunction (DD), indeterminate DF (DF-I), and nonreported DF (DF-NR) for 3 quarters preceding DF2016. After DF2016 release, reporting of DD decreased by 57% (P < .001), nDF increased by 76% (P < .001), DF-NR increased by 266% (P < .001), and DF-I did not change significantly (P = .40). Grade 1 DD decreased by 64% (P < .001), grade 2 DD decreased by 51% (P < .001), and grade 3 DD did not change significantly (P = .18). Provider level analysis showed increased heterogeneity in grade 1 DD reporting and decreased heterogeneity in DD grades 2 or higher, after DF2016. Systolic dysfunction reporting remained relatively stable (22%→21%→20%) compared to a significant decrease in isolated DD (35%→21%→10%). CONCLUSION: The 2016 guidelines update has impacted DF reporting patterns significantly. The likelihood of reporting DD decreased significantly, especially for grades 1 and 2. Inter-provider heterogeneity in DF reporting improved for grades 2 and 3 but worsened for grade 1. There was more than threefold increase in failure to report DF, suggesting a decrease in provider confidence.

In-situ Coronary Thrombosis in Antiphospholipid Syndrome: A Case Report.

Antiphospholipid antibody syndrome (APS) is a systemic autoimmune disorder characterized by arterial and venous thrombosis, often accompanied by elevated titers of anti-phospholipid antibodies. Cardiac involvement in APS is not uncommon. However, acute myocardial infarction (AMI) from in-situ thrombosis is a rare but important manifestation of APS. We present a rare case of AMI in a young female with APS secondary to in-situ coronary thrombosis.

Redefining the fluoroscopic landmarks for common femoral arterial puncture during cardiac catheterization: Femoral angiogram and computed tomography angiogram (FACT) study of common femoral artery anatomy.

BACKGROUND: The mid-femoral head (F50 ) is a common fluoroscopic target for common femoral artery (CFA) puncture during cardiac catheterization. Punctures above the inguinal ligament (marking the proximal end of CFA) increase the risk of retroperitoneal hemorrhage and are classified as high punctures. METHODS: We retrospectively analyzed 114 CT angiograms for the anatomic relationship of the inguinal ligament to the femoral head (FH) and inferior epigastric artery (IEA). We analyzed 114 CT angiograms and 500 femoral angiograms, for the relation of the mid-point of CFA to F50 and F75 (the junction of upper 3/4th and lower 1/4th of FH). RESULTS: The proximal third of femoral head (F33 ) (-1.4 mm) and IEA nadir (-2.9 mm) were closer approximations to the inguinal ligament than the IEA origin (-12.8 mm) or cranial end of FH (-15.2 mm). The inguinal ligament correlated better with the IEA nadir than F33 (R2 = 0.49 vs. 0.001). F75 was a closer approximation for the mid-point of the CFA than F50 (0.3 mm vs. -9.2 mm). Using F75 as the target for CFA puncture carried the lowest risk for non-CFA punctures (18.6%), while using F50 had a 41.2% risk for non-CFA punctures. F75 had an increased risk for low punctures (14.2%) but F50 had a far higher risk for high punctures (36.6%). CONCLUSIONS: The nadir of IEA is the best landmark for identifying the inguinal ligament (the proximal end of CFA) and defining high punctures. F75 is a more accurate target for successful CFA puncture than F50.

Takotsubo cardiomyopathy: Pathophysiology and role of cardiac biomarkers in differential diagnosis.

Takotsubo cardiomyopathy (TC) is characterized by reversible ventricular dysfunction, not limited to the distribution of an epicardial coronary artery. A disease primarily afflicting post-menopausal women, it is frequently mistaken for acute anterior wall myocardial infarction. Alternatively called Stress Cardiomyopathy, physical or emotional triggers are identified in only three fourths of TC patients. Long considered a benign condition, recent findings suggest poor short term prognosis similar to acute coronary syndrome (ACS). Despite the widely recognized pathophysiological role of catecholamine excess, its diagnostic role is uncertain. TC is suspected based on typical wall motion abnormalities in ventriculogram or echocardiogram. Several additional electrocardiographic, laboratory and imaging parameters have been studied with the goal of clinical diagnosis of TC. While several clinical clues differentiate it from ACS, a clinical diagnosis is often elusive leading to avoidable cardiac catheterizations. Natriuretic peptides (NPs), a family of peptide hormones released primarily in response to myocardial stretch, play a significant role in pathophysiology, diagnosis as well as treatment of congestive heart failure. TC with its prominent ventricular dysfunction is associated with a significant elevation of NPs. NPs are elevated in ACS as well but the degree of elevation is typically lesser than in TC. Markers of myocardial injury such as troponin are usually elevated to a higher degree in ACS than in TC. This differential elevation of NPs and markers of myocardial injury may play a role in early clinical recognition of TC.

Obstructive sleep apnea and cardiovascular disease.

Obstructive sleep apnea (OSA) is a sleep-disordered breathing condition, which is increasingly being recognized as having wide-ranging pathophysiological effects on multiple organ systems. Although multiple factors affect the incidence and severity of OSA, male sex and obesity seem to play an influential role. The apnea-ventilation cycle, characterized by abnormalities in gas exchange, exaggerated respiratory effort and frequent arousals, has been shown to have deleterious effects on circulatory hemodynamics, the autonomic milieu, hormonal balance, inflammatory and coagulation cascades, endothelial function, and the redox state, with potential cardiovascular significance. Consequently, OSA is being increasingly implicated in a multitude of cardiovascular diseases (CVD) such as hypertension, congestive heart failure, atrial fibrillation, stroke, coronary artery disease, pulmonary hypertension, and metabolic syndrome. The strength of association for individual CVD is varied, and outcomes of clinical studies are conflicting. In addition, obesity, which is closely linked to both OSA and CVD, makes it harder to ascertain the independent role of OSA on CVD. Although available evidence is inconclusive, there is an increasing recognition of the direct role for OSA in CVD. Similarly, although several studies have demonstrated the cardiovascular benefits of OSA treatment, further studies are needed to confirm this.

Gender differences in coronary artery disease: review of diagnostic challenges and current treatment.

Coronary artery disease (CAD) in women is an important public health concern. However, the delayed onset of CAD in women and the apparent protective effect of estrogen are partly responsible for the misconception that CAD primarily affects men. Though women share the same traditional risk factors as men, they have some unique risk factors and differences in pathophysiology. Women are more likely to have atypical symptoms, contributing to the under-diagnosis of CAD. Fewer women than men receive pharmacological treatment for CAD on admission but more women receive anxiolytics, antidepressants, and narcotics. Disparities have been found in the administration and performance of both noninvasive testing and cardiac catheterization. The frequent absence of angiographic disease in symptomatic women often leads to searching for a noncardiac etiology for chest pain rather than the recognition of a higher incidence of nonocclusive CAD in women, a concept supported by imaging studies. Observational studies have pointed toward a beneficial effect of hormone replacement therapy (HRT) on CAD, but more recent randomized trials have disputed this and advocate against the use of HRT for CAD prevention. The role of HRT in CAD is still debated. Physicians have to be acutely aware of gender bias and gender-based differences in clinical presentation, accuracy of diagnostic tests, and clinical outcomes.

Accuracy of multislice computed tomography coronary angiography: a pooled estimate.

A PUBMED search was performed for peer-reviewed studies published in English from 2002 through August 2006. Accuracy parameters for detection of obstructive coronary artery disease by MSCT (multislice computed tomography) coronary angiography were analyzed on patient and segment basis. Pooled estimates of sensitivity (SN), specificity, positive predictive value, and negative predictive value (NPV) in patient-based analyses were 93%, 82%, 83%, and 92%, respectively. For 64/40-slice MSCT the respective accuracy estimates were 96%, 91%, 93%, and 96% and were better compared with 16-slice MSCT. Also, more segments were evaluated by 64-slice MSCT (96%) compared with 16-slice MSCT (86%). The SN and NPV of MSCT coronary angiography for patients with low coronary artery calcium (CAC) score were 92% and 99% compared with 77% and 89% for patients with high CAC score. The accuracy estimates for MSCT in studying coronary artery by-pass grafts and intracoronary stents showed a SN and NPV of 97% and 97% for graft occlusion or stenosis and only 71% and 93% respectively for in-stent restenosis. Diagnostic accuracy of MSCT coronary angiography has improved with the newer 64-slice versions. High CAC scores can affect the accuracy of MSCT coronary angiography. Although the accuracy of MSCT in evaluating native vessel and graft disease has improved significantly, its reliability in studying intracoronary stents remains uncertain.

Noninvasive cardiac imaging with computed tomography.

Despite major improvements in the treatment of heart disease, it remains a major source of morbidity and mortality on a global scale. Currently, invasive coronary angiography remains the gold standard for identification of obstructive coronary artery disease. However, recent advances in computerized tomographic (CT) techniques of the heart allow for accurate, noninvasive characterization of atherosclerotic coronary disease and other cardiac abnormalities. The calculation of coronary artery calcium scores with electron beam CT has largely been supplanted by high-resolution CT angiography using multislice detectors (MSCT) which can provide detailed multidimensional visualization of cardiac structures. Although evaluation of obstructive coronary disease is the primary use of MSCT, its use in identifying congenital defects, planning thoracic procedures and characterizing cardiac function continues to grow. Accordingly, appropriate incorporation of MSCT/CT angiography into clinical practice continues to be defined. Several limitations to MSCT remain which reduce its accuracy, such as in patients with arrhythmia and in patients with either coronary stents or heavily calcified coronaries. Despite its current limitations, MSCT remains a rapidly advancing field and an increasingly valuable tool for the noninvasive evaluation of cardiac pathology.