190 SARS-CoV-2 associated myopericarditis in a patient with previous myocarditis

Aims Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is well described as being responsible for multi-organ involvement and SARS-CoV-2 cardiac involvement was observed since the beginning of the spread of the infection. However, there are no descriptions of acute myopericarditis in patient with previous myocarditis. Methods and results Cardiac involvement was assessed with electrocardiographic and echocardiographic changes and with increased levels of cardiac high-sensitivity troponin T (hs-cTnT). Diagnosis was confirmed with cardiac magnetic resonance imaging (CMR) and coronary artery disease (CAD) was excluded with coronary angiography. A 53-years-old woman with hypokinetic cardiomyopathy due to a previous myocarditis and recent COVID-19 pneumonia reached the Emergency Department with chest pain and tachycardia in December 2020. Twelve-lead ECG was not conclusive and after detection of significative increase of hs-cTnT she was admitted to the Cardiology Department. Transthoracic echocardiography showed reduction of left ventricle ejection fraction, subendocardial bright appearance and mild pericardial effusion. Coronary angiography excluded obstructive CAD and CMR confirmed diagnosis of recent myocarditis and worsening of left and right ventricular ejection fraction compared to a previous CMR. Patient was treated with evidence-based therapy for heart failure, prednisone, intravenous immunoglobulins, ibuprofen, and colchicine. Cardiac biomarkers reduced within the normal range, symptoms improved, and the patient was discharged asymptomatic and haemodynamically stable. Conclusions SARS-CoV-2, as already described in literature, can be associated with inflammatory cardiac involvement. This is the first report of SARS-CoV-2 associated myopericarditis in a patient with previous history of myocarditis and recent SARS-CoV-2 pneumonia. In our experience the patient was successfully treated with evidence-based therapy for heart failure and immunomodulation therapy.

What Is the Importance of Electrocardiography in the Routine Screening of Patients with Repaired Tetralogy of Fallot?

Background: In patients following complete repair of the tetralogy of Fallot, the duration of the QRS complex is associated with the size and mechanical function of the right ventricle, which are contemporarily assessed by cardiac magnetic resonance (CMR). Methods: 38 patients aged 18.0–54.9 years (median age 24.9 years) who had undergone complete repair of the tetralogy of Fallot were examined using CMR and concomitant 24 h ambulatory electrocardiography monitoring. We used statistical analysis to investigate the correlations between electrocardiographic parameters (heart rate, HR; PQ interval, PQ; QRS duration, QRS; and corrected QT interval, QTc) and CMR results (right ventricular ejection fraction, RVEF; right ventricular end-diastolic volume index, RVEDVI; and right ventricular end-systolic volume index, RVESVI) for patients after early and late repair. Results: The ECG-based parameters were not correlated with time since repair. There were significant correlations between QRS duration and RVEF (r = −0.61), RVEDVI (r = 0.56), and RVESVI (r = 0.54) for early operated patients but not for late-operated patients. No other substantial correlations were reported. Conclusion: Despite its role in screening for arrhythmias, electrocardiography has a limited role as a predictor of morphology and function of the right ventricle in patients after repair of the tetralogy of Fallot.

Assessment of Coronary Inflammation by Pericoronary Fat Attenuation Index in Clinically Suspected Myocarditis with Infarct-Like Presentation

Background: The pathophysiology of angina-like symptoms in myocarditis is still unclear. Perivascular fat attenuation index (pFAI) by coronary computed tomography angiography (CCTA) is a non-invasive marker of coronary inflammation (CI) in atherosclerosis. We explored the presence of CI in clinically suspected myocarditis with infarct-like presentation. Methods: We retrospectively included 15 consecutive patients (67% male, age 30 ± 10 years) with clinically suspected infarct-like myocarditis who underwent CCTA to rule out coronary artery disease. Right coronary artery (RCA) pFAI mean value was compared with that of healthy volunteers. Results: Mean RCA pFAI value was −92.8 ± 8.4 HU, similar to that of healthy volunteers (−95.2 ± 6.0, p = 0.8). We found no correlation between RCA pFAI mean values and peak Troponin I (r = −0.43, p = 0.11) and C-reactive protein at diagnosis (r = −0.25, p = 0.42). Patients with higher pFAI values showed higher biventricular end-systolic volumes (ESV) (p = 0.038 for left and p = 0.024 for right ventricle) and lower right ventricular ejection fraction (RVEF) (p = 0.038) on cardiovascular magnetic resonance. Conclusions: In clinically suspected myocarditis with infarct-like presentation, RCA pFAI values are lower than those validated in atherosclerosis. The correlation between higher pFAI values, higher biventricular ESV and lower RVEF, may suggest a role of pFAI in predicting non-atherosclerotic CI (i.e., infective/immune-mediated “endothelialitis”).

Added predictive value of right ventricular ejection fraction compared with conventional echocardiographic measurements in patients who underwent diverse cardiovascular procedures

ABSTRACTBackground and AimRight ventricular (RV) ejection fraction (EF) assessed by 3D echocardiography is a powerful measure to detect RV dysfunction. However, its prognostic value in routine clinical practice has been scarcely explored. Accordingly, we aimed at investigating whether RVEF is associated with 2-year all-cause mortality in patients who underwent diverse cardiovascular procedures and to test whether RVEF can overcome conventional echocardiographic parameters in terms of outcome prediction.Patients and MethodsOne hundred and seventy-four patients were retrospectively identified who underwent clinically indicated transthoracic echocardiography comprising 3D acquisitions. The patient population consisted of heart failure with reduced ejection fraction patients (44%), heart transplanted patients (16%), and severe valvular heart disease patients (39%). Beyond conventional echocardiographic measurements, RVEF was quantified by 3D echocardiography. The primary endpoint of our study was all-cause mortality at two years.ResultsTwenty-four patients (14%) met the primary endpoint. Patients with adverse outcomes had significantly lower RVEF (alive vs. dead; 48±9 vs. 42±9%, p<0.01). However, tricuspid annular plane systolic excursion (21±7 vs. 18±4mm), and RV systolic pressure (36±15 vs. 39±15mmHg) were similar. By Cox analysis, RVEF was found to be associated with adverse outcomes (HR [95% CI]: 0.945 [0.908 – 0.984], p<0.01). By receiver-operator characteristic analysis, RVEF exhibited the highest AUC value compared with the other RV functional measures (0.679; 95% CI: 0.566 – 0.791).ConclusionsConventional echocardiographic measurements may be inadequate to support a granular risk stratification in patients who underwent different cardiac procedures. RVEF may be a robust clinical parameter, which is significantly associated with adverse outcomes

Right ventricular remodelling after endo-exclusion during pulmonary valve replacement: evaluation by cardiac magnetic resonance

OBJECTIVES Pulmonary valve replacement (PVR) performed for pulmonary valve regurgitation is the most common indication for reoperation during mid-to-long-term follow-up after tetralogy of Fallot repair. An aneurysmal dilation of the infundibulum is often associated secondary to the infundibulotomy performed in the first operation. The right ventricular outflow tract reconstruction with endo-exclusion aims to exclude the non-contractile segments of the dilated right ventricular. This study intends to assess the safety and efficiency of the endo-exclusion technique. METHODS Between January 2010 and December 2018, 86 patients underwent a PVR with (n = 46) or without (n = 40) endo-exclusion. The current study compares the outcomes in terms of survival, reintervention, structural valve deterioration, right ventricular function (volume and right ventricular ejection fraction) and pulmonary valve gradient. The median follow-up time was 4.45 years (1.9 months to 9.87 years). RESULTS There was no 30-day mortality. There was no difference in the freedom from reintervention at 7 years (without endo-exclusion, 97%, versus with endo-exclusion, 94%, log-rank = 0.68) or in the freedom from structural pulmonary valve deterioration at 7 years (without endo-exclusion, 94%, versus with endo-exclusion, 89%, log-rank = 0.94). No significant difference was observed in the indexed right ventricular end-diastolic volume (102.2 ± 34 ml/m2 in the PVR without endo-exclusion group and 93.3 ± 22 ml/m2 in the PVR with endo-exclusion group, P = 0.61). No significant difference was observed in the right ventricular function (right ventricular ejection fraction: 46 ± 11% in the PVR without endo-exclusion group and 46 ± 9% in the PVR with endo-exclusion group, P = 0.88). CONCLUSIONS PVR with or without endo-exclusion is a safe and effective procedure. PVR with endo-exclusion allows implantation without structural deformation of the valve and therefore excellent short- and medium-term results.

Right Ventricular Ejection Fraction for the Prediction of Major Adverse Cardiovascular and Heart Failure-Related Events

Background: There is increasing evidence that right ventricular ejection fraction (RVEF) may provide incremental value to left ventricular (LV) ejection fraction for the prediction of major adverse cardiovascular events. To date, generalizable utility for RVEF quantification in patients with cardiovascular disease has not been established. Using a large prospective clinical outcomes registry, we investigated the prognostic value of RVEF for the prediction of major adverse cardiovascular events- and heart failure-related outcomes. Methods: Seven thousand one hundred thirty-one consecutive patients with known or suspected cardiovascular disease undergoing cardiovascular magnetic resonance imaging were prospectively enrolled. Multichamber volumetric quantification was performed by standardized operational procedures. Patients were followed for the primary composite outcome of all-cause death, survived cardiac arrest, admission for heart failure, need for transplantation or LV assist device, acute coronary syndrome, need for revascularization, stroke, or transient ischemic attack. A secondary, heart failure focused outcome of heart failure admission, need for transplantation/LV assist device or death was also studied. Results: Mean age was 54±15 years. The mean LV ejection fraction was 55±14% (range 6%–90%) with a mean RVEF of 54±10% (range 9%–87%). At a median follow-up of 908 days, 870 (12%) patients experienced the primary composite outcome and 524 (7%) the secondary outcome. Each 10% drop in RVEF was associated with a 1.3-fold increased risk of the primary outcome ( P <0.001) and 1.5-fold increased risk of the secondary outcome ( P <0.001). RVEF was an independent predictor following comprehensive covariate adjustment, inclusive of LV ejection fraction. Patients with an RVEF<40% experienced a 3.1-fold risk of the primary outcome ( P <0.001) with a 1-year cumulative event rate of 22% versus 7% above this cutoff. Conclusions: RVEF is a powerful and independent predictor of major adverse cardiac events with broad generalizability across patients with known or suspected cardiovascular disease. These findings support migration towards biventricular phenotyping for the classification of risk in clinical practice. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04367220.

The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications

Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.

Prognostic Value of Right Ventricular Ejection Fraction Assessed by 3D Echocardiography in COVID-19 Patients

Background: RVEF (right ventricular ejection fraction) measured by three-dimensional echocardiography (3DE) has been used in evaluating right ventricular (RV) function and can provide useful prognostic information in other various cardiovascular diseases. However, the prognostic value of 3D-RVEF in coronavirus disease 2019 (COVID-19) remains unknown. We aimed to investigate whether 3D-RVEF can predict the mortality of COVID-19 patients.Methods: A cohort of 128 COVID-19-confirmed patients who had undergone echocardiography were studied. Thirty-one healthy volunteers were also enrolled as controls. COVID-19 patients were divided into three subgroups (general, severe, and critical) according to COVID-19 severity-of-illness. Conventional RV structure and function parameters, RV free wall longitudinal strain (FWLS) and 3D-RVEF were acquired. RVFWLS was measured by two-dimensional speckle tracking echocardiography. RVEF was acquired by 3DE.Results: Compared with controls, 2D-RVFWLS and 3D-RVEF were both significantly decreased in COVID-19 patients (−27.2 ± 4.4% vs. −22.9 ± 4.8%, P &lt; 0.001; 53.7 ± 4.5% vs. 48.5 ± 5.8%, P &lt; 0.001). Critical patients were more likely to have a higher incidence of acute cardiac injury and acute respiratory distress syndrome (ARDS), and worse prognosis than general and severe patients. The critical patients exhibited larger right-heart chambers, worse RV fractional area change (RVFAC), 2D-RVFWLS, and 3D-RVEF and higher proportion of pulmonary hypertension than general and severe patients. Eighteen patients died during a median follow-up of 91 days. The multivariate Cox regression analysis revealed the acute cardiac injury, ARDS, RVFAC, RVFWLS, and 3D-RVEF were independent predictors of death. 3D-RVEF (chi-square to improve 18.3; P &lt; 0.001), RVFAC (chi-square to improve 4.5; P = 0.034) and 2D-RVFWLS (chi-square to improve 5.1; P = 0.024) all provided additional prognostic value of higher mortality over clinical risk factors. Moreover, the incremental predictive value of 3D-RVEF was significantly (P &lt; 0.05) higher than RVFAC and RVFWLS.Conclusion: 3D-RVEF was the most robust independent predictor of mortality in COVID-19 patients and provided a higher predictive value over conventional RV function parameters and RVFWLS, which may be helpful to identify COVID-19 patients at a higher risk of death.