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ObjectiveTo assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19).MethodsThis single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion ResultsA total of 200 patients were included in the final analysis (median age 62 (IQR 52–74) years, 65.5% men). The prevalence of PH and RVD was 12.0% (24/200) and 14.5% (29/200), respectively. Patients with PH were older and had a higher burden of pre-existing cardiac comorbidities and signs of more severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (radiological lung involvement, laboratory findings and oxygenation status) compared with those without PH. Conversely, patients with RVD had a higher burden of pre-existing cardiac comorbidities but no evidence of more severe SARS-CoV-2 infection compared with those without RVD. The presence of PH was associated with a higher rate of in-hospital death or ICU admission (41.7 vs 8.5%, pConclusionsAmong hospitalised non-ICU patients with COVID-19, PH (and not RVD) was associated with signs of more severe COVID-19 and with worse in-hospital clinical outcome.Trial registration numberNCT04318366

Objective To assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19). Methods This single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion

Myocardial ischaemia is usually caused by abnormalities of the epicardial coronary arteries. In the past 30 years, however, several studies have shown that abnormalities in the coronary microcirculation may also cause or contribute to myocardial ischaemia in several conditions. In a number of patients who present with anginal attacks in the absence of any apparent cardiac or systemic disease, coronary microvascular dysfunction (CMD) has been suggested to be the unique cause of symptoms.w1 Myocardial blood flow (MBF) abnormalities and the consequent myocardial alterations related to CMD may differ substantially from those caused by flow limiting stenoses in epicardial coronary arteries. In the latter case, the impairment of MBF is generally regional and distributed within the territories subtended by the stenosed artery, resulting in detectable segmental impairment of contractile function. In contrast, in the case of CMD, the abnormality may not necessarily involve the territory subtended by a major coronary branch, but it may affect the whole left ventricle diffusely or be distributed in a scattered manner.1 w1 CMD may be sustained by several pathogenetic mechanisms including structural, functional, and extravascular alterations that can contribute to the condition in different ways. On the basis of the clinical settings in which it occurs, CMD can be classified into four types: (1) dysfunction occurring in the absence of coronary artery disease (CAD) and myocardial diseases; (2) dysfunction occurring in the absence of CAD, but in the presence of myocardial diseases; (3) dysfunction occurring concomitantly with CAD; (4) iatrogenic dysfunction.1 CMD in the presence of myocardial diseases is sustained in most instances by adverse remodelling of intramural coronary arterioles, and can be identified by invasive or non-invasive assessment of coronary flow reserve (CFR). CFR—the ratio of MBF during near maximal coronary vasodilatation to basal MBF—is an integrated measure of flow through both …

In population studies including patients with new onset heart failure, progressive heart failure appears to be the single most common cause of death (52%), with sudden death accounting for only 22% of deaths within the first 6 months of diagnosis.1 Studies published in recent years have shown that nuclear cardiology, both single photon emission computed tomography (SPECT) and positron emission tomography (PET), has the potential to provide clinically useful information enabling better stratification and optimal choice of treatment for patients with heart failure. Older age, greater functional impairment, poorer systolic function of the left ventricle, lower serum sodium, poorer renal function, broader QRS complex, lower blood pressure, and inability to tolerate disease modifying drugs such as angiotensin converting enzyme (ACE) inhibitors, are generally associated with a poorer prognosis and are mentioned in guidelines for heart failure management.2 There is a pressing need for improved risk stratification for patients developing heart failure, with the goal of better identification of those for whom more aggressive therapy is likely to be beneficial. ### Cardiac autonomic dysfunction From a pathophysiological viewpoint, there is increased sympathetic activity in the hearts of patients with congestive heart failure, which is a generalised rather than a regional phenomenon, and contributes to the remodelling process of the whole left ventricle (figure 1). The myocardium of patients with systolic heart failure is characterised by a significant reduction of pre-synaptic norepinephrine (noradrenaline) uptake and post-synaptic β-adrenoceptor density.3 Figure 1 Increased cardiac sympathetic activity in heart failure. A reduced cardiac output entails decreased inhibitory inputs (baroreceptor afferent fibres) and increased excitatory inputs (mechanoreceptor afferent fibres) to the dorsolateral medulla. This results in increased cardiac sympathetic activity and reduced vagal output. Courtesy of Ornella Rimoldi MD. #### Imaging pre-synaptic norepinephrine handling Metaiodobenzylguanidine (MIBG) is a structural analogue of norepinephrine that shares the same uptake and storage mechanisms as norepinephrine. MIBG can be …

OBJECTIVE—Previous studies have suggested that resting myocardial blood flow is within normal limits in most chronically dysfunctional left ventricular segments which improve function after coronary artery revascularisation (hibernating myocardium). The aim of this study was to assess myocardial blood flow and coronary vasodilator reserve in hibernating myocardium before and after coronary revascularisation. PATIENTS AND METHODS— 30 patients with multivessel coronary disease undergoing coronary revascularisation (21 patients with bypass grafting and nine with coronary angioplasty), and 21 age and sex matched healthy volunteers (controls). Myocardial blood flow (MBF, ml/min/g) was measured by positron emission tomography using oxygen-15 water at rest and after dipyridamole (MBFdip, 0.56 mg/kg in four minutes). Coronary vasodilator reserve was calculated as MBFdip/MBF. Regional wall motion was assessed with echocardiography. RESULTS—Before revascularisation there were 48 remote and 275 dysfunctional myocardial segments, of which 163 (59%) improved function after revascularisation (hibernating). In hibernating segments coronary vasodilator reserve before revascularisation was significantly lower than in remote segments (1.97 (0.7), p

Imaging with positron emission tomography (PET) offers unrivalled sensitivity and specificity for research into biochemical pathways and pharmacological mechanisms in vivo. Cardiac and neurological research with PET has flourished over the past 20 years, but it is only more recently that cardiology has begun to benefit from the advantages provided by PET. From the physical point of view, scanning of the heart presents a challenge because of greater complications in correcting for photon attenuation and scattered radiation, and because of movement of the heart and lungs.#### Unique features of PET The success of PET is based on the properties of the isotopes used (table 1). Their short physical half lives make it possible to administer a tracer dose high enough to obtain useful data, but such that the radiation burden to the patient is acceptably low. Positron emitters do not exist in nature and they must be produced artificially by means of a particle accelerator (generally a cyclotron).1 Production of isotopes with the shortest half lives has to be carried out in the vicinity of the scanner and necessitates the installation of cyclotron and radiochemistry facilities. However, 18F compounds can be delivered from a relatively remote site of production. The commercial success of PET has been driven by 18F labelled fluorodeoxyglucose (FDG) which is used to measure glucose metabolism in tissues. Because of the longer half life of 18F (table 1), many centres rely on production from a centralised cyclotron, thus avoiding the expense of individual facilities. However, research centres aiming to derive most from the power of PET require on site production of a range of …

OBJECTIVE--To assess the relation between left ventricular function and myocardial beta adrenoceptor density. METHODS--17 patients with hypertrophic cardiomyopathy, six with and 11 without heart failure, were studied. Left ventricular function was assessed by echocardiography, and myocardial beta adrenoceptors by positron emission tomography. Patient data were compared with those obtained in normal controls. RESULTS--Myocardial beta adrenoceptor density in the 17 patients was 7.00 (SD 1.90) pmol/g v 11.50 (2.18) pmol/g in normal controls (P < 0.01). beta Adrenoceptor density in the six patients with left ventricular failure was 5.61 (0.88) pmol/g v 7.71 (1.86) pmol/g in the 11 patients with normal ventricular function (P < 0.05), and there was a significant correlation (r = 0.52; P < 0.05) between left ventricular fractional shortening and myocardial beta adrenoceptor density. A positive correlation (r = 0.51; P < 0.05) was also found between myocardial beta adrenoceptor density and the E/A transmitral flow ratio, an index of left ventricular diastolic function. CONCLUSIONS--There is myocardial beta adrenoceptor downregulation in patients with hypertrophic cardiomyopathy with or without signs of heart failure.

To investigate the influence of infarct zone viability on remodelling after late recanalisation of an occluded infarct related artery.A subgroup of 26 volunteers from TOAT (the open artery trial) underwent dobutamine stress cardiovascular magnetic resonance at baseline to assess the amount of viable myocardium present with follow up to assess remodelling at one year. TOAT studied patients with left ventricular dysfunction after anterior myocardial infarction (MI) associated with isolated proximal occlusion of the left anterior descending coronary artery with randomisation to percutaneous coronary intervention (PCI) with stent at 3.6 weeks after MI (PCI group) or to medical treatment alone (medical group).In the PCI group there was a significant relation between the number of viable segments within the infarct zone and improvement in end systolic volume index (-7.7 ml/m2, p = 0.02) and increased ejection fraction (4.1%, p = 0.03). The relation between viability and improvements in end diastolic volume index (-8.8 ml/m2, p = 0.08) and mass index (-6.3 g/m2, p = 0.01) did not reach significance (p = 0.27 and p = 0.8, respectively). In the medical group, there was no significant relation between the number of viable segments in the infarct zone and the subsequent changes in end diastolic (p = 0.84) and end systolic volume indices (p = 0.34), ejection fraction (p = 0.1), and mass index (p = 0.24).The extent of viable myocardium in the infarct zone is related to improvements in left ventricular remodelling in patients who undergo late recanalisation of an occluded infarct related artery.

The recently published meta-analysis by Wolfrum et al assessed the ability of percutaneous closure of patent foramen ovale (PFO) to reduce the incidence of recurrent stroke based on three randomised controlled clinical trials (RCT). This analysis did not demonstrate a superiority of the closure of PFO compared with medical …

We present a case of a 73 year old woman with double aortic arch and separate origin of the right common carotid and right subclavian arteries, found coincidentally during cardiac angiography. She has a history of coronary artery disease …

Editor,—We read with interest the article by Al-Mohammad and colleagues on the prevalence of hibernating myocardium in patients with ischaemic left ventricular dysfunction.1Although we agree with the authors that positron emission tomography (PET) can provide very accurate information for the identification of hibernating myocardium, general statements regarding PET as being the “gold standard” for the diagnosis of viability might be misleading in view of recently published data.2 In a particular subset of patients (those with severe postischaemic left ventricular dysfunction) PET is more accurate than other imaging techniques and, because of its technical characteristics, it is able to provide superior information on tissue viability. However, this requires the adoption of steady-state and standardised study conditions such as those achieved during hyperinsulinaemic euglycaemic clamp for an accurate quantification of the uptake of 18F fluorodeoxyglucose (FDG) by the myocardium. In addition this method does not require the simultaneous measurement of myocardial blood flow for the assessment of viability. Using this method we have shown that in patients with severe …