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Aims To explore whether left ventricular reverse remodelling (LVRR) is a predictor of outcomes in patients with functional mitral regurgitation (FMR) undergoing MitraClip procedure. Methods and results We analysed 184 consecutive patients with FMR who underwent successful MitraClip procedure. LVRR was defined as a reduction in left ventricular end‐systolic volume ≥ 10% from baseline to 6 months. LVRR was observed in 79 (42.9%) patients. Compared with non‐LVRR, LVRR patients were more likely to be females, less likely to have an ischaemic aetiology of mitral regurgitation or a prior (<6 months) heart failure (HF) hospitalization, and had smaller left ventricular dimensions. New York Heart Association class improved from baseline up to 1‐year follow‐up in both groups. Higher rates of overall survival (87.3% vs. 75.2%, P = 0.039), freedom from HF hospitalization (77.2% vs. 60%, P = 0.020), and freedom from the composite endpoint (cardiovascular mortality or HF hospitalization) (74.7% vs. 55.2%; P = 0.012) were observed in LVRR vs. non‐LVRR patients at 2‐year follow‐up. LVRR was associated with a significant reduction of the adjusted relative risk of mortality, HF hospitalization and composite endpoint [hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.20–0.96, P = 0.040; HR 0.55; 95% CI 0.32–0.97, P = 0.038; and HR 0.54; 95% CI 0.32–0.92, P = 0.023, respectively]. Female gender, absence of diabetes, freedom from prior HF hospitalization, non‐ischaemic aetiology of mitral regurgitation, and left ventricular end‐diastolic diameter < 75 mm were found to be independent predictors of LVRR. Conclusions Left ventricular reverse remodelling is associated with better long‐term outcomes in patients with FMR successfully treated with MitraClip. A careful patient selection may be useful as specific baseline features predict favourable left ventricular remodelling. [Correction added on 17 January 2019, after online publication: the preceding sentence has been changed.]

In patients at intermediate risk of CAD, hybrid imaging allows non-invasive co-localization of myocardial perfusion defects and subtending coronary arteries, impacting clinical decision-making in almost one every five subjects.

Multislice CT provides information on coronary luminal narrowing and on the structural abnormalities of the coronary arterial wall using densitometric analysis. We sought to investigate the effects of coronary luminal narrowing, structural abnormalities of the coronary arterial wall, and cardiovascular risk factors on regional and global myocardial blood flow (MBF) reserve. Methods: We studied 68 patients (mean age 6 SD, 61 6 10 y; 41 men, 27 women) with an intermediate probability of coronary artery disease. We measured the severity of coronary stenoses and the fibroadipose, fibromuscular, and calcium components of the coronary arterial wall by 64-row multislice CT coronary angiography. We also measured regional and global MBF reserve by PET using 13 Nammonia as a flow tracer at rest and after dipyridamole. Results: One or more significant coronary stenoses ($50% luminal narrowing) was present in 32 patients (47%), and nonsignificant stenoses were present in 15 patients (22%). Regional MBF reserve was significantly different in the territories perfused by normal coronary arteries, nonsignificant coronary stenoses, and significant coronary stenoses (P , 0.001). Calcium content was higher in the coronary arteries with significant or nonsignificant stenoses (0.95% 6 1.08% and 0.73% 6 0.93%, respectively) than in those without stenoses (0.11% 6 0.38%, P , 0.001). Significant coronary stenosis (P 5 0.047) and calcium content (P 5 0.017) were the only independent determinants of impaired regional MBF reserve using multivariate analysis. At multiple logistic regression analysis, the Framingham risk score, an index of global cardiovascular risk burden, was the only significant determinant of global MBF reserve (P 5 0.028). Conclusion: Coronary stenoses and coronary calcium content independently affect regional MBF reserve. Framingham risk score is the only significant determinant of global MBF reserve. Coronary blood flow reserve is a recognized indicator of the functional significance of coronary stenoses (1) and used to establish the need for coronary revascularization in the case of intermediate lesions (2). However, the use of absolute measurement of myocardial blood flow (MBF) and MBF reserve by PET has challenged this concept (3). Although PET-derived regional MBF reserve is inversely related to the degree of coronary stenoses, considerable interindividual variability exists (4,5). Early atherosclerosis (6), the function of downstream coronary microcirculation (7), and cardiovascular risk burden (8) have been reported as additional determinants of MBF reserve. However, the relationship between all these components and MBF impairment remains undetermined, mainly because of the limitations of diagnostic approaches used to date.Multislice CT (MSCT) and PET have the potential to better elucidate these relationships. MSCT can provide information not only on luminal narrowing but also on structural abnormalities of the vascular wall by means of densitometric analysis (9). Furthermore, MSCT can estimate coronary calcium...

An altered early SS-MIBG, assessed with a low-dose imaging protocol and a CZT cardiac camera, identifies patients with more impaired myocardial perfusion and contractile function.

Aims To investigate the prognostic relevance of coronary anatomy, coronary function, and early revascularization in patients with stable coronary artery disease (CAD). Methods and results From March 2009 to June 2012, 430 patients with suspected CAD (61 ± 9 years, 62% men) underwent coronary anatomical imaging by computed tomography coronary angiography (CTCA) and coronary functional imaging followed by invasive coronary angiography (ICA) if at least one non-invasive test was abnormal. Obstructive CAD was documented by ICA in 119 patients and 90 were revascularized within 90 days of enrolment. Core laboratory analysis showed that 134 patients had obstructive CAD by CTCA (>50% stenosis in major coronary vessels) and 79 significant ischaemia by functional imaging [>10% left ventricular (LV) myocardium]. Over mean follow-up of 4.4 years, major adverse events (AEs) (all-cause death, non-fatal myocardial infarction, or hospital admission for unstable angina or heart failure) or AEs plus late revascularization (LR) occurred in 40 (9.3%) and 58 (13.5%) patients, respectively. Obstructive CAD at CTCA was the only independent imaging predictor of AEs [hazard ratio (HR) 3.2, 95% confidence interval (CI) 1.10–9.30; P = 0.033] and AEs plus LR (HR 4.3, 95% CI 1.56–11.81; P = 0.005). Patients with CAD in whom early revascularization was performed in the presence of ischaemia and deferred in its absence had fewer AEs, similar to patients without CAD (HR 2.0, 95% CI 0.71–5.51; P = 0.195). Conclusion Obstructive CAD imaged by CTCA is an independent predictor of clinical outcome. Early management of CAD targeted to the combined anatomical and functional disease phenotype improves clinical outcome.

Objective— Circulating levels of high-sensitivity cardiac troponin T (hs-cTnT) and N terminal pro brain natriuretic peptide (NT-proBNP) are predictors of prognosis in patients with coronary artery disease (CAD). We aimed at evaluating the effect of coronary atherosclerosis and myocardial ischemia on cardiac release of hs-cTnT and NT-proBNP in patients with suspected CAD. Approach and Results— Hs-cTnT and NT-proBNP were measured in 378 patients (60.1±0.5 years, 229 males) with stable angina and unknown CAD enrolled in the Evaluation of Integrated Cardiac Imaging (EVINCI) study. All patients underwent stress imaging to detect myocardial ischemia and coronary computed tomographic angiography to assess the presence and characteristics of CAD. An individual computed tomographic angiography score was calculated combining extent, severity, composition, and location of plaques. In the whole population, the median (25–75 percentiles) value of plasma hs-cTnT was 6.17 (4.2–9.1) ng/L and of NT-proBNP was 61.66 (31.2–132.6) ng/L. In a multivariate model, computed tomographic angiography score was an independent predictor of the plasma hs-cTnT (coefficient 0.06, SE 0.02; P =0.0089), whereas ischemia was a predictor of NT-proBNP (coefficient 0.38, SE 0.12; P =0.0015). Hs-cTnT concentrations were significantly increased in patients with CAD with or without myocardial ischemia ( P <0.005), whereas only patients with CAD and ischemia showed significantly higher levels of NT-proBNP ( P <0.001). Conclusions— In patients with stable angina, the presence and extent of coronary atherosclerosis is related with circulating levels of hs-cTnT, also in the absence of ischemia, suggesting an ischemia-independent mechanism of hs-cTnT release. Obstructive CAD causing myocardial ischemia is associated with increased levels of NT-proBNP.

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