scholarly journals Myocardial Perfusion Imaging After Severe COVID-19 Infection Demonstrates Regional Ischemia Rather Than Global Blood Flow Reduction

2021 ◽  
Vol 8 ◽  
Author(s):  
George D. Thornton ◽  
Abhishek Shetye ◽  
Dan S. Knight ◽  
Kris Knott ◽  
Jessica Artico ◽  
...  
Keyword(s):  
Blood Flow ◽  
Myocardial Perfusion ◽  
Left Ventricular ◽  
Regional Perfusion ◽  
Left Ventricular Ejection ◽  
Stress Perfusion ◽  
Post Discharge ◽  
High Prevalence ◽  
Perfusion Defects ◽  
Perfusion Cmr

Background: Acute myocardial damage is common in severe COVID-19. Post-mortem studies have implicated microvascular thrombosis, with cardiovascular magnetic resonance (CMR) demonstrating a high prevalence of myocardial infarction and myocarditis-like scar. The microcirculatory sequelae are incompletely characterized. Perfusion CMR can quantify the stress myocardial blood flow (MBF) and identify its association with infarction and myocarditis.Objectives: To determine the impact of the severe hospitalized COVID-19 on global and regional myocardial perfusion in recovered patients.Methods: A case-control study of previously hospitalized, troponin-positive COVID-19 patients was undertaken. The results were compared with a propensity-matched, pre-COVID chest pain cohort (referred for clinical CMR; angiography subsequently demonstrating unobstructed coronary arteries) and 27 healthy volunteers (HV). The analysis used visual assessment for the regional perfusion defects and AI-based segmentation to derive the global and regional stress and rest MBF.Results: Ninety recovered post-COVID patients {median age 64 [interquartile range (IQR) 54–71] years, 83% male, 44% requiring the intensive care unit (ICU)} underwent adenosine-stress perfusion CMR at a median of 61 (IQR 29–146) days post-discharge. The mean left ventricular ejection fraction (LVEF) was 67 ± 10%; 10 (11%) with impaired LVEF. Fifty patients (56%) had late gadolinium enhancement (LGE); 15 (17%) had infarct-pattern, 31 (34%) had non-ischemic, and 4 (4.4%) had mixed pattern LGE. Thirty-two patients (36%) had adenosine-induced regional perfusion defects, 26 out of 32 with at least one segment without prior infarction. The global stress MBF in post-COVID patients was similar to the age-, sex- and co-morbidities of the matched controls (2.53 ± 0.77 vs. 2.52 ± 0.79 ml/g/min, p = 0.10), though lower than HV (3.00 ± 0.76 ml/g/min, p< 0.01).Conclusions: After severe hospitalized COVID-19 infection, patients who attended clinical ischemia testing had little evidence of significant microvascular disease at 2 months post-discharge. The high prevalence of regional inducible ischemia and/or infarction (nearly 40%) may suggest that occult coronary disease is an important putative mechanism for troponin elevation in this cohort. This should be considered hypothesis-generating for future studies which combine ischemia and anatomical assessment.

scholarly journals Heart-Kidney Biomarkers in Patients Undergoing Cardiac Stress Testing

2011 ◽  
Vol 2011 ◽  
pp. 1-8 ◽  
Author(s):  
Mikko Haapio ◽  
Andrew A. House ◽  
Massimo de Cal ◽  
Dinna N. Cruz ◽  
Paolo Lentini ◽  
...  
Keyword(s):  
Myocardial Perfusion ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Segmental Defect ◽  
Ventricular Ejection Fraction ◽  
Cardiac Stress ◽  
Plasma Ngal ◽  
Ischemia Group ◽  
Perfusion Defects ◽  
Myocardial Perfusion Defects

We examined association of inducible myocardial perfusion defects with cardiorenal biomarkers, and of diminished left ventricular ejection fraction (LVEF) with kidney injury marker plasma neutrophil gelatinase-associated lipocalin (NGAL). Patients undergoing nuclear myocardial perfusion stress imaging were divided into 2 groups. Biomarkers were analyzed pre- and poststress testing. Compared to the patients in the low ischemia group (n=16), the patients in the high ischemia group (n=18) demonstrated a significantly greater rise in cardiac biomarkers plasma BNP, NT-proBNP and cTnI. Subjects were also categorized based on pre- or poststress test detectable plasma NGAL. With stress, the group with no detectable NGAL had a segmental defect score 4.2 compared to 8.2 (P=.06) in the detectable NGAL group, and 0.9 vs. 3.8 (P=.03) at rest. BNP rose with stress to a greater degree in patients with detectable NGAL (10.2 vs. 3.5 pg/mL,P=.03). LVEF at rest and with stress was significantly lower in the detectable NGAL group; 55.8 versus 65.0 (P=.03) and 55.1 vs. 63.8 (P=.04), respectively. Myocardial perfusion defects associate with biomarkers of cardiac stress, and detectable plasma NGAL with significantly lower LVEF, suggesting a specific heart-kidney link.

scholarly journals Myocardial perfusion after COVID-19 infection: No persisting impaired myocardial blood flow in surviving patients

2021 ◽  
Vol 22 (Supplement_2) ◽  
Author(s):  
G Thornton ◽  
A Shetye ◽  
K Knott ◽  
Y Razvi ◽  
K Vimalesvaran ◽  
...  
Keyword(s):  
Blood Flow ◽  
Myocardial Blood Flow ◽  
Microvascular Disease ◽  
Myocardial Damage ◽  
Stress Perfusion ◽  
Perfusion Image ◽  
Funding Sources ◽  
Perfusion Defects ◽  
Quantitative Stress ◽  
Perfusion Cmr

Abstract Funding Acknowledgements Type of funding sources: None. Background  Acute myocardial damage is common in hospitalized patients with severe COVID-19, with evidence of myocardial infarction and myocarditis demonstrated on cardiovascular magnetic resonance (CMR). Post-mortem studies have also implicated microvascular thrombosis, which may cause persistent microvascular disease.  Purpose  To determine the long-term coronary sequelae in recovered COVID-19 using multiparametric CMR including state-of-the-art inline quantitative stress myocardial blood flow (sMBF) mapping to assess global and regional sMBF. Methods  Prospective, multicentre observational study of recovered COVID-19 patients scanned at three London CMR units. Results were compared to a propensity-matched, pre-COVID chest pain cohort (104 patients referred for perfusion CMR, with subsequently demonstrated unobstructed coronary arteries) and 27 healthy volunteers (HV). Perfusion image analysis was performed using a novel artificial intelligence approach deriving global and regional stress and rest MBF with a cut-off of >2.25mL/g/min signifying normal sMBF and <1.82mL/g/min abnormal sMBF (Kotecha JCVI 2019).  Results  104 recovered, post-COVID patients (median age 62 years, 76% male; 89[87%] hospitalised, 41/89[46%] requiring ICU) underwent adenosine-stress perfusion CMR at a median 131(IQR 43-179) days from COVID-19 diagnosis. Median LVEF was 67% (IQR 60-71%; 12 (11.5%) with impaired LVEF), 51 patients (49%) had late gadolinium enhancement (LGE); 18% infarct-pattern and 33% non-ischaemic LGE.  Global stress MBF in post-COVID patients was no different to age-, sex- and co-morbidities-matched controls (2.57 ± 0.77 vs. 2.40 ± 0.75 ml/g/min, p = 0.11, Figure 1), though lower than HV (3.00 ± 0.76 ml/g/min, p = 0.001). Post-COVID, multivariate predictors of low sMBF were male sex (OR 0.57, 95%CI 0.41-0.80, p = 0.001) and hypertension (OR 0.67, 95%CI 0.51-0.88, p = 0.004), but not COVID-19 disease severity (ICU admission) or presence of scar (ischemic/non-ischemic).  21/42 with reduced sMBF (<2.25mL/g/min) had regional perfusion defects consistent with epicardial coronary disease. Conclusions   COVID-19 survivors do not demonstrate evidence of reduced global MBF by CMR compared to risk factor matched controls. Stress perfusion CMR identifies etiology of acute myocardial damage (infarction/myocarditis) and presence of occult coronary ischemia.

scholarly journals Use of quantitative myocardial perfusion mapping by CMR for characterisation of ischaemia in patients post coronary artery bypass graft surgery

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
A Seraphim ◽  
K Knott ◽  
AM Beirne ◽  
J Augusto ◽  
K Menacho ◽  
...  
Keyword(s):  
Blood Flow ◽  
Myocardial Perfusion ◽  
Myocardial Blood Flow ◽  
Perfusion Defect ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Artery Bypass Graft ◽  
Quantitative Myocardial Perfusion ◽  
Perfusion Defects ◽  
Perfusion Cmr

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Background Quantitative myocardial perfusion mapping using Cardiac Magnetic Resonance (CMR) imaging is used for evaluation of ischaemia in the context of native vessel coronary disease, but its diagnostic performance in patients with grafts is not well established. Perfusion defects are often detected in these patients, but whether these are a consequence of a technical limitation (delayed contrast arrival from graft conduits) or a true reflection of reduced myocardial blood flow is unclear. Methods 39 patients undergoing stress perfusion CMR with previous coronary artery bypass graft (CABG) surgery, unobstructed left internal mammary artery (LIMA) grafts to the left anterior descending (LAD) artery on coronary angiography and no CMR evidence of prior LAD infarction were included. Myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) were evaluated with quantitative perfusion mapping and the factors determining MBF in the LIMA-LAD territory (AHA segments 1,2,7,8,13,14), including the impact of delayed contrast arrival through the LIMA graft were evaluated. Results In 28 out of 39 cases a myocardial perfusion defect was reported on visual assessment in LIMA-LAD myocardial territory, despite the presence of unobstructed LIMA graft and no LAD infarction. Chronic total occlusion (CTO) of the native LAD was an independent predictor of stress MBF (B=-0.36, p =0.027) and the strongest predictor of MPR (B=-0.55, p 0.005) within the LIMA-LAD myocardial territory after adjusting for age, left ventricular (LV) ejection fraction, and presence of diabetes. CTO of the native LAD was associated with a reduction in stress MBF in the basal myocardial segments (-0.57ml/g/min, p = 0.002) but had no effect on the MBF of apical segments (-0.31ml/g/min, p = 0.084). Increasing the maximum value for allowable arterial delay (TA) of contrast in the quantitative mapping algorithm resulted in a small increase in myocardial blood flow in the LIMA-LAD territory both at stress (0.07 ± 0.08ml/g/min, p < 0.001) and rest (0.06 ± 0.05ml/g/min, p < 0.001). Conclusions Perfusion defects detected in LIMA-LAD subtended territories are common despite graft patency. These defects are likely to represent genuine reduction in MBF, resulting from native LAD coronary occlusion. Prolonged contrast transit time associated with LIMA grafts results in small underestimation of MBF as measured by quantitative CMR perfusion mapping, but does not account for the degree of MBF reduction seen in these patients. Figure 1. Study patient with unobstructed LIMA to LAD graft and evidence of inducible perfusion defect in LIMA-LAD territories. (A): First pass perfusion CMR imaging. (B): Perfusion mapping showing reduced stress MBF in mid antero-septum (0.85ml/g/min) compared to the apical septum (1.65ml/g/min). (C): Late gadolinium enhancement showing no evidence of previous infarction. (D,E): Coronary angiography demonstrating unobstructed LIMA graft (D) and anastomosis site (E). Abstract Figure 1.

scholarly journals Use of quantitative cardiovascular magnetic resonance myocardial perfusion mapping for characterization of ischemia in patients with left internal mammary coronary artery bypass grafts

2021 ◽  
Vol 23 (1) ◽  
Author(s):  
Andreas Seraphim ◽  
Kristopher D. Knott ◽  
Anne-Marie Beirne ◽  
Joao B. Augusto ◽  
Katia Menacho ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cardiovascular Magnetic Resonance ◽  
Coronary Artery ◽  
Magnetic Resonance ◽  
Myocardial Perfusion ◽  
Myocardial Blood Flow ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Internal Mammary ◽  
Perfusion Defects

Abstract Background Quantitative myocardial perfusion mapping using cardiovascular magnetic resonance (CMR) is validated for myocardial blood flow (MBF) estimation in native vessel coronary artery disease (CAD). Following coronary artery bypass graft (CABG) surgery, perfusion defects are often detected in territories supplied by the left internal mammary artery (LIMA) graft, but their interpretation and subsequent clinical management is variable. Methods We assessed myocardial perfusion using quantitative CMR perfusion mapping in 38 patients with prior CABG surgery, all with angiographically-proven patent LIMA grafts to the left anterior descending coronary artery (LAD) and no prior infarction in the LAD territory. Factors potentially determining MBF in the LIMA–LAD myocardial territory, including the impact of delayed contrast arrival through the LIMA graft were evaluated. Results Perfusion defects were reported on blinded visual analysis in the LIMA–LAD territory in 27 (71%) cases, despite LIMA graft patency and no LAD infarction. Native LAD chronic total occlusion (CTO) was a strong independent predictor of stress MBF (B = − 0.41, p = 0.014) and myocardial perfusion reserve (MPR) (B = − 0.56, p = 0.005), and was associated with reduced stress MBF in the basal (1.47 vs 2.07 ml/g/min; p = 0.002) but not the apical myocardial segments (1.52 vs 1.87 ml/g/min; p = 0.057). Extending the maximum arterial time delay incorporated in the quantitative perfusion algorithm, resulted only in a small increase (3.4%) of estimated stress MBF. Conclusions Perfusion defects are frequently detected in LIMA–LAD subtended territories post CABG despite LIMA patency. Although delayed contrast arrival through LIMA grafts causes a small underestimation of MBF, perfusion defects are likely to reflect true reductions in myocardial blood flow, largely due to proximal native LAD disease.

scholarly journals Flow manipulation and the association with myocardial contractility during extracorporeal life support (FLAME)

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
SKT Ma ◽  
WC Sin ◽  
CW Ngai ◽  
ASK Wong ◽  
WM Chan ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cardiogenic Shock ◽  
Myocardial Contractility ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Contractility ◽  
Left Ventricular Contractility ◽  
Extracorporeal Blood

Abstract Funding Acknowledgements Type of funding sources: None. Background Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an advanced technique in extracorporeal life support (ECLS) used to support extreme circulatory failure including patients with cardiac arrest and cardiogenic shock refractory to conventional support. It is a long-standing belief that peripheral V-A ECMO poses increased afterload to the inured heart, but conventional echocardiographic measurements are often insensitive in detecting subtle changes in loading conditions. Purpose This study aimed to evaluate the effects of varying blood flow during peripheral V-A ECMO on intrinsic myocardial contractility, using detailed echocardiographic assessment including speckle tracking echocardiography (STE). Methods Adult patients with acute cardiogenic shock who were supported by peripheral V-A ECMO from April 2019 to September 2020 were recruited. Serial hemodynamic and cardiac performance parameters were measured by transthoracic echocardiogram (TTE) within 48 hours after implementation of V-A ECMO, at different levels of extracorporeal blood flow – 100%, 120% and 50% of target blood flow (TBF). Results A total of 30 patients were included. 22 (71%) were male, and the mean (SD) age was 54 (13) years. The major indications for V-A ECMO were myocardial infarction (19, 63% patients), and myocarditis (5, 17%). With a decrease in extracorporeal blood flow from 100% to 50% of TBF, mean arterial pressure (MAP) dropped from 76+/-3 to 64+/-3mmHg (p <0.001), and cardiac index (CI) increased from 0.89+/-0.13 to 1.27+/-0.18L/min/m2 (p < 0.001). All indices of left ventricular contractility improved at a lower extracorporeal blood flow: the myocardial contractility measured by global longitudinal peak systolic strain (GLPSS) improved from -3+/-0.7% to -5+/-0.8% (p < 0.001); left ventricular ejection fraction (LVEF) increased from 21.5+/-2.6% to 30.9+/-2.7% (p < 0.001) and 19.7+/-3.1% to 28.4+/-3.2% (p < 0.001) by biplane and linear methods, respectively; left ventricular index of myocardial performance (LIMP) improved from 1.51+/-0.12 to 1.03+/-0.09 (p < 0.001). Similar findings were reproduced when comparing left ventricular contractility at extracorporeal blood flows of 120% and 50% of TBF. Conclusions The ECMO blood flow rate in peripheral V-A ECMO is inversely related to myocardial contractility, and is quantifiable by myocardial strain measured by STE.

Abstract 13303: Cardio-ankle Vascular Index Predicts New Onset Stroke in Patients With Heart Failure

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Yu Hotsuki ◽  
Akiomi YOSHIHISA ◽  
Yu Sato ◽  
Yasuhiro Ichijo ◽  
Koichiro Watanabe ◽  
...  
Keyword(s):  
Heart Failure ◽  
Regression Tree ◽  
Left Ventricular ◽  
Classification And Regression Tree ◽  
Left Ventricular Ejection ◽  
Chronic Obstructive ◽  
Post Discharge ◽  
Ventricular Ejection Fraction ◽  
Patients With Heart Failure ◽  
New Onset

Aim: We aimed to evaluate the implication of cardio-ankle vascular index (CAVI) to predict new onset stroke in patients with heart failure (HF). Methods and Results: This was a prospective observational study, which recruited clinical data of a total of 898 patients hospitalized for HF. According to the survival classification and regression tree analysis, the accurate cut-off value of CAVI in predicting post-discharge stroke was 9.6. We divided patients into two groups: the high CAVI group (CAVI > 9.6, n = 230, 25.6%) and the low CAVI group (CAVI ≤ 9.6, n = 668, 74.4%). We compared the patients’ characteristics and occurrence of new onset stroke. The high CAVI group was older (73.5 vs. 66.0 years old, P < 0.001) and had a higher prevalence of male sex (74.3% vs. 62.0%, P = 0.001) and prior stroke (23.5% vs. 17.5%, P = 0.047). The high CAVI group showed higher levels of B-type natriuretic peptide (246.0 vs. 165.1 pg/mL, P < 0.001) and lower levels of estimated glomerular filtration rate (51.6 vs. 61.8 mL/kg/1.73 m2, P < 0.001). In contrast, left ventricular ejection fraction, and prevalence of other co-morbidities such as hypertension, diabetes mellitus, dyslipidemia, chronic obstructive pulmonary disease was comparable between the two groups. The Kaplan-Meier analysis demonstrated that rate of new onset stroke was higher in the high CAVI group than in the low CAVI group ( Figure , log-rank P = 0.001). After adjusting for potential confounding factors, high CAVI was an independent predictor of new onset stroke (hazard ratio 2.359, 95% confidence interval 1.223-4.513, P=0.010). Conclusions: CAVI independently predicts new onset stroke in patients with HF.

scholarly journals Comparison of the prognostic value of stress and rest pulmonary transit time estimation using myocardial perfusion CMR

2021 ◽  
Vol 22 (Supplement_2) ◽  
Author(s):  
A Seraphim ◽  
K Knott ◽  
K Menacho ◽  
J Augusto ◽  
R Davies ◽  
...  
Keyword(s):  
Myocardial Perfusion ◽  
Transit Time ◽  
Cardiovascular Events ◽  
Prognostic Value ◽  
Time Estimation ◽  
Left Ventricular ◽  
Major Adverse Cardiovascular Events ◽  
Pulmonary Transit Time ◽  
Perfusion Cmr ◽  
Center Study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship Background Pulmonary transit time (PTT) is a quantitative biomarker of cardiopulmonary status. Rest PTT was previously shown to predict outcomes in specific disease models, but clinical adoption is hindered but challenges in data acquisition. Whether evaluation of PTT during stress encodes incremental prognostic information has not been previously investigated as scale. Objectives To compare the prognostic value of stress and rest PTT derived from a fully automated, in-line method of estimation using perfusion CMR, in a large patient cohort. Methods A retrospective two-center study of patients referred clinically for adenosine stress myocardial perfusion assessment using CMR. Analysis of right and left ventricular cavity arterial input function curves from first pass perfusion was performed automatically, allowing the in-line estimation of both rest and stress PTT. Association with major adverse cardiovascular events (MACE) was evaluated. MACE was defined as a composite outcome of myocardial infarction, stroke, heart failure admission and ventricular tachycardia or appropriate ICD treatment (including ICD shock and/or anti-tachycardia pacing). Results 985 patients (67% male, median age 62 years (IQR 52,71)) were included, with median left ventricular ejection fraction (LVEF) of 62% (IQR 54-69). Median stress PTT was shorter than rest PTT 6.2 (IQR 5.1, 7.7) seconds versus 7.7 (IQR, 6.4, 9.2) seconds. Stress and rest PTT were highly correlated (r = 0.69; p &lt; 0.001). Stress PTT also correlated with LVEF (r=-0.37), stress MBF (r=-0.31), LVEDVi (r = 0.24), LA area index (r = 0.32) (p &lt; 0.001 for all). Over a median follow-up period of 28.6 (IQR, 22.6 35,7) months, MACE occurred in 61 (6.2%) patients. After adjusting for prognostic factors, both rest and stress PTT, independently predicted MACE, but not all-cause mortality. For every 1xSD (2.39s) increase in rest PTT the adjusted hazard ratio (HR) for MACE was 1.43 (95% CI 1.10-1.85, p = 0.007). The hazard ratio for one standard deviation (2.64s) increase in stress PTT was 1.34 (95% CI 1.048-1.723; p = 0.020) after adjusting for age, LVEF, hypertension, diabetes, sex and presence of LGE Conclusions In this 2-center study of 985 patients, we deploy a fully automated method of PTT estimation using perfusion mapping with CMR and show that both stress and rest PTT are independently associated with adverse cardiovascular outcomes. In this patient cohort, there is no clear incremental prognostic value of stress PTT, over its evaluation during rest. Figure 1. Stress and Rest Pulmonary Transit Time estimation using myocardial perfusion CMR Figure 2. Event-free survival curves for major adverse cardiovascular events (Heart failure hospitalization, myocardial infarction, stroke and ventricular tachycardia/ICD treatment) according to mean rest PTT (8.05seconds) and mean stress PTT (6.7seconds). Log-rank for both p &lt; 0.05

scholarly journals Expert consensus regarding treatment of iron deficiency in stable and decompensated patients with heart failure

Kardiologiia ◽  
2021 ◽  
Vol 61 (4) ◽  
pp. 73-78
Author(s):  
Yu. V. Mareev ◽  
S. R. Gilarevsky ◽  
Yu. L. Begrambekova ◽  
Yu. M. Lopatin ◽  
A. A. Garganeeva ◽  
...  
Keyword(s):  
Heart Failure ◽  
Iron Deficiency ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ferric Carboxymaltose ◽  
Ventricular Ejection Fraction ◽  
Patients With Heart Failure ◽  
High Prevalence ◽  
Acute Decompensation

In recent years there has been significant interest in treating iron deficiency (ID) in patients with heart failure (HF) due to its high prevalence and detrimental effects in this population. As stated in the 2020 Russain HF guidelines, Intravenous ferric carboxymaltose remains the only proven therapy for ID.This document was prompted by the results from the recent AFFIRM-AHF trial which demonstrates that treatment of ID after acute HF decompensation reduces the risk of future decompensations. Experts have concluded that in HF patients with acute decompensation, a left ventricular ejection fraction of < 50% and ID, Intravenous ferric carboxymaltose reduces future HF hospitalisations. Patients with stable HF may also benefit from treatment of ID to improve quality of life and alleviate symptoms.  It is, therefore, reasonable to screen for and treat ID in patients with HF.

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