Publications by authors named "Theodoros D Karamitsos"

119 Publications

Prognostic role of left ventricular apical aneurysm in hypertrophic cardiomyopathy: A systematic review and meta-analysis.

Int J Cardiol 2021 Mar 29. Epub 2021 Mar 29.

Center of Cardiomyopathies and Inherited Cardiac Diseases, 1st Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece.

Objectives: The aim of this study was to systematically review and quantitatively synthesize existing evidence about the prognostic value of LV apical aneurysm in patients with HCM.

Background: Hypertrophic cardiomyopathy (HCM) represents a common inherited heart disease associated with enormous diversity in morphologic expression and clinical course. With the increasing penetration of advanced high resolution cardiovascular imaging into routine HCM practice, a subset of HCM patients with left ventricular (LV) apical aneurysm have become more widely recognized.

Methods: Medline was searched for studies describing the prognostic implication of LV apical aneurysm in patients with HCM. In the main analysis the combined endpoint of major HCM-related outcomes was assessed. Separate analyses for sudden cardiac death (SCD) events and thromboembolic events were also performed.

Results: Six studies comprising of 2382 patients met the inclusion criteria. In the pooled analysis, the presence of LV apical aneurysm was significantly associated with major adverse outcomes (pooled OR: 5.13, 95 CI: 2.85 to 9.23, I:31%), increased risk of SCD arrhythmic events (pooled OR: 4.67, 95% CI: 2.30 to 9.48, I: 38%) and thromboembolic events (pooled OR: 6.30, 95% CI: 1.52 to 26.19, I: 66%).

Conclusions: These data demonstrate that LV apical aneurysm in HCM patients is associated with an increased risk for SCD events and thromboembolism. This finding might encourage the inclusion of LV apical aneurysm into the HCM SCD risk stratification algorithm as a novel risk marker that supports consideration for primary prevention implantable cardioverter defibrillator and anticoagulation for stroke prophylaxis.
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http://dx.doi.org/10.1016/j.ijcard.2021.03.056DOI Listing
March 2021

Cardiac magnetic resonance in patients with muscular dystrophies: strengthening the data.

Eur J Prev Cardiol 2020 Jun 10. Epub 2020 Jun 10.

1st Department of Cardiology, Aristotle University of Thessaloniki, Greece.

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http://dx.doi.org/10.1177/2047487320932693DOI Listing
June 2020

Bolus Intravenous Procainamide in Patients with Frequent Ventricular Ectopics during Cardiac Magnetic Resonance Scanning: A Way to Ensure High Quality Imaging.

Diagnostics (Basel) 2021 Jan 27;11(2). Epub 2021 Jan 27.

First Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece.

Acquiring high-quality cardiac magnetic resonance (CMR) images in patients with frequent ventricular arrhythmias remains a challenge. We examined the safety and efficacy of procainamide when administered on the scanner table prior to CMR scanning to suppress ventricular ectopy and acquire high-quality images. Fifty consecutive patients (age 53.0 [42.0-58.0]; 52% female, left ventricular ejection fraction 55 ± 9%) were scanned in a 1.5 T scanner using a standard cardiac protocol. Procainamide was administered at intermittent intravenous bolus doses of 50 mg every minute until suppression of the ectopics or a maximum dose of 10 mg/kg. The average dose of procainamide was 567 ± 197 mg. Procainamide successfully suppressed premature ventricular contractions (PVCs) in 82% of patients, resulting in high-quality images. The baseline blood pressure (BP) was mildly reduced (mean change systolic BP -12 ± 9 mmHg; diastolic BP -4 ± 9 mmHg), while the baseline heart rate (HR) remained relatively unchanged (mean HR change -1 ± 6 bpm). None of the patients developed proarrhythmic changes. Bolus intravenous administration of procainamide prior to CMR scanning is a safe and effective alternative approach for suppressing PVCs and acquiring high-quality images in patients with frequent PVCs and normal or only mildly reduced systolic function.
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http://dx.doi.org/10.3390/diagnostics11020178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911068PMC
January 2021

Retraction notice to Mapping the Future of Myocardial Ischemia Testing With Cardiac Magnetic Resonance: J Am Coll Cardiol 71 (2018) 980-982.

J Am Coll Cardiol 2020 10;76(16):1917

First Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece.

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http://dx.doi.org/10.1016/j.jacc.2020.08.040DOI Listing
October 2020

HEllenic Registry on Myocarditis SyndromES on behalf of Hellenic Heart Failure Association: The HERMES-HF Registry.

ESC Heart Fail 2020 Sep 16. Epub 2020 Sep 16.

2nd Department of Cardiology, Attikon University Hospital, University of Athens, Athens, Greece.

Aims: Despite the existence of many studies, there are still limited data about the characteristics of myocarditis in Greece. This led to the creation of the Greek Myocarditis Registry aiming to document the different symptoms and treatment of myocarditis, assess possible prognostic factors, and find similarities and differences to what is already published in literature. This paper is a preliminary descriptive analysis of this Registry.

Methods And Results: We analysed data for the hospitalization period of all patients included in the Registry from December 2015 until November 2017. Statistics are reported as frequency (%) or median and inter-quartile range (IQR) as appropriate. In total, 146 patients were included; 83.3% of the patients reported an infection during the last 3 months. The most common symptom, regardless of the underlying infection, was chest pain (82.2%) followed by dyspnoea (18.5%), while the most common finding in clinical examination was tachycardia (26.7%). Presentation was more frequent in the winter months. ECG findings were not specific, with the repolarization abnormalities being the most frequent (60.3%). Atrial fibrillation was observed in two patients, both of whom presented with a reduced ventricular systolic function. Left ventricular ejection fraction changed significantly during the hospitalization [55% (IQR: 50-60%) on admission vs. 60% (IQR: 55-60%) on discharge, P = 0.0026]. Cardiac magnetic resonance was performed in 88 patients (61%), revealing mainly subepicardial and midcardial involvement of the lateral wall. Late gadolinium enhancement was present in all patients, while oedema was found in 39 of them. Only 11 patients underwent endomyocardial biopsy. Discharge medication consisted mainly of beta-blockers (71.9%) and angiotensin-converting enzyme inhibitors (41.8%), while 39.7% of the patients were prescribed both.

Conclusions: This preliminary analysis describes the typical presentation of myocarditis patients in Greece. It is a first step in developing a better prognostic model for the course of the disease, which will be completed after the incorporation of the patients' follow-up data.
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http://dx.doi.org/10.1002/ehf2.12894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754904PMC
September 2020

Comprehensive review of hemolysis in ventricular assist devices.

World J Cardiol 2020 Jul;12(7):334-341

Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, United States.

Ventricular assist devices (VADs) have played an important role in altering the natural history of end-stage heart failure. Low-grade hemolysis has been traditionally described in patients with VADs, indicating effective device functionality. However, clinically significant hemolysis could be crucial in terms of prognosis, calling for prompt therapeutic actions. The absence of solid and widely approved diagnostic criteria for clinically significant hemolysis, render the utilization of hemolysis laboratory markers challenging. Hemolysis incidence varies (5%-18%) depending on definition and among different VAD generations, being slightly higher in continuous-flow devices than in pulsatile devices. Increased shear stress of red blood cells and underlying device thrombosis appear to be the main pathogenetic pathways. No certain algorithm is available for the management of hemolysis in patients with VADs, while close clinical and laboratory monitoring remains the cornerstone of management. Imaging examinations such as echocardiography ramp test or computed tomography scan could play a role in revealing the underlying cause. Treatment should be strictly personalized, including either pharmacological (antithrombotic treatment) or surgical interventions.
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http://dx.doi.org/10.4330/wjc.v12.i7.334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415236PMC
July 2020

Cardiovascular magnetic resonance as a complementary method to transthoracic echocardiography for aortic valve area estimation in patients with aortic stenosis: A systematic review and meta-analysis.

Hellenic J Cardiol 2020 Jun 11. Epub 2020 Jun 11.

1st Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece. Electronic address:

Background: Aortic stenosis (AS) is the most common valvular heart disease. While two-dimensional transthoracic echocardiography (2D-TTE) is the standard imaging modality for AS assessment, cardiac magnetic resonance (CMR) offers a reliable and reproducible alternative. The aim of this study was to compare AVA measurements as determined by TTE and CMR in patients with AS.

Methods: Electronic databases were searched to identify studies comparing TTE continuity equation to CMR planimetry for AVA assessment. A meta-analysis of mean difference was conducted by using the random effects model. Sensitivity analysis was performed after excluding studies reporting AVA indexed to body surface area (BSA). Heterogeneity was assessed with I.

Results: A total of 12 studies, encompassing 621 patients, were included in our systematic review. In the pooled analysis, measurements of AVA by CMR planimetry were found to be significantly higher than those calculated by the continuity equation in TTE (pooled mean difference: 0.09, 95% confidence intervals (CI): 0.01, 0.17, and I: 93%). The results remained significant, albeit with moderate heterogeneity this time, after excluding the analysis measurements of AVA indexed to BSA (pooled mean difference: 0.08, 95% CI: 0.03 to 0.13, and I = 61%).

Conclusions: CMR planimetry slightly overestimates AVA compared to TTE continuity equation. Although, 2D-TTE should be the primary imaging modality for the estimation of AVA, CMR may be useful when there is discrepancy with the clinical assessment or when TTE results are discordant or difficult to obtain.
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http://dx.doi.org/10.1016/j.hjc.2020.05.008DOI Listing
June 2020

Cardiac magnetic resonance in patients with muscular dystrophies: strengthening the data.

Eur J Prev Cardiol 2020 Jun 9:2047487320932693. Epub 2020 Jun 9.

1st Department of Cardiology, Aristotle University of Thessaloniki, Greece.

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http://dx.doi.org/10.1177/2047487320932693DOI Listing
June 2020

Prognostic value of cardiovascular magnetic resonance T1 mapping techniques in non-ischemic dilated cardiomyopathy: A systematic review and meta-analysis.

Int J Cardiol 2020 08 19;312:110-116. Epub 2020 Apr 19.

1st Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece. Electronic address:

Background: Cardiovascular magnetic resonance T1 mapping is a non-invasive tool for quantifying tissue alterations in the myocardium. Its prognostic value in non-ischemic dilated cardiomyopathy (DCM) remains unclear. The purpose of this study was to synthetize available data and explore the prognostic value of T1 mapping in DCM.

Methods: We searched Pubmed, Embase, Cochrane Library and Scopus for cohort studies up to 28 March 2020 that reported prognostic data for cardiovascular magnetic resonance T1 mapping in patients with DCM. Hazard ratios (HRs) were pooled using random-effects meta-analysis. Values were expressed as standard deviation (SD) of normal controls. Heterogeneity was assessed with the I statistic.

Results: Eight studies were included in the meta-analysis, with a total of 1242 patients. Extracellular volume fraction (ECV) had high prognostic value for a composite outcome of mortality and morbidity with HR 1.38 (95% confidence interval, 1.18-1.61). Native T1 was also shown to have high prognostic value for a composite outcome of mortality and morbidity with HR 1.20 (95% confidence interval, 1.14-1.27). Heterogeneity was moderate for the ECV analysis (I = 64%).

Conclusions: ECV and native T1 could potentially be used to improve risk stratification in DCM. Future studies should investigate the prognostic value of T1 mapping by separating mortality and morbidity as primary outcomes and evaluate its incremental value in addition to standard risk stratification criteria.
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http://dx.doi.org/10.1016/j.ijcard.2020.04.052DOI Listing
August 2020

Levoatriocardinal Vein: A Rarely Recognized Cause of Recurrent Cardiac and Cerebral Thromboembolic Events.

Can J Cardiol 2020 04 15;36(4):589.e9-589.e11. Epub 2019 Nov 15.

Department of Congenital Cardiology and Cardiac Surgery, Mitera Hospital, Athens, Greece. Electronic address:

Levoatriocardinal vein (LACV) is a rare congenital anomaly of the systemic veins. We describe the case of a 43-year-old patient who presented with a transient ischemic attack episode, desaturation, and ventricular arrhythmias. Transesophageal echocardiography diagnosed a patent foramen ovale, and magnetic resonance imaging revealed 2 small myocardial infarcts, despite normal coronaries on subsequent angiography. Echocardiography and cardiac computed tomography revealed an LACV with bidirectional flow. The patient underwent percutaneous LACV and patent foramen ovale closure, with immediate saturation increase after occlusion of the LACV. To the best of our knowledge, this is the first time an LACV is identified as the cause of recurrent thromboembolic events.
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http://dx.doi.org/10.1016/j.cjca.2019.11.007DOI Listing
April 2020

Myocardial Tissue Characterization and Fibrosis by Imaging.

JACC Cardiovasc Imaging 2020 05 18;13(5):1221-1234. Epub 2019 Sep 18.

Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.

Myocardial fibrosis, either focal or diffuse, is a common feature of many cardiac diseases and is associated with a poor prognosis for major adverse cardiovascular events. Although histological analysis remains the gold standard for confirming the presence of myocardial fibrosis, endomyocardial biopsy is invasive, has sampling errors, and is not practical in the routine clinical setting. Cardiac imaging modalities offer noninvasive surrogate biomarkers not only for fibrosis but also for myocardial edema and infiltration to varying degrees, and have important roles in the diagnosis and management of cardiac diseases. This review summarizes important pathophysiological features in the development of commonly encountered cardiac diseases, and the principles, advantages, and disadvantages of various cardiac imaging modalities (echocardiography, single-photon emission computer tomography, positron emission tomography, multidetector computer tomography, and cardiac magnetic resonance) for myocardial tissue characterization, with an emphasis on imaging focal and diffuse myocardial fibrosis.
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http://dx.doi.org/10.1016/j.jcmg.2019.06.030DOI Listing
May 2020

Meta-Analysis of Transthoracic Echocardiography Versus Cardiac Magnetic Resonance for the Assessment of Aortic Regurgitation After Transcatheter Aortic Valve Implantation.

Am J Cardiol 2019 10 2;124(8):1246-1251. Epub 2019 Aug 2.

1st Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece. Electronic address:

Residual aortic regurgitation (AR) is a major complication after transcatheter aortic valve implantation (TAVI). Although the echocardiographic assessment of post-TAVI AR remains challenging, cardiac magnetic resonance (CMR) allows direct quantification of AR. The aim of this study was to review the level of agreement between 2-dimensional transthoracic echocardiography (2D TTE) and CMR on grading the severity of AR after TAVI, and determine the accuracy of TTE in detecting moderate or severe AR. Electronic databases were searched in order to identify studies comparing 2D TTE to CMR for post-TAVI AR assessment. Kappa coefficient was used to determine the level of agreement between the 2 imaging modalities. CMR was used as the reference standard in order to assess the diagnostic accuracy of 2D TTE. Seven studies were included in this systematic review. Six studies reported a low correlation between 2D TTE and CMR (kappa coefficient ranging from -0.02 to 0.41), whereas one study showed good agreement with a kappa coefficient of 0.72. Given the heterogeneity in the included studies the diagnostic accuracy of TTE was evaluated by estimating the hierarchical summary receiver operator characteristic curve. The area under the curve for detection of moderate or severe AR with TTE was 0.83 (95% confidence interval 0.79 to 0.86). In conclusion, despite the reported significant disconcordance between TTE and CMR grading of AR, TTE has sufficient ability to discriminate moderate or severe AR from mild or none AR after TAVI in the clinical setting. CMR should be considered when TTE results are equivocal.
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http://dx.doi.org/10.1016/j.amjcard.2019.07.036DOI Listing
October 2019

The Prognostic Role of Late Gadolinium Enhancement in Aortic Stenosis: A Systematic Review and Meta-Analysis.

JACC Cardiovasc Imaging 2020 02 17;13(2 Pt 1):385-392. Epub 2019 Jul 17.

1st Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece. Electronic address:

Objectives: The aim of this systematic review was to explore the prognostic value of late gadolinium enhancement (LGE) in patients with aortic stenosis (AS).

Background: Myocardial fibrosis is a common feature of many cardiac diseases. Cardiac magnetic resonance (CMR) has the ability to noninvasively detect regional fibrosis by using the LGE technique. Several studies have explored whether LGE is associated with adverse outcome in patients with AS.

Methods: Electronic databases were searched to identify studies investigating the ability of LGE to predict all-cause mortality in patients with AS. A random effects model meta-analysis was conducted. Heterogeneity was assessed with the I statistic.

Results: Six studies comprising 1,151 patients met our inclusion criteria. LGE was present in 49.1% of patients with AS. In the pooled analysis, LGE was found to be a strong univariate predictor of all-cause mortality (pooled unadjusted odds ratio: 2.56; 95% confidence interval: 1.83 to 3.57; I = 0%). Four of the included studies reported adjusted hazard ratios for mortality. LGE was independently associated with mortality, even after adjusting for baseline characteristics (pooled adjusted hazard ratio: 2.50; 95% confidence interval: 1.64 to 3.83; I = 0%).

Conclusions: Fibrosis on LGE-CMR is a powerful predictor of all-cause mortality in patients with AS and may serve as a novel marker for risk stratification. Future studies should explore whether LGE-CMR can also be used to optimize timing of AS-related interventions.
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http://dx.doi.org/10.1016/j.jcmg.2019.03.029DOI Listing
February 2020

Cardiac Magnetic Resonance T1 Mapping for Cardiac Amyloidosis: The Best Way Forward.

JACC Cardiovasc Imaging 2020 01 12;13(1 Pt 1):81-82. Epub 2019 Jun 12.

1st Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.

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http://dx.doi.org/10.1016/j.jcmg.2019.04.011DOI Listing
January 2020

MitraClip device for patients with functional mitral valve regurgitation: A systematic review.

Hellenic J Cardiol 2019 Mar - Apr;60(2):101-107. Epub 2019 Mar 8.

1st Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece. Electronic address:

Background: MitraClip device is a novel therapeutic option for patients with degenerative mitral valve regurgitation. Nevertheless, several studies have also focused on the safety and efficacy of this method in functional mitral valve regurgitation (FMR).

Aim: To systematically review all original studies that provided mortality data among FMR patients treated with MitraClip.

Materials And Methods: We conducted an in-depth literature search of 3 electronic databases (Medline, Scopus and Cochrane Library) in order to identify studies investigating the efficacy of MitraClip in FMR. Thirty-day and 12-month mortality after MitraClip implantation were the measured outcomes.

Results: Twenty-eight studies, involving 2383 patients, were included. The phenotype of the studied population was characterized by clinical and echocardiographic parameters suggesting severe FMR (NYHA III-IV: 91%, MR≥3+: 98%) with high surgical risk (mean Euroscore: 24.6%). The Mitraclip device was successfully implanted in 95.8% of patients, resulting in a reduction of two or more degrees of MR. Thirty day and 12-month mortality rates were estimated to be 2.3% and 18.9%, respectively.

Conclusions: MitraClip appears to be a safe therapeutic option for patients with FMR who are considered to be at high surgical risk.
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http://dx.doi.org/10.1016/j.hjc.2019.02.003DOI Listing
February 2020

The interplay between metabolic alterations, diastolic strain rate and exercise capacity in mild heart failure with preserved ejection fraction: a cardiovascular magnetic resonance study.

J Cardiovasc Magn Reson 2018 12 24;20(1):88. Epub 2018 Dec 24.

Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.

Background: Heart failure (HF) is characterized by altered myocardial substrate metabolism which can lead to myocardial triglyceride accumulation (steatosis) and lipotoxicity. However its role in mild HF with preserved ejection fraction (HFpEF) is uncertain. We measured myocardial triglyceride content (MTG) in HFpEF and assessed its relationships with diastolic function and exercise capacity.

Methods: Twenty seven HFpEF (clinical features of HF, left ventricular EF >50%, evidence of mild diastolic dysfunction and evidence of exercise limitation as assessed by cardiopulmonary exercise test) and 14 controls underwent H-cardiovascular magnetic resonance spectroscopy (H-CMRS) to measure MTG (lipid/water, %), P-CMRS to measure myocardial energetics (phosphocreatine-to-adenosine triphosphate - PCr/ATP) and feature-tracking cardiovascular magnetic resonance (CMR) imaging for diastolic strain rate.

Results: When compared to controls, HFpEF had 2.3 fold higher in MTG (1.45 ± 0.25% vs. 0.64 ± 0.16%, p = 0.009) and reduced PCr/ATP (1.60 ± 0.09 vs. 2.00 ± 0.10, p = 0.005). HFpEF had significantly reduced diastolic strain rate and maximal oxygen consumption (VO max), which both correlated significantly with elevated MTG and reduced PCr/ATP. On multivariate analyses, MTG was independently associated with diastolic strain rate while diastolic strain rate was independently associated with VO max.

Conclusions: Myocardial steatosis is pronounced in mild HFpEF, and is independently associated with impaired diastolic strain rate which is itself related to exercise capacity. Steatosis may adversely affect exercise capacity by indirect effect occurring via impairment in diastolic function. As such, myocardial triglyceride may become a potential therapeutic target to treat the increasing number of patients with HFpEF.
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http://dx.doi.org/10.1186/s12968-018-0511-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304764PMC
December 2018

Myocardial Perfusion Is Impaired and Relates to Cardiac Dysfunction in Patients With Atrial Fibrillation Both Before and After Successful Catheter Ablation.

J Am Heart Assoc 2018 08;7(15):e009218

1 Division of Cardiovascular Medicine University of Oxford Oxford United Kingdom.

Background Atrial fibrillation ( AF ) is associated with myocardial infarction, and patients with AF and no obstructive coronary artery disease can present with symptoms and evidence of cardiac ischemia. We hypothesized that microvascular coronary dysfunction underlies these observations. Methods and Results Myocardial blood flow ( MBF ) at baseline and during adenosine stress and left ventricular and left atrial function were evaluated by magnetic resonance in 49 patients with AF (25 paroxysmal, 24 persistent) with no history of epicardial coronary artery disease or diabetes mellitus, before and 6 to 9 months after ablation. Findings were compared with those obtained in matched controls in sinus rhythm (n=25). Before ablation, patients with AF had impaired left atrial function and left ventricular ejection fraction and strain indices (all P<0.05 versus controls). MBF was impaired in patients both under baseline conditions (1.21±0.24 mL/min per g·[mm Hg·bpm/10] versus 1.34±0.28 mL/min per g·[mm Hg·bpm/10] in controls, P=0.044) and during adenosine stress (2.29±0.48 mL/min per g versus 2.73±0.37 mL/min per g in controls, P<0.001). Under baseline conditions, MBF correlated with left ventricular strain and left atrial function (all P≤0.001), so that cardiac function was most impaired in patients with the lowest MBF . Baseline and stress MBF remained unchanged postablation (both P=ns), and baseline MBF showed similar correlations with functional indices to those present preablation (all P≤0.001). Conclusions Baseline and stress MBF are significantly impaired in patients with AF but no epicardial coronary artery disease. Reduction in MBF is proportional to severity of left ventricular and left atrial dysfunction, even after successful ablation. Coronary microvascular dysfunction may be a relevant pathophysiological mechanism in patients with a history of AF .
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http://dx.doi.org/10.1161/JAHA.118.009218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6201472PMC
August 2018

Anti-TNF modulation reduces myocardial inflammation and improves cardiovascular function in systemic rheumatic diseases.

Int J Cardiol 2018 Nov 25;270:253-259. Epub 2018 Jun 25.

University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, UK; First Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece. Electronic address:

Background: Rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are common disorders associated with increased rates of cardiovascular disease (CVD), but the contribution of cytokine-induced inflammation to impaired cardiovascular function in these conditions remains poorly understood.

Objectives: We assessed the effect of anti-TNF therapy on myocardial and vascular function, myocardial tissue characteristics and perfusion in inflammatory arthropathy and systemic rheumatic disease (IASRD) patients, using cardiovascular magnetic resonance (CMR).

Methods: 20 RA patients, 7 AS patients, 5 PsA patients without previously known CVD scheduled to commence anti-TNF therapy and 8 RA patients on standard disease modifying antirheumatic drugs underwent CMR at 1.5 T, including cine, tagging, pulse wave velocity (PWV), T2-weighted, native and postcontrast T1 mapping, ECV quantification, rest and stress perfusion and late gadolinium enhancement (LGE) imaging.

Results: Following anti-TNF therapy, there was significant reversal of baseline subclinical cardiovascular dysfunction, as evidenced by improvement in peak systolic circumferential strain (p < 0.001), peak diastolic circumferential strain rate (p < 0.001), and total aortic PWV, (p < 0.001). This was accompanied by a reduction in myocardial inflammation, as assessed by T2-weighted imaging (p = 0.005), native T1 mapping (p = 0.009) and ECV quantification (p = 0.001), as well as in serum inflammatory markers like CRP (p < 0.001) and ESR (p < 0.001), and clinical measures of disease activity (DAS28-CRP, p = 0.001; BASDAI, p < 0.001). A trend towards improvement in myocardial perfusion was observed (p = 0.07). Focal myocardial fibrosis, as detected by LGE CMR was not altered by anti-TNF therapy (p = 0.92).

Conclusions: Anti-TNF therapy reduces subclinical myocardial inflammation and improves cardiovascular function in RA, AS and PsA. CMR may be used to track disease progression and response to therapy. Future CMR-based studies to demonstrate effect of anti-TNF therapy modulation of vascular structure and function on hard clinical events and outcomes would be useful.
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http://dx.doi.org/10.1016/j.ijcard.2018.06.099DOI Listing
November 2018

Inconsistent high sensitivity troponin T and I measurements in a patient with rheumatoid arthritis.

Hellenic J Cardiol 2019 Jan - Feb;60(1):59-60. Epub 2018 Mar 30.

1(st) Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece.

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http://dx.doi.org/10.1016/j.hjc.2018.03.004DOI Listing
August 2020

Data on diagnostic performance of stress perfusion cardiac magnetic resonance for coronary artery disease detection at the vessel level.

Data Brief 2018 Feb 7;16:869-875. Epub 2017 Dec 7.

1st Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Stress perfusion cardiac magnetic resonance (CMR) has been proposed as an important gatekeeper for invasive coronary angiography (ICA) and percutaneous coronary interventions (PCI) in patients evaluated for possible coronary artery disease (CAD) (Fihn et al., 2012; Montalescot et al., 2013) [1], [2]. Several meta-analyses have evaluated the accuracy of stress perfusion CMR to diagnose CAD at the vessel level (Danad et al., 2017; Dai et al., 2016; Jiang et al., 2016; Takx et al., 2015; Li et al., 2015; Desai and Jha, 2013; Jaarsma et al. 2012; Hamon et al., 2010; Nandalur et al. 2007) [3], [4], [5], [6], [7], [8], [9], [10], [11]. However, they included in the same analysis studies with different definitions of significant CAD (i.e. fractional flow reserve [FFR] < 0.75 and < 0.80 or coronary stenosis ≥ 50% and ≥ 70%), magnetic field strength (1.5 or 3 Tesla [T]), and study protocol (integration or not of late gadolinium enhancement [LGE] into stress perfusion protocol). Data of 34 studies (6091 arteries) have been pooled with the aim of analyzing the accuracy of stress perfusion CMR for the diagnosis of ischemic heart disease at the vessel level according to different definitions of significant CAD, magnetic field strength and study protocol (Arnold et al., 2010; Bettencourt et al., 2013; Cheng et al., 2007; Chiribiri et al., 2013; Cury et al., 2006; De Mello et al., 2012; Donati et al., 2010; Ebersberger et al., 2013; Gebker et al., 2008; Greulich et al., 2015; Hussain et al., 2016; Ishida et al., 2005, 2003; Kamiya et al., 2014; Kitagawa et al., 2008; Klein et al., 2008; Klem et al., 2006; Klumpp et al., 2010; Krittayaphong et al., 2009; Lockie et al., 2011; Ma et al., 2012; Merkle et al., 2007; Meyer et al., 2008; Mor-Avi et al., 2008; Pan et al., 2015; Papanastasiou et al., 2016; Pons Lladó et al., 2004; Sakuma et al., 2005; Salerno et al., 2014; Scheffel et al., 2010; van Werkhoven et al., 2010; Walcher et al., 2013; Watkins et al., 2009; Yun et al., 2015) [12-45]. This article describes data related article titled "Diagnostic Performance of Stress Perfusion Cardiac Magnetic Resonance for the Detection of Coronary Artery Disease" (Kiaos et al., submitted for publication) [46].
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http://dx.doi.org/10.1016/j.dib.2017.11.096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5847623PMC
February 2018

Mapping the Future of Myocardial Ischemia Testing With Cardiac Magnetic Resonance.

J Am Coll Cardiol 2018 03;71(9):980-982

First Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece. Electronic address:

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http://dx.doi.org/10.1016/j.jacc.2017.12.047DOI Listing
March 2018

Diagnostic Accuracy of Cardiovascular Magnetic Resonance in Acute Myocarditis: A Systematic Review and Meta-Analysis.

JACC Cardiovasc Imaging 2018 11 14;11(11):1583-1590. Epub 2018 Feb 14.

First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece. Electronic address:

Objectives: The purpose of this systematic review was to explore the diagnostic accuracy of various cardiovascular magnetic resonance (CMR) index tests for the diagnosis of acute myocarditis in adult patients.

Background: Acute myocarditis remains one of the most challenging diagnoses in cardiology. CMR has emerged as the diagnostic tool of choice to detect acute myocardial injury and necrosis in patients with suspected myocarditis.

Methods: We considered all diagnostic cohort and case-control studies. We searched MEDLINE, EMBASE, Cochrane Library, SCOPUS, and Web of Science up to April 21, 2017. We used the Quality Assessment of Diagnostic Accuracy Studies-2 tool to assess the quality of included studies. PROSPERO registration number CRD42017055778 was used.

Results: Twenty-two studies were included in the systematic review. Because significant heterogeneity exists among the studies, we only present hierarchical receiver operator curves. The areas under the curve (AUC) for each index test were for T1 mapping 0.95 (95% confidence interval [CI]: 0.93 to 0.97), for T2 mapping 0.88 (95% CI: 0.85 to 0.91), for extracellular volume fraction (ECV) 0.81 (95% CI: 0.78 to 0.85), for increased T2 ratio/signal 0.80 (95% CI: 0.76 to 0.83), for late gadolinium enhancement (LGE) 0.87 (95% CI: 0.84 to 0.90), for early gadolinium enhancement (EGE) 0.78 (95% CI: 0.74 to 0.81), and for the Lake Louise criteria (LLC) 0.81 (95% CI: 0.77 to 0.84). Native T1 mapping had superior diagnostic accuracy across all index tests. The AUC of T2 mapping was greater than the AUC of increased T2 ratio/signal and EGE, whereas ECV showed no superiority compared with other index tests. LGE had better diagnostic accuracy compared with the classic CMR index tests, similar accuracy with T2 mapping and ECV, and only T1 mapping surpassed it.

Conclusions: Novel CMR mapping techniques provide high diagnostic accuracies for the diagnosis of acute myocarditis and constitute promising successors of the classic elements of the LLC for routine diagnostic protocols.
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http://dx.doi.org/10.1016/j.jcmg.2017.12.008DOI Listing
November 2018

Cardiovascular magnetic resonance characterization of myocardial and vascular function in rheumatoid arthritis patients.

Hellenic J Cardiol 2019 Jan - Feb;60(1):28-35. Epub 2018 Jan 31.

University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK; First Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece. Electronic address:

Background: Rheumatoid arthritis (RA) is a multisystem, autoimmune disorder and confers one of the strongest risks for cardiovascular disease (CVD) morbidity and mortality.

Objective: To assess myocardial function and vascular stiffness in RA patients with and without cardiovascular risk factors (CVRFs) using cardiovascular magnetic resonance (CMR).

Methods: Twenty-three RA patients with no CVRFs (17 female, mean age 52 ± 13 years), 46 RA patients with CVRFs (32 female, mean age 53 ± 12), 50 normal controls (32 female, mean age 50 ± 11 years), and 13 controls with CVRFs (7 female, mean age 55 ± 7 years), underwent CMR at 1.5 Tesla, including evaluation of left ventricular (LV) ejection fraction, strain, and vascular elasticity (aortic distensibility [AD] and pulse wave velocity [PWV]). Disease activity and duration were recorded for each patient. Subjects with known symptomatic CVD were excluded.

Results: LV volumes, mass, and ejection fraction were similar in the four groups. RA patients with CVRFs showed the greatest abnormality in mid short-axis circumferential systolic strain, peak diastolic strain rate, and vascular indices. RA patients without CVRFs showed a similar degree of vascular dysfunction and deformational abnormality as controls with CVRFs. AD and total PWV correlated with myocardial strain and RA disease activity. On multivariate regression analysis, strain was related to age, RA disease activity, AD, and PWV.

Conclusion: CMR demonstrates impaired myocardial deformation and vascular function in asymptomatic RA patients, worse in those with CVRFs. Subclinical cardiovascular abnormalities are frequent and appear to be incremental to those due to traditional CVRFs and likely contribute to the excess CVD in RA.
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http://dx.doi.org/10.1016/j.hjc.2018.01.008DOI Listing
December 2019

Magnetic resonance imaging is a safe technique in patients with prosthetic heart valves and coronary stents.

Hellenic J Cardiol 2019 Jan - Feb;60(1):38-39. Epub 2017 Dec 29.

1st Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece.

The paper refers to the safety of MRI in patients with prosthetic heart valves or coronary stents. This condition is commonly regarded as a contraindication for MRI, where patients with these stents or valves are excluded from yielding the diagnostic imaging information provided by one of the most important noninvasive imaging modalities. On the basis of available evidence to date, all patients with prosthetic heart valves or coronary stents can safely undergo MRI at 1.5 T and the vast majority at 3 T.
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http://dx.doi.org/10.1016/j.hjc.2017.12.001DOI Listing
December 2019

Correction to: Adenosine stress CMR T1-mapping detects early microvascular dysfunction in patients with type 2 diabetes mellitus without obstructive coronary artery disease.

J Cardiovasc Magn Reson 2017 12 7;19(1):99. Epub 2017 Dec 7.

University of Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.

In the original publication of this article [1] Fig. 1 was incorrect due to the use of a colour bar with wrong range in error.
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http://dx.doi.org/10.1186/s12968-017-0406-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719930PMC
December 2017

Diagnostic performance of stress perfusion cardiac magnetic resonance for the detection of coronary artery disease: A systematic review and meta-analysis.

Int J Cardiol 2018 Feb 24;252:229-233. Epub 2017 Nov 24.

1st Department of Cardiology, Aristotle University of Thessaloniki, Thessaloniki, Greece. Electronic address:

Introduction: The purpose of this study was to investigate the accuracy of qualitative stress perfusion cardiac magnetic resonance (CMR) to diagnose ischemia-causing lesions according to different definitions of significant coronary artery disease (CAD), and magnetic field strength.

Methods: We searched PubMed, Web of Science, and the Cochrane Library for studies evaluating diagnostic performance of qualitative stress perfusion CMR for diagnosis of CAD versus coronary angiography or fractional flow reserve (FFR) from inception to 10 September 2017. We used hierarchical models to synthesize the available data.

Results: Sixty-seven studies (7113 patients) met the inclusion criteria. The patient-based analysis of studies using FFR as the reference standard demonstrated a mean sensitivity of 0.90 (95% confidence interval [CI], 0.85-0.93) and a mean specificity of 0.85 (95% CI, 0.80-0.89). The patient-based analyses for detecting coronary stenosis ≥50% and coronary stenosis ≥70% at 1.5T and for detecting coronary stenosis ≥50% and coronary stenosis ≥70%, at 3T, demonstrated a mean sensitivity of 0.82 (95% CI, 0.79-0.84), 0.86 (95% CI, 0.83-0.89), 0.90 (95% CI, 0.82-0.95), and 0.91 (95% CI, 0.79-0.96), respectively; with a mean specificity of 0.75 (95% CI, 0.71-0.80), 0.77 (95% CI, 0.71-0.81), 0.79 (95% CI, 0.69-0.86), and 0.74 (95% CI, 0.59-0.85).

Conclusion: Qualitative stress perfusion CMR has high accuracy for the diagnosis of CAD, irrespective of the reference standard and the magnet strength. Studies using FFR as the reference standard had higher diagnostic accuracy on a patient level compared to studies using coronary angiography, with a notable difference in specificity.
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http://dx.doi.org/10.1016/j.ijcard.2017.11.066DOI Listing
February 2018

Pregnancy associated plasma protein-A as a prognostic biomarker of all-cause mortality and cardiovascular events in patients presenting with chest pain: a systematic review.

Biomarkers 2018 Feb 16;23(1):1-9. Epub 2017 Nov 16.

d VA Eastern Colorado Healthcare System and Division of Cardiology , University of Colorado , Denver , CO , USA.

Aim: Novel biomarkers have been proposed for identification of patients at greater risk of future adverse events among those presenting with chest pain. In this review, we aim to elucidate the ability of pregnancy associated plasma protein-A (PAPP-A) to predict mortality and other cardiovascular events in this patient population.

Methods: A literature search of the electronic databases Medline, Scopus, Cochrane Library and ClinicalTrials.gov was performed in order to identify studies investigating the utility of PAPP-A to predict mortality and adverse cardiovascular events in patients with chest pain.

Results: Eight studies met our inclusion criteria. Five of these studies pertained to patients with confirmed ischemic chest pain, while the rest included patients presenting with chest pain possibly due to acute coronary syndrome, irrespectively of the underlying cause. Although the results for long-term events were inconclusive in both groups of patients, higher PAPP-A concentrations were found to be a significant predictor of short-term adverse events in patients with confirmed ischemic chest pain.

Conclusions: PAPP-A appears to be a potentially useful biomarker for short-term risk stratification of patients presenting with chest pain of ischemic origin. However, there is an eminent need for more standardized clinical studies investigating the prognostic value of this biomarker.
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http://dx.doi.org/10.1080/1354750X.2017.1397194DOI Listing
February 2018

Iatrogenic Lutembacher Syndrome after Percutaneous Mitral Commissurotomy.

J Heart Valve Dis 2017 05;26(3):368-371

First Department of Cardiology, AHEPA Hospital, Aristotle University, Thessaloniki, Greece.

Atrial septal defects (ASDs) are common immediately after percutaneous mitral commissurotomy (PMC). They are usually small, hemodynamically insignificant, and tend to decrease or disappear within 6 to 12 months. Herein, a case is described of persistent ASD in a patient with mitral valve stenosis who had undergone successful PMC three years previously. The patient had signs and symptoms of right heart failure and severe tricuspid regurgitation (TR) with borderline right ventricular systolic function on echocardiography, in addition to the ASD. Cardiac magnetic resonance (CMR) imaging played a significant role in decision-making by clarifying the anatomy of the ASD and severity of the shunt, measuring right ventricular systolic function, and providing absolute quantification for TR. The right ventricular systolic function was normal on CMR, rendering the patient suitable for surgical treatment. Persistent iatrogenic ASDs have become an increasingly common finding after invasive procedures requiring trans-septal puncture and the manipulation of catheters. Multimodality imaging can provide significant aid in the management of patients with valvular heart disease complicated by iatrogenic shunts.
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May 2017