Publications by authors named "Theano Papavassiliu"

89 Publications

Prediction of cardiac events with non-contrast magnetic resonance feature tracking in patients with ischaemic cardiomyopathy.

ESC Heart Fail 2021 Nov 24. Epub 2021 Nov 24.

1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Heidelberg, D-68167, Germany.

Aims: The aim of this study was to evaluate the prognostic value of feature tracking (FT) derived cardiac magnetic resonance (CMR) strain parameters of the left ventricle (LV)/right ventricle (RV) in ischaemic cardiomyopathy (ICM) patients treated with an implantable cardioverter-defibrillator (ICD). Current guidelines suggest a LV-ejection fraction ≤35% as major criterion for ICD implantation in ICM, but this is a poor predictor for arrhythmic events. Supplementary parameters are missing.

Methods And Results: Ischaemic cardiomyopathy patients (n = 242), who underwent CMR imaging prior to primary and secondary implantation of ICD, were classified depending on EF ≤ 35% (n = 188) or >35% (n = 54). FT parameters were derived from steady-state free precession cine views using dedicated software. The primary endpoint was a composite of cardiovascular mortality (CVM) and/or appropriate ICD therapy. There were no significant differences in FT-function or LV-/RV-function parameters in patients with an EF ≤ 35% correlating to the primary endpoint. In patients with EF > 35%, standard CMR functional parameters, such as LV-EF, did not reveal significant differences. However, significant differences in most FT parameters correlating to the primary endpoint were observed in this subgroup. LV-GLS (left ventricular-global longitudinal strain) and RV-GRS (right ventricular-global radial strain) revealed the best diagnostic performance in ROC curve analysis. The combination of LV-GLS and RV-GRS showed a sensitivity of 85% and a specificity of 76% for the prediction of future events.

Conclusions: The impact of FT derived measurements in the risk stratification of patients with ICM depends on LV function. The combination of LV-GLS/RV-GRS seems to be a predictor of cardiovascular mortality and/or appropriate ICD therapy in patients with EF > 35%.
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http://dx.doi.org/10.1002/ehf2.13712DOI Listing
November 2021

Risk stratification of patients with Brugada syndrome: the impact of myocardial strain analysis using cardiac magnetic resonance feature tracking.

Hellenic J Cardiol 2021 Sep-Oct;62(5):329-338. Epub 2021 Jun 1.

First Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Germany.

Objective: This study evaluated the prognostic significance of cardiac magnetic resonance myocardial feature tracking (CMR-FT) in patients with Brugada syndrome (BrS) to detect subclinical alterations and predict major adverse events (MAE).

Methods: CMR was performed in 106 patients with BrS and 25 healthy controls. Biventricular global strain analysis was assessed using CMR-FT. Patients were followed over a median of 11.6 [8.8 ± 13.8] years.

Results: The study cohort was subdivided according to the presence of a spontaneous type 1 ECG (sECG) into sBrS (BrS with sECG, n = 34 (32.1%)) and diBrS (BrS with drug-induced type 1 ECG, n = 72 (67.9%)). CMR-FT revealed morphological differences between sBrS and diBrS patients with regard to right ventricular (RV) strain (circumferential (%) (sBrS -7.9 ± 2.9 vs diBrS - 9.5 ± 3.1, p = 0.02) and radial (%) (sBrS 12.0 ± 4.3 vs diBrS 15.4 ± 5.4, p = 0.004)). During follow-up, MAE occurred in 11 patients (10.4%). Multivariable analysis was performed to identify independent predictors for the occurrence of events during follow-up. The strongest predictive value was found for RV circumferential strain (OR 3.2 (95% CI 1.4 - 6.9), p = 0.02) and RVOT/BSA (OR 3.1 (95% CI 1.0 - 7.0), p = 0.03).

Conclusions: Myocardial strain analysis detected early subclinical alterations, prior to apparent changes in myocardial function, in patients with BrS. While usual functional parameters were within the normal range, CMR-FT revealed pathological results in patients with an sECG. Moreover, RV circumferential strain and RVOT size provided additional prognostic information on the occurrence of MAE during follow-up, which reflects electrical vulnerability.
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http://dx.doi.org/10.1016/j.hjc.2021.05.003DOI Listing
November 2021

Determinants of arterial stiffness in patients with atrial fibrillation.

Arch Cardiovasc Dis 2021 Aug-Sep;114(8-9):550-560. Epub 2021 Apr 23.

First department of medicine (cardiology), University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, European Centre for AngioScience (ECAS), 68167 Mannheim, Germany; DZHK (German centre for cardiovascular research) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany. Electronic address:

Background: Arterial stiffness has emerged as a strong predictor of cardiovascular disease, end-organ damage and all-cause mortality. Although increased arterial stiffness has been described as a predictor of atrial fibrillation, the relationship between arterial stiffness and atrial fibrillation is uncertain.

Aim: We assessed arterial stiffness in patients with atrial fibrillation compared with that in a control group.

Methods: We enrolled 151 patients with atrial fibrillation who underwent pulmonary vein isolation (mean age 71.1±9.8 years) and 54 control patients with similar cardiovascular risk profiles and sinus rhythm, matched for age (mean age 68.6±15.7 years) and sex. Aortic distensibility as a measure of arterial stiffness was assessed by transoesophageal echocardiography. Patients with atrial fibrillation were followed over a median of 21 (15 to 31) months.

Results: Compared with control patients, patients with atrial fibrillation had significantly lower aortic distensibility (1.8±1.1 vs. 2.1±1.1 10mmHg; P=0.02). Age (hazard ratio 0.67, 95% confidence interval 0.003 to 0.03; P=0.02) and pulse pressure (hazard ratio -1.35, 95% confidence interval -0.07 to -0.03; P<0.0001) were the strongest predictors of decreased aortic distensibility in the study cohort. This effect was independent of the type of atrial fibrillation (paroxysmal/persistent). During follow-up, decreased aortic distensibility was a predictor of cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, with a higher incidence rate of events in patients in the lowest aortic distensibility quartile (P=0.001).

Conclusions: Aortic distensibility was significantly reduced in patients with atrial fibrillation, with age and pulse pressure showing the strongest correlation, independent of the type of atrial fibrillation. Additionally, decreased aortic distensibility was associated with cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, which showed a quartile-dependent occurrence.
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http://dx.doi.org/10.1016/j.acvd.2020.12.009DOI Listing
October 2021

Extent of peri-infarct scar on late gadolinium enhancement cardiac magnetic resonance imaging and outcome in patients with ischemic cardiomyopathy.

Heart Rhythm 2021 06 28;18(6):954-961. Epub 2021 Jan 28.

Department of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany.

Background: Only a minority of patients who receive an implantable cardioverter-defibrillator (ICD) on the basis of left ventricular ejection fraction receive appropriate ICD therapy. Peri-infarct scar zone assessed by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is a possible substrate for ventricular tachyarrhytmias (VTAs).

Objective: The aim of our prospective study was to determine whether LGE-CMR parameters can predict the occurrence of VTA in patients with ischemic cardiomyopathy (ICM).

Methods: Two hundred sixteen patients with ICM underwent CMR imaging before primary or secondary ICD implantation and were prospectively followed. We assessed CMR indices and CMR scar characteristics (infarct core and peri-infarct zone) to predict outcome and VTAs.

Results: Patients were followed up for 1497 days (interquartile range 697-2237 days). Forty-seven patients (21%) received appropriate therapy during follow-up. Patients with appropriate ICD therapy had smaller core scar (31.5% ± 8.5% vs 36.8% ± 8.9%; P = .0004) but larger peri-infarct scar (12.4% ± 2.6% vs 10.5% ± 2.9%; P = .0001) than did patients without appropriate therapy. In multivariate Cox regression analysis, peri-infarct scar (hazard ratio 1.15; 95% confidence interval 1.07-1.24; P = .0001) was independently and significantly associated with VTAs whereas left ventricular ejection fraction, right ventricular ejection fraction, core scar, and left atrial ejection fraction were not.

Conclusion: Scar extent of peri-infarct border zone was significantly associated with appropriate ICD therapy. Thus, LGE-CMR parameters can identify a subgroup of patients with ICM and an increased risk of life-threatening VTAs.
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http://dx.doi.org/10.1016/j.hrthm.2021.01.023DOI Listing
June 2021

Arterial Stiffness Is Associated With Increased Symptom Burden in Patients With Atrial Fibrillation.

Can J Cardiol 2020 12 3;36(12):1949-1955. Epub 2020 Sep 3.

First Department of Medicine - Cardiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Germany. Electronic address:

Background: Increased arterial stiffness (AS) has been described as a predictor of atrial fibrillation (AF). This study was performed to assess whether increased AS leads to a higher symptom burden in patients with AF.

Methods: One hundred sixty-two consecutive patients (104 male, 58 female) with diagnosed AF (paroxysmal or persistent) were enrolled. Symptoms most likely attributable to AF were quantified according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (SAF) scale. AS indices (aortic distensibility, cyclic circumferential strain, and aortic compliance) were characterized using transoesophageal echocardiography.

Results: The cohort was divided into asymptomatic to oligosymptomatic (SAF scale 0-1, n = 78 [48.1%]) and symptomatic (SAF scale ≥ 2, n = 84 [51.9%]) patients. Symptomatic patients tended to be younger (median, 75 [interquartile range (IQR) 67-80] vs 71 [65-79]; P = 0.047) and were more likely to be female (22 [28.2%] vs 36 [42.9%]; P = 0.052). Hypertension was more frequent in symptomatic patients. Aortic compliance indices each were reduced in symptomatic patients, most pronounced for aortic compliance (median, 0.05 [IQR 0.03-0.06] vs 0.04 [0.03-0.05] cm/mm Hg; P = 0.01) followed by cyclic circumferential strain (median, 0.09 [IQR 0.07-0.11] vs 0.07 [0.04-0.10]; P = 0.02) and aortic distensibility (10 mm Hg, median, 1.74 [IQR 1.34-2.24] vs 1.54 [1.12-2.08]; P = 0.03). Multivariable analysis revealed aortic compliance as an independent predictor for symptoms in patients with AF with an odds ratio of 2.6 (95% confidence interval, 1.2-3.4; P = 0.003).

Conclusions: AS contributes to a high symptom burden in patients with AF, emphasizing the prognostic role of AS in the early detection and prevention in patients with AF.
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http://dx.doi.org/10.1016/j.cjca.2020.08.022DOI Listing
December 2020

Risk stratification in families with history of idiopathic ventricular fibrillation.

HeartRhythm Case Rep 2020 Jul 29;6(7):386-389. Epub 2020 Mar 29.

First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany.

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http://dx.doi.org/10.1016/j.hrcr.2020.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360980PMC
July 2020

Extent of Late Gadolinium Enhancement Predicts Thromboembolic Events in Patients With Hypertrophic Cardiomyopathy.

Circ J 2020 04 1;84(5):754-762. Epub 2020 Apr 1.

1st Department of Medicine Cardiology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg.

Background: Thromboembolic complications such as ischemic stroke or peripheral arterial thromboembolism are known complications in hypertrophic cardiomyopathy (HCM). We sought to assess the clinical and cardiovascular magnetic resonance (CMR) characteristics of patients with HCM suffering from thromboembolic events and analyzed the predictors of these unfavorable outcomes.Methods and Results:The 115 HCM patients underwent late gadolinium enhanced (LGE) CMR and were included in the study. Follow-up was 5.6±3.6 years. The primary endpoint was the occurrence of thromboembolic events (ischemic stroke or peripheral arterial thromboembolism). It occurred in 17 (14.8%) patients (event group, EG), of whom 64.7% (11) were men. During follow-up, 10 (8.7%) patients died. Patients in the EG showed more comorbidities, such as heart failure (EG 41.2% vs. NEG (non-event group) 14.3%, P<0.01) and atrial fibrillation (AF: EG 70.6% vs. NEG 36.7%, P<0.01). Left atrial end-diastolic volume was significantly higher in the EG (EG 73±24 vs. NEG 50±33 mL/m, P<0.01). Both the presence and extent of LGE were enhanced in the EG (extent% EG 23±15% vs. NEG 8±9%, P<0.0001). No patient without LGE experienced a thromboembolic event. Multivariate analysis revealed AF and LGE extent as independent predictors.

Conclusions: LGE extent (>14.4%) is an independent predictor for thromboembolic complications in patients with HCM and might therefore be considered as an important risk marker. The risk for thromboembolic events is significantly elevated if accompanied by AF.
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http://dx.doi.org/10.1253/circj.CJ-19-0936DOI Listing
April 2020

Recurrence of Atrial Fibrillation in Dependence of Left Atrial Volume Index.

In Vivo 2020 Mar-Apr;34(2):889-896

First Department of Medicine - Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany

Background/aim: Despite advances in the treatment strategies of patients with atrial fibrillation (AF), the risk of AF recurrences is still over 50%. An increased left atrial volume index (LAVI) reflects left ventricular diastolic dysfunction (DD) and deterioration of the LA function. This study aims to determine AF recurrence following cardioversion (CV) or catheter ablation for AF (pulmonary vein isolation; PVI) in dependence of DD and LAVI.

Patients And Methods: One hundred and sixty-two patients with paroxysmal or persistent AF in whom either CV or PVI were performed were included and followed over a mean of 22.9±3.8 months. Recurrence was defined as any recurrence of AF that occurred 3 months following the procedure. DD and LAVI were assessed using transthoracic echocardiography (TTE).

Results: Recurrent AF occurred in 100 (61.7%) patients, predominantly following CV [CV 41 (76.2%) vs. PVI 59 (54.6%), p<0.0001]. Both DD and an increased LAVI were more common in the recurrence-group [DD 46.0% vs. 14.5%, p=0.0001; LAVI (ml/m) 49.0±18.6 vs. 26.3±7.0, p<0.0001]. ROC analysis revealed LAVI>36 ml/m as cut-off (p<0.0001, AUC=0.92, 95%CI=0.87-0.97, sensitivity=76%, specificity=94%). In the multivariate analysis, DD (HR=1.6, 95%CI=1.3-2.1, p=0.04) and LA enlargement (defined as LAVI>36 ml/m with HR=2.1, 95%CI=1.8-2.7, p<0.0001) could be identified as independent predictors of AF recurrence after attempting to control the heart rhythm.

Conclusion: LA enlargement and DD are independent risk factors associated with AF recurrence after initial successful rhythm control attempt. These findings have implications for timing of either ablation or CV.
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http://dx.doi.org/10.21873/invivo.11854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7157897PMC
December 2020

Correlation of machine learning computed tomography-based fractional flow reserve with instantaneous wave free ratio to detect hemodynamically significant coronary stenosis.

Clin Res Cardiol 2020 Jun 29;109(6):735-745. Epub 2019 Oct 29.

First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany.

Background: Fractional flow reserve based on coronary CT angiography (CT-FFR) is gaining importance for non-invasive hemodynamic assessment of coronary artery disease (CAD). We evaluated the on-site CT-FFR with a machine learning algorithm (CT-FFR) for the detection of hemodynamically significant coronary artery stenosis in comparison to the invasive reference standard of instantaneous wave free ratio (iFR).

Methods: This study evaluated patients with CAD who had a clinically indicated coronary computed tomography angiography (cCTA) and underwent invasive coronary angiography (ICA) with iFR-measurements. Standard cCTA studies were acquired with third-generation dual-source computed tomography and analyzed with on-site prototype CT-FFR software.

Results: We enrolled 40 patients (73% males, mean age 67 ± 12 years) who had iFR-measurement and CT-FFR calculation. The mean calculation time of CT-FFR values was 11 ± 2 min. The CT-FFR algorithm showed, on per-patient and per-lesion level, respectively, a sensitivity of 92% (95% CI 64-99%) and 87% (95% CI 59-98%), a specificity of 96% (95% CI 81-99%) and 95% (95% CI 84-99%), a positive predictive value of 92% (95% CI 64-99%), and 87% (95% CI 59-98%), and a negative predictive value of 96% (95% CI 81-99%) and 95% (95% CI 84-99%). The area under the receiver operating characteristic curve for CT-FFR on per-lesion level was 0.97 (95% CI 0.91-1.00). Per lesion, the Pearson's correlation between the CT-FFR and iFR showed a strong correlation of r = 0.82 (p < 0.0001; 95% CI 0.715-0.920).

Conclusion: On-site CT-FFR correlated well with the invasive reference standard of iFR and allowed for the non-invasive detection of hemodynamically significant coronary stenosis.
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http://dx.doi.org/10.1007/s00392-019-01562-3DOI Listing
June 2020

Non-invasive measurement of hemodynamic response to postural stress using inert gas rebreathing.

Biomed Rep 2019 Sep 18;11(3):98-102. Epub 2019 Jul 18.

First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine, University of Heidelberg, European Center for AngioScience, D-68167 Mannheim, Germany.

In postural stress, an increased preload volume leads to higher stroke volume (SV) according to the Frank-Starling law of the heart. The present study aimed to evaluate the hemodynamic response to postural stress using non-invasive inert gas rebreathing (IGR) in patients with normal as well as impaired left ventricular function. Hemodynamic measurements were performed in 91 patients undergoing cardiac magnetic resonance imaging (CMR). Mean cardiac output and SV determined by IGR were 4.4±1.3 l/min and 60±19 ml in the upright position, which increased significantly to 5.0±1.2 l/min and 75±23 ml in the supine position (P<0.01). Left ventricular systolic function was normal [ejection fraction (EF) ≥55%] in 42 patients as determined by CMR. In 21 patients, EF was mildly abnormal (45-54%), in 16 patients moderately abnormal (30-44%) and in 12 patients severely abnormal (<30%). An overall trend for a lower percentage change in SV (%ΔSV) was indicated with increasing impairment of ejection fraction. In patients with abnormal EF in comparison to those with normal EF, the %ΔSV was significantly lower (13% vs. 22%; P=0.03). Non-invasive measurement of cardiac function using IGR during postural changes may be feasible and detected significant difference in %ΔSV in patients with normal and impaired EF according to the Frank-Starling law of the heart. Several clinical scenarios including cases of heart rhythm disturbances or pulmonary or congenital heart disease are worthy of further investigation.
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http://dx.doi.org/10.3892/br.2019.1229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684938PMC
September 2019

Saturation-Recovery Myocardial T-Mapping during Systole: Accurate and Robust Quantification in the Presence of Arrhythmia.

Sci Rep 2018 03 27;8(1):5251. Epub 2018 Mar 27.

Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.

Myocardial T-mapping, a cardiac magnetic resonance imaging technique, facilitates a quantitative measure of fibrosis which is linked to numerous cardiovascular symptoms. To overcome the problems of common techniques, including lack of accuracy and robustness against partial-voluming and heart-rate variability, we introduce a systolic saturation-recovery T-mapping method. The Saturation-Pulse Prepared Heart-rate independent Inversion-Recovery (SAPPHIRE) T-mapping method was modified to enable imaging during systole. Phantom measurements were used to evaluate the insensitivity of systolic T-mapping towards heart-rate variability. In-vivo feasibility and accuracy were demonstrated in ten healthy volunteers with native and post-contrast T-mappping during systole and diastole. To show benefits in the presence of RR-variability, six arrhythmic patients underwent native T-mapping. Resulting systolic SAPPHIRE T-values showed no dependence on arrhythmia in phantom (CoV < 1%). In-vivo, significantly lower T (1563 ± 56 ms, precision: 84.8 ms) and ECV-values (0.20 ± 0.03) than during diastole (T = 1580 ± 62 ms, p = 0.0124; precision: 60.2 ms, p = 0.03; ECV = 0.21 ± 0.03, p = 0.0098) were measured, with a strong correlation of systolic and diastolic T (r = 0.89). In patients, mis-triggering-induced motion caused significant imaging artifacts in diastolic T-maps, whereas systolic T-maps displayed resilience to arrythmia. In conclusion, the proposed method enables saturation-recovery T-mapping during systole, providing increased robustness against partial-voluming compared to diastolic imaging, for the benefit of T-measurements in arrhythmic patients.
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http://dx.doi.org/10.1038/s41598-018-23506-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869699PMC
March 2018

Correction to: High sensitivity troponin T and I reflect mitral annular plane systolic excursion being assessed by cardiac magnetic resonance imaging.

Eur J Med Res 2018 02 19;23(1). Epub 2018 Feb 19.

First Department of Medicine, Faculty of Medicine Mannheim, University Medical Center Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Following publication of the original article [1], the authors reported that there was a mistake in the Methods section → Measurements of biomarkers (page 6, line 3): 2000g should read 2500g. So, the correct sentence should be "All samples were obtained by venipuncture into serum monovettes and centrifuged at 2500g for 10 min at 20 °C."
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http://dx.doi.org/10.1186/s40001-018-0306-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5817869PMC
February 2018

Impact of left atrial appendage morphology on thrombus formation after successful left atrial appendage occlusion: Assessment with cardiac-computed-tomography.

Sci Rep 2018 01 26;8(1):1670. Epub 2018 Jan 26.

First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany.

A standardized imaging algorithm by cardiac computed tomography angiography (cCTA) (LOVE-view) was used in 30 patients to evaluate the influence of different left atrial appendage (LAA) morphologies on development of thrombosis in the LAA 6 months after implantation of an occlusion device (Watchman or Amplatzer-Cardiac-Plug) in patients with non-valvular atrial fibrillation, CHADS-VASc-Score >1 and a contraindication for oral anticoagulation. The distribution of different LAA morphologies was 40% windsock, 17% broccoli and 43% chicken wing type. There was no significant difference in the level of thrombosis regarding LAA morphology or the type of chosen occlusion device. The rates of complete LAA thrombosis was 40% in broccoli type, 33% in windsock and 15% in chicken wing type. Independently of LAA type, 13% had none and 60% incomplete thrombosis. The ratio of density (LA/LAA) was 0.14 in patients with complete thrombosis and 0.67 in those with none or incomplete thrombosis. cCTA and the LOVE-view-imaging-algorithm were shown to be a valuable method for standardized imaging in clinical routine in a greater set of patients. Surprisingly thrombosis of the occluded LAA was still in progress in most cases at 6 months, whereas further studies are needed defining its clinical consequences, especially for the selection of the optimal post-procedural antithrombotic treatment strategy.
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http://dx.doi.org/10.1038/s41598-018-19385-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786001PMC
January 2018

Low Prevalence of Inappropriate Shocks in Patients With Inherited Arrhythmia Syndromes With the Subcutaneous Implantable Defibrillator Single Center Experience and Long-Term Follow-Up.

J Am Heart Assoc 2017 Oct 17;6(10). Epub 2017 Oct 17.

Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.

Background: Up to 40% of patients with transvenous implantable cardioverter-defibrillator (ICD) experience lead-associated complications and may suffer from high complication rates when lead extraction is indicated. Subcutaneous ICD may represent a feasible alternative; however, the efficacy of the subcutaneous ICD in the detection and treatment of ventricular arrhythmias in patients with hereditary arrhythmia syndromes has not been fully evaluated.

Methods And Results: Patients with primary hereditary arrhythmia syndromes who fulfilled indication for defibrillator placement were eligible for enrollment. Between 2010 and 2016, 62 consecutive patients with primary hereditary arrhythmia syndromes, without indication for antibradycardia therapy, were enrolled in the study. Mean follow-up was 31.0±14.2 months. The study cohort comprised of 24 patients with Brugada syndrome, 17 with idiopathic ventricular fibrillation, 6 with long-QT syndrome, 1 with short-QT syndrome, 3 with catecholaminergic polymorphic ventricular tachycardia, 8 with hypertrophic cardiomyopathy, and 3 with arrhythmogenic right ventricular cardiomyopathy. Thirty-nine patients were implanted for secondary prevention. Twenty-two patients had a previous transvenous ICD implanted, but required revision because of infection or lead defects. A total of 20 spontaneous ventricular tachyarrhythmias requiring shock intervention occurred in 10 patients during follow-up. All episodes were terminated within the first ICD shock delivery with 80 J. Two patients had inappropriate therapies caused by oversensing following an uneventful implantation. No pocket-site infections and no premature revisions have occurred during follow-up.

Conclusions: Our study supports the use of the subcutaneous ICD for both secondary and primary prevention of sudden cardiac death as a reliable alternative to the conventional transvenous ICD.
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http://dx.doi.org/10.1161/JAHA.117.006265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721842PMC
October 2017

Galectin-3 Reflects Left Atrial Function being Assessed by Cardiac Magnetic Resonance Imaging.

Clin Lab 2017 Oct;63(10):1701-1710

Background: This study aims to evaluate the association between galectin-3 and left atrial function (LAF) in patients undergoing cMRI.

Methods: Patients undergoing cMRI were prospectively enrolled. Right ventricular dysfunction (< 50%) was excluded. Blood samples for biomarker measurements of galectin-3 and NT-proBNP were collected at the time of cMRI examination.

Results: A total of 84 patients were included. Median LVEF was 59% (IQR 51 - 64%). Galectin-3 was inversely correlated with overall LAF within a multivariable linear regression model (Beta -0.27; T -2.54; p = 0.01). Galectin-3 increased significantly according to the different stages of impaired LAF (p = 0.003) and was able to discriminate both patients with impaired LAF < 55% (AUC = 0.70, p = 0.002) and LAF < 45% (AUC = 0.69, p = 0.004). In multivariable logistic regression models, galectin-3 was still associated with impaired LAF (LAF < 55%: OR = 2.64, p = 0.07; LAF < 45%: OR = 6.65, p = 0.007).

Conclusions: This study demonstrates that galectin-3 is able to reflect LAF being assessed by cMRI.
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http://dx.doi.org/10.7754/Clin.Lab.2017.170507DOI Listing
October 2017

High sensitivity troponin T and I reflect mitral annular plane systolic excursion being assessed by cardiac magnetic resonance imaging.

Eur J Med Res 2017 Oct 4;22(1):38. Epub 2017 Oct 4.

First Department of Medicine, Faculty of Medicine Mannheim, University Medical Center Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Purpose: This study aims to evaluate the association between high sensitivity troponins (hsTn) and mitral annular plane systolic excursion (MAPSE) in patients undergoing cardiac magnetic resonance imaging (cMRI).

Methods: Patients undergoing cMRI were prospectively enrolled. Patients with right ventricular dysfunction (< 50%) were excluded. Blood samples for measurements of hsTn and amino-terminal pro-brain natriuretic peptide (NT-proBNP) were collected at the time of cMRI.

Results: 84 patients were included. Median left ventricular ejection fraction was 59% (IQR 51-64%). HsTn were correlated inversely with MAPSE within multivariable linear regression models (hsTnI: Beta - 0.19; T - 1.96; p = 0.05; hsTnT: Beta - 0.26; T - 3.26; p = 0.002). HsTn increased significantly according to decreasing stages of impaired MAPSE (p < 0.003). HsTn discriminated patients with impaired MAPSE < 11 mm (hsTnT: AUC = 0.67; p = 0.008; hsTnI: AUC = 0.64; p = 0.03) and < 8 mm (hsTnT: AUC = 0.79; p = 0.0001; hsTnI: AUC = 0.75; p = 0.001) and were still significantly associated in multivariable logistic regression models with impaired MAPSE < 11 mm (hsTnT: OR = 4.71; p = 0.002; hsTnI: OR = 4.22; p = 0.009).

Conclusions: This study demonstrates that hsTn are able to reflect MAPSE being assessed by cMRI.
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http://dx.doi.org/10.1186/s40001-017-0281-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628434PMC
October 2017

Incremental benefit of late gadolinium cardiac magnetic resonance imaging for risk stratification in patients with hypertrophic cardiomyopathy.

Sci Rep 2017 07 24;7(1):6336. Epub 2017 Jul 24.

1st Department of Medicine, University Medical Centre Mannheim, Mannheim, Germany.

Hypertrophic cardiomyopathy (HCM) has a low risk for sudden cardiac death (SCD). The ESC clinical risk prediction model estimates the risk of SCD using clinical and echocardiographical parameters without taking into account cardiac magnetic resonance (CMR) parameters. Therefore, we compared the CMR characteristics of 149 patients with low, intermediate and high ESC risk scores. In these patients left and right ventricular ejection fraction and volumes were comparable. Patients with a high ESC risk score revealed a significantly higher extent of late gadolinium enhancement (LGE) compared to patients with intermediate or a low risk scores. During follow-up of 4 years an extent of LGE ≥20% identified patients at a higher risk for major adverse cardiac arrhythmic events in the low and intermediate ESC risk group whereas an extent of LGE <20% was associated with a low risk of major adverse cardiac arrhythmic events despite a high ESC risk score ≥6%. Hence, we hypothesize that the extent of fibrosis might be an additional risk marker.
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http://dx.doi.org/10.1038/s41598-017-06533-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524944PMC
July 2017

High sensitivity troponin T and I reflect left atrial function being assessed by cardiac magnetic resonance imaging.

Ann Clin Biochem 2018 Mar 27;55(2):264-275. Epub 2017 Nov 27.

1 First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany.

Background Left atrial function (LAF) plays an interactive role between pulmonary and systemic circulation. Cardiac biomarkers, such as amino-terminal pro-brain natriuretic peptide (NT-proBNP) and troponins, might reflect cardiac function. This study aims to evaluate the association between high sensitivity troponins (hsTn) and left atrial function in patients undergoing cardiac magnetic resonance imaging (cMRI). Methods Patients undergoing cardiac magnetic resonance imaging (cMRI) were enrolled prospectively. Patients with right ventricular dysfunction (<50%) were excluded. Blood samples for measurements of hsTn and NT-proBNP were collected at the time of cMRI. Results Eighty-four patients were included. Median LVEF was 59% (IQR 51-64%). HsTn correlated inversely with LAF within multivariable linear regression models (hsTnI: Beta -0.46; T -4.44; P = 0.0001; hsTnT: Beta -0.29; T -3.06; P = 0.003). High sensitivity troponins increased significantly according to decreasing stages of impaired LAF ( P = 0.0001). High sensitivity troponins discriminated patients with impaired LAF < 55% (hsTnT: AUC = 0.80; P = 0.0001; hsTnI: AUC = 0.74; P = 0.0001) and <45% (hsTnT: AUC = 0.75; P = 0.0001; hsTnI: AUC = 0.73; P = 0.001) and were still significantly associated in multivariable logistic regression models (LAF < 55%: hsTnT: OR = 21.78; P = 0.0001; hsTnI: OR = 5.96; P = 0.009; LAF < 45%: hsTnT: OR = 10.27; P = 0.0001; hsTnI: OR = 12.56; P = 0.001). Conclusions This study demonstrates that hsTn are able to reflect LAF being assessed by cardiac magnetic resonance imaging.
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http://dx.doi.org/10.1177/0004563217714004DOI Listing
March 2018

Clinical and echocardiographic analysis of patients suffering from recurrent takotsubo cardiomyopathy.

J Geriatr Cardiol 2016 Nov;13(11):888-893

First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany; DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany.

Background: Recurrence of takotsubo cardiomyopathy (TTC) is a well-known complication. However, current literature lists only a few isolated cases. We aimed to determine the incidence and clinical significance of recurrent TTC.

Methods & Results: Our institutional database constituted a collective of 114 patients diagnosed with TTC since 2003. Close follow-up of these patients revealed a recurrence of TTC in seven of these (6.1%). The time interval between the index event and its recurrence varied between six months and six years. Arterial hypertension was more revealed in the recurrence group of TTC compared to non-recurrence group, ( = 0.02). Chronic obstructive pulmonary disease and/or asthma was more diagnosed in the recurrence group, ( = 0.04). Clinical events like right ventricular involvement, TTC related complications such as life-threatening arrhythmias, pulmonary congestion and in hospital death were observed more frequently in the recurrent episode. Over a mean follow-up of one year the mortality rate was similar in both groups.

Conclusions: Recurrence of TTC within six years after index event is not an uncommon phenomenon. In the event of right ventricular involvement in the relapse phase, it might be associated with a higher complication rate. TTC recurrence should be the first differential diagnosis in patients with a past history of TTC.
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http://dx.doi.org/10.11909/j.issn.1671-5411.2016.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253404PMC
November 2016

Galectin-3 Reflects Mitral Annular Plane Systolic Excursion Being Assessed by Cardiovascular Magnetic Resonance Imaging.

Dis Markers 2016 1;2016:7402784. Epub 2016 Dec 1.

First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, Heidelberg University, Mannheim, Germany.

. This study investigates whether serum levels of galectin-3 may reflect impaired mitral annular plane systolic excursion (MAPSE) in patients undergoing cardiac magnetic resonance imaging (cMRI). . Patients undergoing cMRI during routine clinical care were included prospectively within an all-comers design. Blood samples for biomarker measurements were collected within 24 hours following cMRI. Statistical analyses were performed in all patients and in three subgroups according to MAPSE (MAPSE I: ≥11 mm, MAPSE II: ≥8 mm-<11 mm, and MAPSE III: <8 mm). Patients with right ventricular dysfunction (<50%) were excluded. . 84 patients were included in the study. Median LVEF was 59% (IQR 51-64%). Galectin-3 correlated significantly with NT-proBNP ( = 0.42, = 0.0001). Galectin-3 increased significantly according to the different stages of impaired MAPSE ( = 0.006) and was able to discriminate both patients with impaired MAPSE <11 mm (area under the curve (AUC) = 0.645, = 0.024) and <8 mm (AUC = 0.733, = 0.003). Combining galectin-3 with NT-proBNP improved discrimination of MAPSE <8 mm (AUC 0.803, = 0.0001). In multivariable logistic regression models galectin-3 was still associated with impaired MAPSE (MAPSE < 11 mm: odds ratio (OR) = 3.53, = 0.018; MAPSE < 8 mm: OR = 3.18, = 0.06). . Galectin-3 reflects MAPSE being assessed by cardiac MRI.
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http://dx.doi.org/10.1155/2016/7402784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5156816PMC
February 2017

Simultaneous Non-Invasive Epicardial and Endocardial Mapping in Patients With Brugada Syndrome: New Insights Into Arrhythmia Mechanisms.

J Am Heart Assoc 2016 11 14;5(11). Epub 2016 Nov 14.

Department of Medicine, University Medical Center Mannheim, Mannheim, Germany.

Background: The underlying mechanisms of Brugada syndrome (BrS) are not completely understood. Recent studies provided evidence that the electrophysiological substrate, leading to electrocardiogram abnormalities and/or ventricular arrhythmias, is located in the right ventricular outflow tract (RVOT). The purpose of this study was to examine abnormalities of epicardial and endocardial local unipolar electrograms by simultaneous noninvasive mapping in patients with BrS.

Methods And Results: Local epicardial and endocardial unipolar electrograms were analyzed using a novel noninvasive epi- and endocardial electrophysiology system (NEEES) in 12 patients with BrS and 6 with right bundle branch block for comparison. Fifteen normal subjects composed the control group. Observed depolarization abnormalities included fragmented electrograms in the anatomical area of RVOT endocardially and epicardially, significantly prolonged activation time in the RVOT endocardium (65±20 vs 38±13 ms in controls; P=0.008), prolongation of the activation-recovery interval in the RVOT epicardium (281±34 vs 247±26 ms in controls; P=0.002). Repolarization abnormalities included a larger area of ST-segment elevation >2 mV and T-wave inversions. Negative voltage gradient (-2.5 to -6.0 mV) between epicardium and endocardium of the RVOT was observed in 8 of 12 BrS patients, not present in patients with right bundle branch block or in controls.

Conclusions: Abnormalities of epicardial and endocardial electrograms associated with depolarization and repolarization properties were found using NEEES exclusively in the RVOT of BrS patients. These findings support both, depolarization and repolarization abnormalities, being operative at the same time in patients with BrS.
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http://dx.doi.org/10.1161/JAHA.116.004095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5210320PMC
November 2016

Rapid functional cardiac imaging after gadolinium injection: Evaluation of a highly accelerated sequence with sparse data sampling and iterative reconstruction.

Sci Rep 2016 12 1;6:38236. Epub 2016 Dec 1.

DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Germany.

To generate a patient-friendly, time-efficient cardiac MRI examination protocol, a highly accelerated real-time CINE MR sequence (SSIR) was acquired in the idle time in between contrast injection and late gadolinium enhancement phase. 20 consecutive patients underwent a cardiac MRI examination including a multi-breath-hold sequence as gold standard (Ref) as well as SSIR sequences with (SSIR-BH) and without breath-hold (SSIR-nonBH). SSIR sequences were acquired 4 minutes after gadolinium injection. Right- (RV) and left-ventricular (LV) volumetric functional parameters were evaluated and compared between Ref and SSIR sequences. Despite reduced contrast between myocardium and intra-ventricular blood, volumetric as well as regional wall movement assessment revealed high agreement between both SSIR sequences and Ref. Excellent correlation and narrow limits of agreements were found for both SSIR-BH and SSIR-nonBH when compared to Ref for both LV (mean LV ejection fraction [EF] Ref: 52.8 ± 12.6%, SSIR-BH 52.3 ± 12.9%, SSIR-nonBH 52.5 ± 12.6%) and RV (mean RV EF Ref: 52.7 ± 9.4%, SSIR-BH 52.0 ± 8.1%, SSIR-nonBH 52.2 ± 9.3%) analyses. Even when acquired in the idle time in between gadolinium injection and LGE acquisition, the highly accelerated SSIR sequence delivers accurate volumetric and regional wall movement information. It thus seems ideal for very time-efficient and robust cardiac MR imaging protocols.
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http://dx.doi.org/10.1038/srep38236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5131289PMC
December 2016

Myocardial T-mapping at 3T using saturation-recovery: reference values, precision and comparison with MOLLI.

J Cardiovasc Magn Reson 2016 Nov 18;18(1):84. Epub 2016 Nov 18.

Computer Assisted Clinical Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Background: Myocardial T-mapping recently emerged as a promising quantitative method for non-invasive tissue characterization in numerous cardiomyopathies. Commonly performed with an inversion-recovery (IR) magnetization preparation at 1.5T, the application at 3T has gained due to increased quantification precision. Alternatively, saturation-recovery (SR) T-mapping has recently been introduced at 1.5T for improved accuracy. Thus, the purpose of this study is to investigate the robustness and precision of SR T-mapping at 3T and to establish accurate reference values for native T-times and extracellular volume fraction (ECV) of healthy myocardium.

Methods: Balanced Steady-State Free-Precession (bSSFP) Saturation-Pulse Prepared Heart-rate independent Inversion-REcovery (SAPPHIRE) and Saturation-recovery Single-SHot Acquisition (SASHA) T-mapping were compared with the Modified Look-Locker inversion recovery (MOLLI) sequence at 3T. Accuracy and precision were studied in phantom. Native and post-contrast T-times and regional ECV were determined in 20 healthy subjects (10 men, 27 ± 5 years). Subjective image quality, susceptibility artifact rating, in-vivo precision and reproducibility were analyzed.

Results: SR T-mapping showed <4 % deviation from the spin-echo reference in phantom in the range of T = 100-2300 ms. The average quality and artifact scores of the T-mapping methods were: MOLLI:3.4/3.6, SAPPHIRE:3.1/3.4, SASHA:2.9/3.2; (1: poor - 4: excellent/1: strong - 4: none). SAPPHIRE and SASHA yielded significantly higher T-times (SAPPHIRE: 1578 ± 42 ms, SASHA: 1523 ± 46 ms), in-vivo T-time variation (SAPPHIRE: 60.1 ± 8.7 ms, SASHA: 70.0 ± 9.3 ms) and lower ECV-values (SAPPHIRE: 0.20 ± 0.02, SASHA: 0.21 ± 0.03) compared with MOLLI (T: 1181 ± 47 ms, ECV: 0.26 ± 0.03, Precision: 53.7 ± 8.1 ms). No significant difference was found in the inter-subject variability of T-times or ECV-values (T: p = 0.90, ECV: p = 0.78), the observer agreement (inter: p > 0.19; intra: p > 0.09) or consistency (inter: p > 0.07; intra: p > 0.17) between the three methods.

Conclusions: Saturation-recovery T-mapping at 3T yields higher accuracy, comparable inter-subject, inter- and intra-observer variability and less than 30 % precision-loss compared to MOLLI.
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http://dx.doi.org/10.1186/s12968-016-0302-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5114738PMC
November 2016

"Diabetes paradox" in Takotsubo Cardiomyopathy.

Int J Cardiol 2016 Dec 17;224:88-89. Epub 2016 Aug 17.

Medical Faculty Mannheim, First Department of Medicine, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.

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http://dx.doi.org/10.1016/j.ijcard.2016.08.136DOI Listing
December 2016

Impact of concomitant atrial fibrillation on the prognosis of Takotsubo cardiomyopathy.

Europace 2017 Aug;19(8):1288-1292

First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.

Aims: Previous studies revealed that patients with Takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. Supraventricular tachycardia is a well-known complication of TTC. This study was performed to determine the short- and long-term prognostic impact of atrial fibrillation associated with TTC patients.

Methods And Results: Our institutional database constituted a collective of 114 patients diagnosed with TTC from 2003 to 2015. The patients were divided into two groups according to the presence (n = 21, 18.4%) or absence (n = 93, 81.5%) of atrial fibrillation. The endpoint was a composite of in-hospital events (thromboembolic events and life-threatening arrhythmias), all-cause mortality, rehospitalization due to heart failure, stroke, and the recurrence of TTC. The in-hospital mortality, 30-day mortality, and long-term mortality were significantly higher in the atrial fibrillation group. Kaplan-Meier analysis indicated a significantly lower event-free survival rate over a mean follow-up of 3 years in the atrial fibrillation group than that in the non-atrial fibrillation group (log-rank, P < 0.01). In a multivariate cox regression analysis, atrial fibrillation (hazard ratio, HR 2.3, 95% confidence interval, CI: 1.1-4.9, P < 0.05) and EF ≤ 35% (HR 2.0, 95% CI: 1.1-3.8, P < 0.05) were the only independent predictors of a primary endpoint.

Conclusion: Rates of in-hospital events and short- as well as long-term mortality were significantly higher in TTC patients suffering from atrial fibrillation compared with patients without atrial fibrillation.
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http://dx.doi.org/10.1093/europace/euw293DOI Listing
August 2017

Influence of electrode positioning on accuracy and reproducibility of electrical velocimetry cardiac output measurements.

Physiol Meas 2016 09 2;37(9):1422-35. Epub 2016 Aug 2.

1st Department of Medicine (Cardiology, Angiology, Pulmonology, Intensive Care), University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.

Electrical velocimetry (EV) is one of the most recent adaptions of impedance cardiography. Previous studies yielded diverging results identifying several factors negatively influencing accuracy. Although electrode arrangement is suspected to be an influencing factor for impedance cardiography in general, no data for EV is available. We aimed to prospectively assess the influence of electrode position on the accuracy and reproducibility of cardiac output (CO) measurements obtained by EV. Two pairs of standard electrocardiographic electrodes were placed at predefined positions of the thorax in 81 patients. The inter-electrode gap was varied between either 5 or 15 cm by caudal movement of the lowest electrode. Measurements were averaged over 20 s and performed twice at each electrode position. Reference values were determined using cardiac magnetic resonance imaging (CMR). Mean bias was 1.2  ±  1.6 l min(-1) (percentage error 22  ±  28%) between COCMR and COEV at the 5 cm gap significantly improving to 0.5  ±  1.6 l min(-1) (8  ±  28%) when increasing the gap (p  <  0.0001). The mean difference between repeated measurements was 0.0  ±  0.3 l min(-1) for the 5 cm and 0.1  ±  0.3 l min(-1) for the 15 cm gap, respectively (p  =  0.3). The accuracy of EV can be significantly improved when increasing the lower inter-electrode gap still exceeding the Critchley and Critchley recommendations. Therefore, absolute values should not be used interchangeably in clinical routine. As the reproducibility was not negatively affected, serial hemodynamic measurements can be reliably acquired in stable patients when the electrode position remains unchanged.
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http://dx.doi.org/10.1088/0967-3334/37/9/1422DOI Listing
September 2016

Prevalence, Clinical Characteristics, and Predictors of Patients with Thromboembolic Events in Takotsubo Cardiomyopathy.

Clin Med Insights Cardiol 2016 12;10:117-22. Epub 2016 Jul 12.

First Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Mannheim, Germany.

Background: Several acute complications related to takotsubo cardiomyopathy (TTC) have been documented recently. However, the incidence and clinical significance of acute thromboembolic events in TTC is not well established.

Methods: A detailed investigation of the clinical characteristics and in-hospital complications of 114 consecutive patients diagnosed with TTC between January 2003 and September 2015 was carried out. This study was initiated to reveal the predictors, clinical significance, and short-term and long-term outcomes of patients with TTC associated with acute thromboembolic events on index presentation.

Results: The incidence of acute thromboembolic events related to TTC was around 12.2%, and these included ventricular thrombi, cerebrovascular events, retinal and brachial artery pathologies, renal, splenic, and aortic involvement. The most frequent complication on initial presentation was cardiogenic shock (20%) accompanied with pulmonary congestion (20%). Interestingly, patients experiencing thromboembolic events had higher C-reactive protein (CRP) levels as compared to the non-thromboembolic group (P = 0.02). Certain thromboembolic events were characterized by the presence of ST-segment elevation in electrocardiogram (P = 0.02). Chest pain was the primary symptom in these patients (P = 0.09). Furthermore, there was significant right ventricular involvement (as assessed by transthoracic echocardiography) in patients presenting with an acute thromboembolic event (P = 0.08). A Kaplan-Meier analysis indicated a significantly higher mortality rate over a mean follow-up of three years in the thromboembolic group than the non-thromboembolic group (log-rank, P = 0.02).

Conclusions: Our results confirmed the relative common occurrence of thromboembolic events in the setting of TTC. Inflammation might play an important role in the development of thromboembolic events, and a right ventricular involvement and ST-segment elevation could be positive predictors for this occurrence. In order to circumvent the risk of a negative outcome, it is recommended that an anticoagulation therapy be initiated in all high-risk patients.
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http://dx.doi.org/10.4137/CMC.S38151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4944829PMC
July 2016

Free-breathing Sparse Sampling Cine MR Imaging with Iterative Reconstruction for the Assessment of Left Ventricular Function and Mass at 3.0 T.

Radiology 2017 Jan 11;282(1):74-83. Epub 2016 Jul 11.

From the Institute of Clinical Radiology and Nuclear Medicine (S.S., T.H., H.H., S.O.S.) and 1st Department of Medicine (C.D., M.B., T.P.), University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; MR Product Innovation and Definition, Siemens Healthcare, Erlangen, Germany (M.O.Z., M.S.); Imaging and Computer Vision, Siemens AG, Corporate Technology, Princeton, NJ (M.S.N.); and DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany (C.D., M.B., S.O.S., T.P.).

Purpose To prospectively evaluate the accuracy of left ventricle (LV) analysis with a two-dimensional real-time cine true fast imaging with steady-state precession (trueFISP) magnetic resonance (MR) imaging sequence featuring sparse data sampling with iterative reconstruction (SSIR) performed with and without breath-hold (BH) commands at 3.0 T. Materials and Methods Ten control subjects (mean age, 35 years; range, 25-56 years) and 60 patients scheduled to undergo a routine cardiac examination that included LV analysis (mean age, 58 years; range, 20-86 years) underwent a fully sampled segmented multiple BH cine sequence (standard of reference) and a prototype undersampled SSIR sequence performed during a single BH and during free breathing (non-BH imaging). Quantitative analysis of LV function and mass was performed. Linear regression, Bland-Altman analysis, and paired t testing were performed. Results Similar to the results in control subjects, analysis of the 60 patients showed excellent correlation with the standard of reference for single-BH SSIR (r = 0.93-0.99) and non-BH SSIR (r = 0.92-0.98) for LV ejection fraction (EF), volume, and mass (P < .0001 for all). Irrespective of breath holding, LV end-diastolic mass was overestimated with SSIR (standard of reference: 163.9 g ± 58.9, single-BH SSIR: 178.5 g ± 62.0 [P < .0001], non-BH SSIR: 175.3 g ± 63.7 [P < .0001]); the other parameters were not significantly different (EF: 49.3% ± 11.9 with standard of reference, 48.8% ± 11.8 with single-BH SSIR, 48.8% ± 11 with non-BH SSIR; P = .03 and P = .12, respectively). Bland-Altman analysis showed similar measurement errors for single-BH SSIR and non-BH SSIR when compared with standard of reference measurements for EF, volume, and mass. Conclusion Assessment of LV function with SSIR at 3.0 T is noninferior to the standard of reference irrespective of BH commands. LV mass, however, is overestimated with SSIR. RSNA, 2016 Online supplemental material is available for this article.
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http://dx.doi.org/10.1148/radiol.2016151002DOI Listing
January 2017

Characteristics and long-term outcome of right ventricular involvement in Takotsubo cardiomyopathy.

Int J Cardiol 2016 Oct 28;220:371-5. Epub 2016 Jun 28.

First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany.

Objective: Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy (SCM) resembles a reversible cardiomyopathy that is characterized by localized wall motion abnormalities in the absence of stenotic coronary vascular disease. Patients typically present with apical ballooning of the left ventricle (LV), however the right ventricle (RV) is also affected in up to 50.0% of patients. Long-term prognosis of classical SCM resembles that of patients after ST elevation myocardial infarction. Data on long-term prognosis of biventricular compared to classical SCM is controversial. The aim of this study was therefore to analyze patients with biventricular SCM regarding in-hospital outcome and long-term prognosis.

Materials And Methods: 114 consecutive patients with SCM were retrospectively analyzed. 88 patients presented with classical SCM, 26 patients (22.8%) were diagnosed with biventricular SCM. Follow-up was conducted for a total of 4.4years. Mean age was 67.1years with 83.3% of patients being female. The primary endpoint was a composite of all-cause mortality, recurrence of SCM and re-hospitalization due to heart failure.

Results: Although patients with biventricular SCM presented with a tendency towards an increased rate of cardiogenic shock (30.8% vs. 15.9%; p=0.09) and significantly more usage of inotropic support upon hospital admission (34.6% vs. 13.6%; p=0.01), there was no difference concerning the primary endpoint in both groups (50.0% vs. 44.3%; p=0.31). Furthermore, there was no difference in mortality both in-hospital (7.7% vs. 7.9%; p=0.66) and during long-term follow-up (27.3% vs. 23.1%; p=0.46).

Conclusion: Patients with biventricular SCM have the same in-hospital and long-term outcome compared to classical SCM.
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http://dx.doi.org/10.1016/j.ijcard.2016.06.240DOI Listing
October 2016

Radiation exposure and contrast agent use related to radial versus femoral arterial access during percutaneous coronary intervention (PCI)-Results of the FERARI study.

Cardiovasc Revasc Med 2016 Dec 15;17(8):505-509. Epub 2016 Jun 15.

First Department of Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.

Background: Data regarding radiation exposure related to radial versus femoral arterial access in patients undergoing percutaneous coronary intervention (PCI) remain controversial. This study aims to evaluate patients enrolled in the FERARI study regarding radiation exposure, fluoroscopy time and contrast agent use.

Methods: The Femoral Closure versus Radial Compression Devices Related to Percutaneous Coronary Interventions (FERARI) study evaluated prospectively 400 patients between February 2014 and May 2015 undergoing PCI either using the radial or femoral access. In these 400 patients, baseline characteristics, procedural data such as procedural duration, fluoroscopy time, dose-area product (DAP) as well as the amount of contrast agent used were documented and analyzed.

Results: Median fluoroscopy time was not significantly different in patients undergoing radial versus femoral access (12.2 vs. 9.8min, p=0.507). Furthermore, median DAP (54.5 vs. 52.0 Gycm2, p=0.826), procedural duration (46.0 vs. 45.0min, p=0.363) and contrast agent use (185.5 vs. 199.5ml, p=0.742) were also similar in radial and femoral PCI.

Conclusion: There was no difference regarding median fluoroscopy time, procedural duration, radiation dose or contrast agent use between radial versus femoral arterial access in PCI.
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http://dx.doi.org/10.1016/j.carrev.2016.05.008DOI Listing
December 2016
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