RESUMEN
OBJECTIVES: This study sought to evaluate the long-term mortality in patients with viral myocarditis, and to establish the prognostic value of various clinical, functional, and cardiovascular magnetic resonance (CMR) parameters. BACKGROUND: Long-term mortality of viral myocarditis, as well as potential risk factors for poor clinical outcome, are widely unknown. METHODS: A total of 222 consecutive patients with biopsy-proven viral myocarditis and CMR were enrolled. A total of 203 patients were available for clinical follow-up, and 77 patients underwent additional follow-up CMR. The median follow-up was 4.7 years. Primary endpoints were all-cause mortality and cardiac mortality. RESULTS: We found a relevant long-term mortality in myocarditis patients (19.2% all cause, 15% cardiac, and 9.9% sudden cardiac death [SCD]). The presence of late gadolinium enhancement (LGE) yields a hazard ratio of 8.4 for all-cause mortality and 12.8 for cardiac mortality, independent of clinical symptoms. This is superior to parameters like left ventricular (LV) ejection fraction, LV end-diastolic volume, or New York Heart Association (NYHA) functional class, yielding hazard ratios between 1.0 and 3.2 for all-cause mortality and between 1.0 and 2.2 for cardiac mortality. No patient without LGE experienced SCD, even if the LV was enlarged and impaired. When focusing on the subgroup undergoing follow-up CMR, we found an initial NYHA functional class >I as the best independent predictor for incomplete recovery (p = 0.03). CONCLUSIONS: Among our population with a wide range of clinical symptoms, biopsy-proven viral myocarditis is associated with a long-term mortality of up to 19.2% in 4.7 years. In addition, the presence of LGE is the best independent predictor of all-cause mortality and of cardiac mortality. Furthermore, initial presentation with heart failure may be a good predictor of incomplete long-term recovery.
Asunto(s)
Biopsia/métodos , Infecciones Cardiovasculares/patología , Miocarditis/patología , Miocardio/patología , Recuperación de la Función , Medición de Riesgo/métodos , Virosis/patología , Adulto , Infecciones Cardiovasculares/mortalidad , Infecciones Cardiovasculares/virología , Causas de Muerte/tendencias , Electrocardiografía , Femenino , Estudios de Seguimiento , Alemania/epidemiología , Humanos , Imagen por Resonancia Cinemagnética , Masculino , Persona de Mediana Edad , Miocarditis/mortalidad , Miocarditis/virología , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Virosis/mortalidad , Virosis/virologíaRESUMEN
Cardiovascular magnetic resonance (CMR) imaging holds promise for diagnosing myocarditis in vivo. The CMR diagnosis of myocarditis is determined by the ventricular morphology/function, late gadolinium enhancement, and T(2)-weighted imaging for myocardial edema. However, in routine clinical practice, we encounter patients with suspected myocarditis in the absence of left ventricular dysfunction, myocardial edema, or late gadolinium enhancement. In the present study, we sought to determine whether the presence of pericardial effusion could serve as a new diagnostic criterion and improve the sensitivity of CMR imaging to detect myocarditis. A total of 35 consecutive patients with biopsy proven virus-associated myocarditis, onset of clinical symptoms within the past 3 months, and normal left ventricular function were enrolled in the present study. All patients underwent echocardiography, CMR imaging, and endomyocardial biopsy for workup of myocarditis. Late gadolinium enhancement was present in 16 patients (46%). Myocardial edema on T(2)-weighted imaging was present in 4 patients, but in just 1, it was the only abnormal finding. Pericardial effusion was present in 14 patients (40%). In 7 patients with myocarditis (20%), pericardial effusion was the only abnormal finding. Pericardial effusion, used as an additional diagnostic criterion, improved the sensitivity of CMR imaging for myocarditis from 46% to 66% (p = 0.023). In conclusion, pericardial effusion detected by CMR imaging might serve as a new diagnostic criterion for the noninvasive diagnosis of myocarditis in patients with recent onset of clinical symptoms and normal left ventricular function.
Asunto(s)
Aumento de la Imagen/métodos , Procesamiento de Imagen Asistido por Computador/métodos , Imagen por Resonancia Magnética/métodos , Miocarditis/diagnóstico , Derrame Pericárdico/diagnóstico , Virosis/diagnóstico , Adulto , Anciano , Biopsia , Ecocardiografía , Edema/diagnóstico , Edema/patología , Electrocardiografía , Endocardio/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Miocarditis/patología , Miocardio/patología , Sensibilidad y Especificidad , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/patología , Virosis/patología , Adulto JovenRESUMEN
OBJECTIVES: We sought to establish the prognostic value of a comprehensive cardiovascular magnetic resonance (CMR) examination in risk stratification of hypertrophic cardiomyopathy (HCM) patients. BACKGROUND: With annual mortality rates ranging between 1% and 5%, depending on patient selection, a small but significant number of HCM patients are at risk for an adverse event. Therefore, the identification of and prophylactic therapy (i.e., defibrillator placement) in patients with HCM who are at risk of dying are imperative. METHODS: Two-hundred forty-three consecutive patients with HCM were prospectively enrolled. All patients underwent initial CMR, and 220 were available for clinical follow-up. The mean follow-up time was 1,090 days after CMR. End points were all-cause and cardiac mortality. RESULTS: During follow-up 20 of the 220 patients died, and 2 patients survived sudden cardiac death due to adequate implantable cardioverter-defibrillator discharge. Most events (n = 16) occurred for cardiac reasons; the remaining 6 events were related to cancer and accidents. Our data indicate that the presence of scar visualized by CMR yields an odds ratio of 5.47 for all-cause mortality and of 8.01 for cardiac mortality. This might be superior to classic clinical risk factors, because in our dataset the presence of 2 risk factors yields an odds ratio of 3.86 for all-cause and of 2.20 for cardiac mortality, respectively. Multivariable analysis also revealed the presence of late gadolinium enhancement as a good independent predictor of death in HCM patients. CONCLUSIONS: Among our population of largely low or asymptomatic HCM patients, the presence of scar indicated by CMR is a good independent predictor of all-cause and cardiac mortality.
Asunto(s)
Cardiomiopatía Hipertrófica/diagnóstico , Cardiomiopatía Hipertrófica/mortalidad , Cicatriz/complicaciones , Cicatriz/diagnóstico , Imagen por Resonancia Magnética/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Factores de RiesgoRESUMEN
BACKGROUND: Perfusion cardiovascular magnetic resonance (CMR) has a high sensitivity for the detection of significant coronary artery disease (CAD). However, the specificity of this method is lower than its sensitivity. The reason for this observation is hitherto unclear and has been either explained by 'false-positive' results or by microvascular dysfunction in patients without CAD. OBJECTIVE: To evaluate whether pathological myocardial perfusion-CMR imaging in symptomatic patients without significant CAD is associated with coronary epicardial or microvascular dysfunction. METHODS: In this retrospective study, 42 patients who presented with unstable angina pectoris underwent (a) an adenosine-stress perfusion-CMR study; (b) coronary angiography; (c) intracoronary acetylcholine (ACh) testing following coronary angiography with exclusion of significant CAD. The CMR protocol comprised cine imaging followed by adenosine first-pass perfusion imaging and late gadolinium enhancement-CMR. Diagnostic left ventriculography and multiplane coronary angiography were performed before intracoronary ACh testing. RESULTS: An adenosine-induced, reversible subendocardial perfusion defect was detected in 22/42 patients (52%) without significant CAD. Coronary epicardial vasospasm was detected in 10/42 patients (24%) while microvascular dysfunction was found in 20/42 patients (48%). Patients with a reversible stress-induced perfusion defect had significantly more often a pathological coronary epicardial or microvascular vasoreaction (20/22; 91%) during intracoronary ACh testing than those without a perfusion defect (10/20; 50%; p<0.01). Univariate correlation analyses revealed a substantial association between a pathological ACh-testing result and a perfusion defect in the antecedent CMR study (r= +0.45; p<0.01). CONCLUSIONS: Reversible perfusion defects depicted by perfusion-CMR in patients without significant CAD are mostly due to coronary epicardial or microvascular dysfunction, and correct interpretation of such perfusion-CMR results may enable targeted treatment.
Asunto(s)
Acetilcolina , Angina de Pecho/diagnóstico , Angiografía Coronaria , Angiografía por Resonancia Magnética , Imagen de Perfusión Miocárdica , Vasodilatadores , Acetilcolina/administración & dosificación , Adenosina , Adulto , Anciano , Anciano de 80 o más Años , Medios de Contraste , Femenino , Gadolinio DTPA , Humanos , Imagen por Resonancia Cinemagnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Vasodilatadores/administración & dosificaciónRESUMEN
OBJECTIVES: We wanted to assess the value of cardiovascular magnetic resonance (CMR) stress testing for evaluation of women with suspected coronary artery disease (CAD). BACKGROUND: A combined perfusion and infarction CMR examination can accurately diagnose CAD in the clinical setting in a mixed gender population. METHODS: We prospectively enrolled 147 consecutive women with chest pain or other symptoms suggestive of CAD at 2 centers (Duke University Medical Center, Robert-Bosch-Krankenhaus). Each patient underwent a comprehensive clinical evaluation, a CMR stress test consisting of cine rest function, adenosine-stress and rest perfusion, and delayed-enhancement CMR infarction imaging, and X-ray coronary angiography within 24 h. The components of the CMR test were analyzed visually both in isolation and combined using a pre-specified algorithm. Coronary artery disease was defined as stenosis > or =70% on quantitative analysis of coronary angiography. RESULTS: Cardiovascular magnetic resonance imaging was completed in 136 females (63.0 +/- 11.1 years), 37 (27%) women had CAD on coronary angiography. The combined CMR stress test had a sensitivity, specificity, and accuracy of 84%, 88%, and 87%, respectively, for the diagnosis of CAD. Diagnostic accuracy was high at both sites (Duke University Medical Center 82%, Robert-Bosch-Krankenhaus 90%; p = 0.18). The accuracy for the detection of CAD was reduced when intermediate grade stenoses were included (82% vs. 87%; p = 0.01 compared the cutoff of stenosis > or =50% vs. > or =70%). The sensitivity was lower in women with single-vessel disease (71% vs. 100%; p = 0.06 compared with multivessel disease) and small left ventricular mass (69% vs. 95%; p = 0.04 for left ventricular mass < or =97 g vs. >97 g). The latter difference was even more significant after accounting for end-diastolic volumes (70% vs. 100%; p = 0.02 for left ventricular mass indexed to end-diastolic volume < or =1.15 g/ml vs. >1.15 g/ml). CONCLUSIONS: A multicomponent CMR stress test can accurately diagnose CAD in women. Detection of CAD in women with intermediate grade stenosis, single-vessel disease, and with small hearts is challenging.