Comparison of Mortality Rate and Severity of Pulmonary Involvement in Coronavirus Disease-2019 Adult Patients With and Without Type 2 Diabetes: A Cohort Study.

OBJECTIVES: Patients with diabetes are potentially at higher risk of mortality due to coronavirus disease-2019 (COVID-19). In this study, we aimed to compare the outcomes and severity of pulmonary involvement in COVID-19 patients with and without diabetes. METHODS: In this cohort study, we recruited patients with diabetes who were hospitalized due to COVID-19 during the period from February 2020 to May 2020. Hospitalized individuals without diabetes were enrolled as control subjects. All patients were followed for 90 days and clinical findings and patients' outcomes were reported. RESULTS: Over a period of 4 months, 127 patients with diabetes and 127 individuals without diabetes with a diagnosis of COVID-19 were recruited. Their mean age was 65.70±12.51 years. Mortality was higher in the group with diabetes (22.8% vs 15.0%; p=0.109), although not significantly. More severe pulmonary involvement (p=0.015), extended hospital stay (p<0.001) and greater need for invasive ventilation (p=0.029) were reported in this population. Stepwise logistic regression revealed that diabetes was not independently associated with mortality (p=0.092). Older age (odds ratio [OR], 1.054; p=0.003), aggravated pulmonary involvement on admission (OR, 1.149; p=0.001), presence of comorbidities (OR, 1.290; p=0.020) and hypothyroidism (OR, 6.576; p=0.021) were associated with mortality. Diabetic foot infection had a strong positive correlation with mortality (OR, 49.819; p=0.016), whereas insulin therapy had a negative correlation (OR, 0.242; p=0.045). CONCLUSIONS: The mortality rate due to COVID-19 did not differ significantly between patients with or without diabetes. Older age, macrovascular complications and presence of comorbidities could increase mortality in people with diabetes. Insulin therapy during hospitalization could attenuate the detrimental effects of hyperglycemia and improve prognosis of patients with COVID-19 and diabetes.

Does sedation influence cardiac magnetic resonance duration for children?

PURPOSE: The aims of our study were to compare cardiac magnetic resonance (CMR) scan time (time elapsed between first and last acquired sequence) and room time (time elapsed between patients' entrance and exit of the MRI room) between sedated and non-sedated children and to assess the contributing factors. METHODS: It is a cohort study performed at a CMR facility in a tertiary-care center. We compared scan time and room time between sedated and non-sedated children and assessed the influence of gender, age, weight, height, body surface area, number of sequences, and patients' diagnosis/previous procedures. RESULTS: We included 140 children (74 sedated and 66 non-sedated), age 7.6 years (3-12) and body surface area 0.83 m2 (0.57-1.25). The most common diagnosis/previous procedures were repaired tetralogy of Fallot, cardiomyopathies and single ventricle. Number of sequences: 18 (16-22). Scan time: 42 min (35-54.2); room time: 53 min (46-63). There was difference in room time between sedated and non-sedated children (57.6 ± 13.6 vs 52.2 ± 15 min, p < 0.05), but not in scan time (47.2 ± 14.1 vs 43.9 ± 16 min, p 0.2). The only factor associated with scan time was the number of sequences (r 0.75, p < 0.001). The only factor associated with room time was single ventricle as indication (r 0.26, p 0.007). CONCLUSIONS: Sedated children spent 5 more minutes in the CMR room than non-sedated children. Single ventricle was associated with increased room time. Number of sequences correlated with scan time. Sedation did not influence these times.

Myocardial Dimensions in Children With Hypertrophic Cardiomyopathy: A Comparison Between Echocardiography and Cardiac Magnetic Resonance Imaging.

BACKGROUND: The primary mode of imaging in hypertrophic cardiomyopathy (HCM) is transthoracic echocardiography (TTE). However, in adults inadequate acoustic windows lead to poor quantification of myocardial thickness compared with cardiac magnetic resonance (CMR) imaging. In comparison, children have better acoustic windows and TTE measurements of wall thickness might be more accurate. The aim of this study was to assess the performance of TTE compared with CMR for the assessment of myocardial thickness in children with HCM. METHODS: Nineteen children (median age, 12.7 years; range, 8.4-18.4 years) with known HCM were studied using TTE and CMR imaging on the same day. The left ventricle was measured off-line using the standard 16-segment model. RESULTS: With CMR imaging 304 (19 × 16) segments were analyzable whereas only 263 were analyzable using echocardiography. Wall thickness measurements according to TTE were greater than those according to CMR imaging in the basal anterolateral, midventricular anterior and anterolateral and apical inferior, lateral and septal segments and smaller for the midventricular inferior and inferoseptal segments. Reproducibility of CMR and TTE measurements was assessed using the intraclass correlation coefficient (ICC). CMR measurements showed excellent intrareader (ICC, 0.929-0.991) and moderate inter-reader (ICC range, 0.512-0.991) reproducibility. TTE measurements revealed moderate intrareader (ICC, 0.575-0.942) and poor inter-reader (ICC range, -1.02 to 0.939) reproducibility. CONCLUSIONS: Echocardiography incompletely assesses circumferential myocardial thickness in a proportion of pediatric patients with HCM. Echocardiography under- and overestimates maximum wall thickness compared with CMR, depending on the location. Measurements using CMR are more reproducible than those obtained using echocardiography.

Right Ventricular Dysfunction in Patients Experiencing Cardiotoxicity during Breast Cancer Therapy.

Background. Right ventricular (RV) dysfunction during cancer therapy related cardiotoxicity and its prognostic implications have not been examined. Aim. We sought to determine the incidence and prognostic value of RV dysfunction at time of LV defined cardiotoxicity. Methods. We retrospectively identified 30 HER2+ female patients with breast cancer treated with trastuzumab (± anthracycline) who developed cardiotoxicity and had a diagnostic quality transthoracic echocardiography. LV ejection fraction (LVEF), RV fractional area change (RV FAC), and peak systolic longitudinal strain (for both LV and RV) were measured on echocardiograms at the time of cardiotoxicity and during follow-up. Thirty age balanced precancer therapy and HER2+ breast cancer patients were used as controls. Results. In the 30 patients with cardiotoxicity (mean ± SD age 54 ± 12 years) RV FAC was significantly lower (42 ± 7 versus 47 ± 6%, P = 0.01) compared to controls. RV dysfunction defined by global longitudinal strain (GLS < -20.3%) was seen in 40% (n = 12). During follow-up in 16 out of 30 patients (23 ± 15 months), there was persistent LV dysfunction (EF < 55%) in 69% (n = 11). Concomitant RV dysfunction at the time of LV cardiotoxicity was associated with reduced recovery of LVEF during follow-up although this was not statistically significant. Conclusion. RV dysfunction at the time of LV cardiotoxicity is frequent in patients with breast cancer receiving trastuzumab therapy. Despite appropriate management, LV dysfunction persisted in the majority at follow-up. The prognostic value of RV dysfunction at the time of cardiotoxicity warrants further investigation.

Unusual intense fluorodeoxyglucose uptake in the intercostal muscles due to severe shortness of breath in a patient with heart failure.

We present a case of unusually intense Fluorodeoxyglucose uptake in the intercostal muscles during a Fluorodeoxyglucose positron emission tomography (FDG-PET). We hypothesized that severe left ventricular failure causing the patient to be short of breath during the study in association with insulin injection as part of study protocol led to the intense uptake of FDG in the respiratory muscles causing such an unusual appearance.

Utility of feed-and-sleep cardiovascular magnetic resonance in young infants with complex cardiovascular disease.

Utilization of cardiovascular magnetic resonance (CMR) is limited in young children because of the need for sedation or general anesthesia (GA). It has been previously shown that CMR can be performed without sedation or GA in young infants who are prone to fall asleep after being fed and swaddled. The purpose of this study was to prospectively prove the feasibility of the feed-and-sleep CMR technique in larger cohorts in the two institutions where the technique was initially developed. This was a prospective dual-center cohort study over a two-year period. All infants younger than 6 months old with complex congenital cardiovascular anomaly who required CMR were recruited for this study. The exclusion criteria included mechanical ventilation, oxygen dependence, feeding difficulties, and any contraindication to CMR. The feed-and-sleep study was performed by fasting the infant for a period of 4 h prior to the scan, placing the infant in a vacuum immobilizer, and feeding the infant just prior to the CMR. The CMR sequences were prioritized to target the area of most importance first. A study was considered complete and diagnostic if the clinical question was answered. A total of 60 infants (39 from center A and 21 from center B) were recruited for this study, 32 male and 28 female, ages ranging from 1 to 177 days (50 ± 54). The CMR studies were diagnostic and answered the clinical questions in all patients. All infants tolerated the procedure well, and no complications were noted in any of the patients. The CMR duration ranged between 4-132 minutes (45 ± 21). The feed-and-sleep approach in selected patients obviates the need of sedation or GA for CMR in infants younger than 6 months old. Therefore, CMR can be utilized whenever echocardiography fails to provide the complete information required for the patients' management.

Utility of coronary CT angiography in outpatients with hypertrophic cardiomyopathy presenting with angina symptoms.

BACKGROUND: Angina is a frequent symptom in patients with hypertrophic cardiomyopathy (HCM); however, it is often not because of significant epicardial coronary artery stenosis. Coronary CT angiography (CCTA) is an excellent modality to rule out significant coronary artery stenosis in the low- and intermediate-risk patients; however, its value in patients with HCM has not been explored. We sought to assess the utility of CCTA in the assessment of patients with HCM and stable anginal symptoms and compare the incidence of epicardial coronary artery stenosis to an age- and gender-matched control group. METHODS: Consecutive outpatients with HCM referred for CCTA over a 3-year period because of stable anginal symptoms (chest pain or shortness of breath) were identified retrospectively. Age- and gender-matched patients without HCM referred for CCTA because of similar symptoms over a 6-month period were used as controls. All patients had CCTA using an Aquilion ONE 320 scanner. The coronary arteries were evaluated independently by 2 blinded observers, and any luminal narrowing was scored quantitatively as follows: >70% = severe; 50% to 70% = moderate; <50% = mild; and none. For the HCM group, results of cardiac single-photon emission CT (SPECT) or cardiac magnetic resonance perfusion studies as well as catheter angiograms were recorded where available. RESULTS: A total of 91 patients with HCM and 91 controls were included. No significant difference in cardiac risk factors was present between the 2 groups. The CCTA was of diagnostic quality in all patients. The median (interquartile range) calcium score was lower in patients with HCM (0 [0-50] vs 2 [0-189]) but did not reach statistical significance (P = .23). The incidence of moderate-to-severe coronary artery stenosis was significantly lower in patients with HCM than in controls (6.6% vs 33.0%; P < .001). The incidence of left anterior descending artery luminal narrowing overall was also significantly lower in the HCM patients (7.0% vs 20.9%; P = .002). There was a higher incidence of myocardial bridging in patients with HCM (40.7% vs 6.6%; P < .001), with longer and deeper bridged segments. Among a subgroup of HCM patients (n = 24) who had either stress perfusion CMR or cardiac single-photon emission CT studies performed, 15 of 24 had false-positive perfusion abnormalities without evidence of luminal obstruction on CCTA. CONCLUSION: We demonstrate the use of CCTA for the assessment of stable anginal symptoms in patients with HCM. The incidence of moderate-to-severe coronary artery stenosis was significantly lower in our HCM patients in comparison to our age-matched, gender-matched, and risk factor-matched control group. Given the high incidence of false-positive findings on perfusion stress studies, we propose that CCTA may be useful for appropriate triage to coronary angiography in the HCM patient with anginal symptoms.

Pulmonary artery pulsatility and effect on vessel diameter assessment in magnetic resonance imaging.

BACKGROUND: Information about thoracic vascular sizes can crucially affect clinical decision-making in cardiovascular disease. A variety of imaging techniques such as catheter angiography, contrast enhanced computed tomography (CT) and cardiac magnetic resonance imaging (CMR) are routinely used to measure vascular diameters. Traditionally, CMR black blood sequences were the main anatomical tool for visualization of vascular anatomy and still are in many centers. More recently, the vessel diameters are measured on multiplanar reconstructions derived from static magnetic resonance angiography (MRA). This study was performed to investigate the variation of vessel diameter measurements on different CMR techniques with respect to their data acquisition scheme. METHODS: We recruited two groups of patients for this prospective study. One group included patients with repaired tetralogy of Fallot (TOF), with at least moderate pulmonary insufficiency and another group of patients who underwent CMR as part of a diagnostic work-up for arrhythmogenic right ventricular cardiomyopathy (ARVC). Additional images of the right pulmonary artery (RPA) were acquired in the double inversion recovery (DIR) black blood, cine steady state free precession (SSFP) and MRA. All images were reviewed by two CMR trained readers using the electronic caliper provided within the picture archiving and communication system package. The maximum diameter of each artery was recorded in millimeters with up to one decimal point. Paired t-tests and Bland-Altman plots were used for comparison of measurements between different sequences. RESULTS: A total of 52 patients were recruited for this study, 26 patients in the TOF group (15 males, age 12.55±2.9) and 26 patients in the ARVC group (15 males, age 15.6±2.3). In both groups, the RPA sizes were not significantly different between the DIR images and diastolic cine SSFP (p>0.05). Measurements on DIR were significantly smaller than those made on systolic cine SSFP or MRA in both groups (p<0.0001). Vessel diameters measured on systolic SSFP were significantly larger than measurements made on diastolic SSFP (p<0.0001). There was no significant difference between vessel measurements on MRA and measurements on systolic cine SSFP (p=0.44 for the TOF group and p=0.79 for ARVC group). Measurements on the MRA datasets were significantly larger than those on diastolic SSFP images (p<0.0001). CONCLUSION: Black blood, white blood and MRA sequences are all reproducible CMR methods for the assessment of arterial diameters in children and adolescents. Measurements from systolic phase SSFP images are comparable to those from contrast-enhanced MRA. Therefore, the administration of contrast medium is not necessary in every case. Cine SSFP images offer the additional advantage over the other methods in such that both the largest and the smallest diameter of the vessel during the cardiac cycle can be assessed using this technique. This is even more relevant in highly pulsatile circulations, such as patients with repaired TOF and significant pulmonary insufficiency.

Isolated anomalous origin of the right coronary artery from the pulmonary artery in an asymptomatic 12-year-old girl: role of MRI in depicting the anatomy, detecting the ischemic burden, and quantifying the amount of left-to-right shunt.

Asymptomatic 12-year-old girl with a heart murmur underwent echocardiogram and suspicious continuous flow was detected in her interventricular septum. She underwent cardiac magnetic resonance (CMR) for further investigation. The CMR images demonstrated anomalous origin of the right coronary artery from the pulmonary artery. Adenosine stress perfusion scan showed an inducible perfusion defect in the right coronary artery and left circumflex artery territories. Flow quantification showed a left-to-right shunt with pulmonary to systemic blood flow ratio (Qp/Qs) of 1.25.

Pulmonary vein flow pattern in children with bidirectional cavopulmonary connection or Fontan circuit.

BACKGROUND: Typical flow velocity profiles in the extraparenchymal pulmonary veins (PVs) demonstrate two major antegrade flow waves: a biphasic systolic wave (S), with S1 and S2 peaks and a monophasic early diastolic wave (D). Flow reversal during atrial systole (A) is common. There is agreement that the forward diastolic PV flow wave is caused by left ventricular relaxation with opening of the mitral valve. The origin of the PV systolic wave, however, remains a topic of debate. Some studies have suggested that the S wave is created by the relaxation of the left atrium and descent of the mitral valve plane. These studies have concluded that forces generated by the right ventricle (RV) have no effect on the S wave. Others suggest that the forward propagation of the right ventricular systolic pressure pulse is the major contributor to the S wave. OBJECTIVE: To determine whether any part of the systolic wave of PV flow is dependent on forces created by the right ventricle. MATERIALS AND METHODS: We assessed PV flow pattern, as obtained by cardiac MRI in 12 cases (39 pulmonary veins) with RV-independent pulmonary circulation (bidirectional cavopulmonary connection or Fontan circulation). Phase-contrast imaging of the PVs was performed on a 1.5-T MR scanner with velocity encoding set at 120 cm/s. We compared these flow patterns with those of a control group of ten children (15 pulmonary veins) who had RV-dependent pulmonary circulation and underwent CMR for other indications. RESULTS: In all PVs of children with RV-independent pulmonary circulation the flow curves showed a single systolic peak in early systole (S1) with the S2 peak consistently absent. PV flow pattern in the control group consistently showed distinct early and late systolic peaks. CONCLUSION: This study supports the concept that S2 is caused by forward propagation of the right ventricular systolic pressure pulse. It also demonstrates that the S1 is independent of the right ventricle.

Normal Drainage, Abnormal Connection: Partial Anomalous Pulmonary Venous Connection and Sinus Venosus Atrial Septal Defect With a Net Right-to-Left Shunt.

A seven-month-old girl with partial anomalous pulmonary venous connection and atrial septal defect underwent cardiac magnetic resonance for further evaluation. Anatomical images and flow quantification confirmed the diagnosis and demonstrated a commitment of the superior vena cava to the left atrium, resulting in a right-to-left shunt and pulmonary/systemic blood flow ratio of 0.85. The findings were confirmed during surgery.

Cardiovascular MRI without sedation or general anesthesia using a feed-and-sleep technique in neonates and infants.

BACKGROUND: MRI in small children generally necessitates the use of general anesthesia. OBJECTIVE: We describe our initial results with a new technique that we name the feed-and-sleep method, whereby an infant can undergo a cardiac MRI without the need for general anesthesia or sedation. MATERIALS AND METHODS: The infant is fasted for 4 h prior to the scan and is then fed by his mother prior to the scan. He is then swaddled with 1 to 2 infant sheets before being placed in a vacuum-bag immobilizer. As air is removed from the bag, the immobilizer becomes a rigid cradle that fits the infant's body. We prioritize the sequences according to the purpose of the study and in the order of clinical importance. RESULTS: Between January 2010 and January 2011 a total of 20 infants with the median age 14.5 days (minimum 2 days, maximum 155 days) underwent CMR studies via this method. All were performed successfully with no distress to the infant. The median scan time was 46.5 min (minimum 20, maximum 66). All had complex congenital heart defects and all planned sequences were acquired with sufficient quality to allow accurate diagnosis and to plan appropriate surgery. CONCLUSION: Using this technique, infants younger than 6 months can complete a cardiovascular MRI without the need for sedation or general anesthesia. We advocate the incorporation of this safe and reliable technique into routine clinical practice.