Search

Cardiac magnetic resonance (CMR) imaging provides valuable prognostic information in patients with ST-elevation myocardial infarction (STEMI). The peri-infarct zone (PIZ) is a potential marker for post-infarction risk stratification. The aim of this study was to assess the prognostic impact of PIZ in a large multicenter STEMI-trial.The study population consisted of 704 consecutive patients undergoing CMR within 10 days after STEMI to assess established parameters of myocardial injury and additionally the extent of PIZ. The primary clinical endpoint was major adverse cardiac events (MACE) consisting of death, re-infarction and new congestive heart failure within 1 year after infarction.The median heterogeneous PIZ-volume in the overall population was 14 ml (interquartile range [IQR] 7 to 24 ml). Male sex, infarct size, and left ventricular ejection fraction were identified as independent predictors of larger PIZ alterations. Patients with MACE had a significantly larger PIZ volume compared to patients without adverse events (21 ml [IQR 12 to 35 ml] versus 14 ml [IQR 7 to 23 ml]; p = 0.001). In stepwise multivariable Cox regression analysis, PIZ median (14 ml) emerged as an independent predictor of MACE (hazard ratio [HR] 2.84; 95% confidence interval [CI] 1.34 to 6.00; p = 0.006) in addition to the Thrombolysis In Myocardial Infarction (TIMI) risk score (HR 1.53; 95% CI 1.19 to 1.53; p 0.001). Addition of PIZ to a CMR risk model comprising LVEF, infarct size and microvascular obstruction resulted in net reclassification improvement of 0.46 (0.19-0.73, p 0.001).In this currently largest prospective, multicenter CMR study assessing PIZ, the extent of PIZ emerged as an independent predictor of MACE and a potential novel marker for optimized risk stratification in STEMI patients. ClinicalTrials.gov: NCT00712101.

Background The short- and long-term prognosis of Takotsubo syndrome (TTS) presenting with right ventricular (RV) involvement remains poorly understood. Research Question What is the incidence and clinical outcome of RV involvement in TTS? Study Design and Methods This study analyzed 839 consecutive patients with TTS (758 female subjects and 81 male subjects) in a multicenter registry. RV involvement was defined as wall motion abnormality of the RV free wall, with or without apical involvement. The median long-term follow-up was 2.1 years (interquartile range, 0.3-4.5 years). The primary outcome was in-hospital and out-of-hospital all-cause mortality. The secondary end point was a composite of in-hospital death, thromboembolic events, cardiogenic shock, pulmonary edema, and malignant arrhythmias. Results The incidence of RV involvement in TTS was 11% (n = 93). More often patients with RV involvement were male compared with patients without RV involvement (P = .02). There was a slight difference in the left ventricular ejection fraction measured in patients with RV involvement vs those patients with isolated left ventricular TTS (38 ± 10% vs 40 ± 10%; P = .03). No major differences in terms of comorbidities were observed between groups except regarding a history of cancer, which was significantly more prevalent in patients with TTS presenting with RV involvement (P = .03). Physical stressors were more prevalent in the RV group (P Interpretation RV involvement defines a high-risk cohort of patients with TTS. Clinical Trial Registration ClinicalTrials.gov ; No.: NCT04361994 ; URL: www.clinicaltrials.gov .

Vorhofflimmern und Herzinsuffizienz mit erhaltener linksventrikularer (LV) Pumpfunktion („heart failure with preserved ejection fraction“ [HFpEF]) nehmen aufgrund zunehmender Erkrankungszahlen einen hohen Stellenwert in der Herzmedizin ein. Beide Krankheitsbilder konnen sich gegenseitig beeinflussen, und bedeutsame kardiovaskulare Risikofaktoren wie Bluthochdruck, Diabetes mellitus, Adipositas sowie eine Einschrankung der Nierenfunktion konnen sowohl bei Vorhofflimmern als auch bei Herzinsuffizienz mit erhaltener Pumpfunktion gehauft beobachtet werden. Aktuell bewahrte Therapiekonzepte fur Patienten mit Herzinsuffizienz und reduzierter LV-Pumpfunktion („heart failure with reduced ejection fraction“ [HFrEF]) scheinen zum gegenwartigen Zeitpunkt leider keinen vergleichbaren prognostischen oder symptomatischen Nutzen fur Patienten mit HFpEF zu haben. Daruber hinaus gibt es Hinweise, dass das Auftreten von Vorhofflimmern bei HFpEF-Patienten mit einer eingeschrankten Prognose vergesellschaftet ist. Auch auf die Funktionen von Niere und Herz hat Vorhofflimmern ungunstige Auswirkungen. Retrospektive Auswertungen von Patienten mit Vorhofflimmern und HFpEF, die mittels Pulmonalvenenisolation behandelt worden waren, konnten zeigen, dass eine interventionelle Behandlung des Vorhofflimmerns zu einer Verbesserung des New-York-Heart-Association(NYHA)-Stadiums und der diastolischen Funktion fuhrte. Aktuell laufende Studien wie die AMPERE-Studie, bei der HFpEF-Patienten mit Vorhofflimmern eingeschlossen und mittels Pulmonalvenenisolation behandelt werden, konnen hoffentlich belastbare prospektive, randomisierte Daten liefern und moglicherweise eine symptomatisch und vielleicht auch prognostisch bedeutsame Therapie fur HFpEF-Patienten mit Vorhofflimmern aufzeigen.

ObjectiveRight ventricular (RV) involvement complicating myocardial infarction (MI) is thought to impact prognosis, but potent RV markers for risk stratification are lacking. Therefore, the aim of this trial was to assess the frequency and prognostic implications of concomitant structural and functional RV injury in MI.MethodsCardiac magnetic resonance (CMR) was performed in 1235 patients with MI (ST-elevation myocardial infarction: n=795; non-STEMI: n=440) 3 days after reperfusion by primary percutaneous coronary intervention. Central core laboratory-masked analyses included structural (oedema representing reversible ischaemia, irreversible infarction, microvascular obstruction (MVO)) and functional (ejection fraction, global longitudinal strain (GLS)) RV alterations. The clinical end point was the 12-month rate of major adverse cardiac events (MACE).ResultsRV ischaemia and infarction were observed in 19.6% and 12.1% of patients, respectively, suggesting complete myocardial salvage in one-third of patients. RV ischaemia was associated with a significantly increased risk of MACE (10.1% vs 6.2%; p=0.035), while patients with RV infarction showed only numerically increased event rates (p=0.075). RV MVO was observed in 2.4% and not linked to outcome (p=0.894). Stratification according to median RV GLS (10.2% vs 3.8%; pConclusionsRV GLS is a predictor of postinfarction adverse events over and above established risk factors, while structural RV involvement was not independently associated with outcome.

Clinical presentation of Takotsubo syndrome (TTS) may range from acute chest pain to dyspnea: the prognostic role of clinical onset is still controversial. Aim of this study was therefore to investigate the prognostic relevance of dyspnea at presentation in patients with TTS. We analyzed 1,071 TTS patients (median age 72 years, 90% female) enrolled in the international multicenter GEIST registry. Patients were divided according to the presence or absence of dyspnea at hospital admission, as clinically assessed by the accepting physician. The primary endpoint was occurrence of in-hospital complications defined as a composite of pulmonary edema, cardiogenic shock and death. Overall, 316 (30%) patients presented with dyspnea at hospital admission. Diabetes, lower left ventricular ejection fraction and presence of pulmonary disease or atrial fibrillation were independently associated with dyspnea. In-hospital pulmonary edema, cardiogenic shock and death (17% vs. 3%, p

The role of coronary collaterals in ST-elevation myocardial infarction (STEMI) remains controversial. So far, studies examining the effect of collaterals on outcome mainly focused on patients presenting early after symptom onset. We sought to investigate the prognostic influence of coronary collateralization in patients presenting with prolonged ischemia late after symptom onset. The study is a subanalysis of a randomized trial addressing thrombus aspiration in STEMI patients presenting between 12 and 48 h after symptom onset with a follow-up period of a minimum of 4 years. A total of 95 patients with a Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1 prior to percutaneous coronary intervention (PCI) were included in the analysis. Of these, 62 patients (65%) had none or poor coronary collateralization according to the Rentrop classification (Rentrop grade 0 or 1) compared to 33 (35%) with well-developed collateralization (Rentrop grade 2 or 3). In comparison, patients with well-developed collateralization had a smaller area of microvascular obstruction (2.1 ± 3.8 vs. 4.5 ± 4.9% of left ventriclular mass (%LV), p = 0.03) and infarct size (27.9 ± 11.7 vs. 34.8 ± 17.2% LV, p = 0.047) on magnetic resonance imaging. Further, mortality at 4-years follow-up was lower (6% Rentrop grade 2 or 3 vs. 25% Rentrop grade 0 or 1, p = 0.02). Poor collateralization was an independent predictor of long-term mortality on multivariate Cox regression analyses in addition to cardiogenic shock and unsuccessful PCI during the index procedure. Sufficient coronary collateralization has a positive impact on microvascular obstruction, infarct size and long-term mortality in STEMI patients presenting between 12 and 48 h after symptom onset.

Sex-specific outcome data following myocardial infarction (MI) are inconclusive with some evidence suggesting association of female sex and increased major adverse cardiac events (MACE). Since mechanistic principles remain elusive, we aimed to quantify the underlying phenotype using cardiovascular magnetic resonance (CMR) quantitative deformation imaging and tissue characterisation.In total, 795 ST-elevation MI patients underwent post-interventional CMR imaging. Feature-tracking (CMR-FT) was performed in a blinded core-laboratory. Left ventricular function was quantified using ejection fraction (LVEF) and global longitudinal/circumferential/radial strains (GLS/GCS/GRS). Left atrial function was assessed by reservoir (εs), conduit (εe) and booster-pump strains (εa). Tissue characterisation included infarct size, microvascular obstruction and area at risk. Primary endpoint was the occurrence of MACE within 1 year.Female sex was associated with increased MACE (HR 1.96, 95% CI 1.13-3.42, p = 0.017) but not independently of baseline confounders (p = 0.526) with women being older, more often diabetic and hypertensive (p 0.001) and of higher Killip-class (p = 0.010). Tissue characterisation was similar between sexes. Women showed impaired atrial (εs p = 0.011, εe p 0.001) but increased systolic ventricular mechanics (GLS p = 0.001, LVEF p = 0.048). While atrial and ventricular function predicted MACE in men only LV GLS and GCS were associated with MACE in women irrespective of confounders (GLS p = 0.036, GCS p = 0.04).In men ventricular systolic contractility is impaired and volume assessments precisely stratify elevated risks. In contrast, women experience reduced atrial but increased ventricular systolic strain. This may reflect ventricular diastolic failure with systolic compensation, which is independently associated with MACE adding incremental value to sex-specific prognosis evaluation.

Acute ST-elevation myocardial infarction (STEMI) is associated with a high incidence of complications as well as a considerable hospitalization rate and economic burden. Preliminary evidence suggests that remote ischemic conditioning (RIC) is a promising non-invasive intervention that may effectively and safely reduce myocardial infarct size, subsequent cardiac events and complications, and mortality. However, RIC's cardio-protective effect remains under debate, especially for single timepoint RIC programs. Adequately powered large-scale randomized controlled trials investigating clinical outcomes are thus needed to clarify the role of full disease cycle RIC programs.The intelligent "Internet Plus"-based full disease cycle remote ischemic conditioning (i-RIC) trial is a pragmatic, multicenter, randomized controlled, parallel group, clinical trial. The term, intelligent "Internet Plus"-based full disease cycle, refers to smart devices aided automatic and real-time monitoring of remote ischemic pre-, per- or post-conditioning intervention for patients with STEMI undergoing percutaneous coronary intervention (PCI). Based on this perspective, 4700 STEMI patients from five hospitals in China will be randomized to a control and an intervention group. The control group will receive PCI and usual care, including pharmacotherapy, before and after PCI. The intervention group will receive pre-, per-, and post-operative RIC combined with long-term i-RIC over a one-month period in addition. A smartphone application, an automated cuff inflation/deflation device and "Internet Plus"-based administration will be used in the long-term phase. The primary outcome is the combined cardiac death or hospitalization for heart failure rate. Secondary outcomes include clinical and functional outcomes: major adverse cardiac and cerebrovascular events rate, all-cause mortality, myocardial reinfarction rate, readmission rate for heart failure and ischemic stroke rate, unplanned revascularization rate, plasma concentration of myocardial infarction-related key biomarkers, infarct size, cardiac function, cardiopulmonary endurance, health-related quality of life, total hospital length of stay, total medical cost, and compliance with treatment regime.The i-RIC trial is designed to test the hypothesis that clinical and functional outcomes can be improved with the i-RIC program in STEMI patients undergoing PCI. The concept of RIC is expected to be enhanced with this intelligent "Internet Plus"-based program focusing on the full disease cycle. If the i-RIC program results in superior improvement in primary and secondary outcomes, it will offer an innovative treatment option for STEMI patients and form the basis of future recommendations.Chinese Clinical Trial Registry ( http://www.chictr.org.cn ): ChiCTR2000031550, 04 April 2020.

Aims To evaluate the prognostic validity of clinical risk factors as well as infarct characterization and myocardial deformation by cardiac magnetic resonance (CMR) in ST-elevation myocardial infarction (STEMI) patients with preserved left ventricular ejection fraction (LVEF) following primary percutaneous coronary intervention (PCI). Methods and results This multicentre, individual patient-data analysis from two large CMR trials included 1247 STEMI patients. Cardiac magnetic resonance examinations were conducted 3 [interquartile range (IQR) 2–4] days after PCI. LVEF, infarct size, microvascular obstruction (MVO), and myocardial strain values were measured. Primary endpoint was defined as composite of major adverse cardiovascular events (MACE) including death, re-infarction, and congestive heart failure. A preserved LVEF (defined as LVEF ≥50%) was observed in 724 patients (=58%). In the overall cohort, 97 patients experienced a MACE event [follow-up time 12 (IQR 12–13) months], and 34 MACE events occurred in the group with preserved LVEF (5% vs. 12% incidence rate in patients with LVEF < 50%). TIMI risk score [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.02–1.59; P = 0.03] and female gender (HR 2.24, 95% CI 1.10–4.57; P = 0.03) emerged as independent clinical determinants of MACE in the patient group with preserved LVEF. Among CMR parameters, the presence of MVO (HR 2.39, 95% CI 1.05–5.46; P = 0.04) and reduced global longitudinal strain (GLS; HR 1.12, 95% CI 1.02–1.23; P = 0.02) independently predicted MACE in the LVEF-preserved population. The addition of MVO and GLS to the clinical prognostic markers (TIMI risk score, female gender) increased (P = 0.02) the prognostic validity [AUC 0.76 (95% CI 0.73–0.79)] compared to the clinical markers alone [AUC 0.65 (0.62–0.69)]. Conclusion In contemporary treated STEMI patients showing preserved LVEF, a CMR-based risk prediction approach assessing MVO and GLS provided strong prognostic value that was incremental to clinical outcome parameters.

Aims To evaluate outcomes of percutaneous left atrial appendage closure (LAAC) in patients with congestive heart failure (CHF) and non‐valvular atrial fibrillation (AF) in a consecutive, industry‐independent registry associated with periprocedural success and complications during long‐term follow‐up. Methods and results For this analysis, we included patients who underwent transcatheter LAAC from January 2014 to December 2019 at the University Heart Center in Lübeck, Germany, and compared patients with presence of CHF defined as patients with a reduced left ventricular ejection fraction (LVEF ≤ 40%), patients with a mid‐range LVEF (LVEF 41–49%), patients with diastolic dysfunction and preserved LVEF (LVEF ≥ 50%), and patients with right‐sided heart failure and impaired right ventricular function (tricuspid annular plane systolic excursion

Objectives To compare the Watchman™ versus Amulet™ left atrial appendage closure (LAAC) devices in a consecutive, industry-independent registry. Background Data reporting a head-to-head comparison between Amulet and Watchman devices are scarce. Methods Patients who underwent LAAC using Watchman or Amulet devices from January 2014 to December 2019 at the University Heart Center Lübeck, Lübeck, Germany were included in the present analysis. Primary endpoints included periprocedural complications (in-hospital death, pericardial tamponade, device embolization, stroke, major bleeding and vascular access complications), and complications during 2-year-follow-up (ischemic stroke, hemorrhagic stroke, thromboembolism, device thrombus, bleeding and death). Results After matching the patients for age (± 5 years), gender, CHA2DS2Vasc score (± 1) and HASBLED score (± 1), each of the Watchman and the Amulet groups included 113 patients. Patients in the Amulet group had significantly more periprocedural complications (2.7% vs 10.6%, p = 0.029; respectively) and more major bleeding complications (0% vs 5.3%, p = 0.029; respectively). During 2-year follow-up, the rate of events was comparable between the Watchman and Amulet groups (18.3% versus 20.8%, p = 0.729; respectively). Conclusion Amulet LAAC device was associated with increased periprocedural complications as compared to Watchman LAAC device. On 2-year follow-up, both devices showed comparable efficacy and safety.

One important complication related to takotsubo syndrome (TTS) is adverse rhythm disorders. Our study was conducted to determine the incidence and management of adverse rhythm disorders in TTS and its long-term prognostic impact. We analyzed 906 TTS patients from 9 European centers. Patients were divided into the adverse rhythm disorders group (encompassing ventricular tachycardia, ventricular fibrillation, torsade de pointes, and asystole or complete atrioventricular block) and non-adverse rhythm disorders group. In our study cohort, we identified 67 (7.4%) patients with presence of adverse rhythm disorders. TTS patients were followed up over a period of 2.8 years. In the adverse rhythm disorders group, 18% of patients presented adverse rhythm disorders before hospital admission. Asystole and/or AV block were significantly more presented before admission (13 patients versus 8 patients; p < 0.01), whereas ventricular tachyarrhythmias were more presented in-hospital (4 patients versus 42 patients; p < 0.01). Adverse rhythm disorders patients suffered more frequently from cardiogenic shock (31% versus 7.6%, p < 0.01) and in-hospital death (10.9% versus 3.6%; p < 0.01). Furthermore, the long-term survival was significantly impaired in adverse rhythm disorders patients as compared with non-adverse rhythm disorders patients; (log-rank p < 0.01). Using multivariate Cox regression analysis, cardiogenic shock (HR 2.86, 95% CI 1.1-6.9; p = 0.02) was identified as independent predictors of adverse rhythm disorders. The short- and long-term mortality rate of TTS patients presenting with adverse rhythm disorders was significantly higher than in TTS patients presenting without it. Therefore, TTS patients with adverse rhythm disorders should be carefully monitored during hospital stay and at long-term follow-up.

Rationale: Remote ischemic conditioning (RIC) or ischemic postconditioning (PostC) may protect the myocardium from ischemia-reperfusion injury in patients with ST-segment–elevation myocardial infarction. Objective: To determine whether combined intrahospital RIC and PostC or PostC alone in addition to primary percutaneous coronary intervention (PCI) reduce long-term clinical events after ST-segment–elevation myocardial infarction. Methods and Results: The present study is a post hoc analysis of a prospective trial which randomized 696 ST-segment–elevation myocardial infarction patients with symptoms P =0.04). The difference was driven by a significantly reduced rate of new congestive heart failure in the RIC and PostC group (2.7% versus 7.8%; odds ratio, 0.32; 95% CI, 0.13–0.84; P =0.02). In contrast, PostC alone did not reduce major adverse cardiac events compared with controls (14.1% versus 16.9%; odds ratio, 0.81; 95% CI, 0.48–1.35; P =0.41), and the reduction of new congestive heart failure was not statistically significant (3.5% versus 7.8%; odds ratio, 0.43; 95% CI, 0.18–1.03; P =0.05). Conclusions: Cardioprotection by combined intrahospital RIC and PostC in addition to primary PCI significantly reduced the rate of major adverse cardiac events and new congestive heart failure after ST-segment–elevation myocardial infarction. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02158468.

Background The results of studies investigating the clinical benefit of a direct stenting (DS) strategy in ST-elevation myocardial infarction (STEMI) are inconsistent and data regarding cardiac magnetic resonance (CMR) parameters of myocardial injury are lacking. The aim of this study was to investigate the effect of DS on myocardial damage in comparison to a conventional stenting technique (CS) with predilation in patients with reperfused STEMI. Methods In a subanalysis of the randomized LIPSIA CONDITIONING trial ( NCT02158468 ), STEMI patients were stratified according to the percutaneous coronary intervention technique into the DS (n = 171) or CS (n = 171) group after matching the patients for age (±5 years), gender, and TIMI flow before coronary intervention. Patients underwent CMR imaging within one week after infarction. Clinical outcome (death, reinfarction, hospitalization for heart failure) was assessed within 6 months after the index event. Results Patients in the DS group had significantly lower infarct size (16 vs. 19% of left ventricular mass; p = 0.046) and microvascular obstruction with significant improvement of left ventricular parameters, which was associated with favorable clinical outcome with a lower incidence of heart failure hospitalizations (4% vs. 11%, p = 0.011) and mortality (5% vs. 12%, p = 0.034) as compared to patients with CS. In multivariate Cox regression analysis, DS was identified as an independent predictor of reduced mortality (HR 0.30, 95% CI 0.11–0.87, p = 0.026). Conclusion In patients with acute reperfused STEMI, DS is safe and feasible with a significant reduction of infarct size compared to CS and subsequent lower incidence of heart failure hospitalizations and mortality.

Takotsubo syndrome (TTS) can be induced by a large variety of physical/emotional triggers; several cases, however, are related to either an overt or occult malignancy, as shown in retrospective studies and case reports. The aim of this study was therefore to evaluate the clinical outcome of patients with TTS and cancer in a meta-analysis study. In June 2018, a Pubmed systematic research was conducted for studies assessing outcome in patients with TTS and cancer. We assessed Mantel-Haenszel pooled estimates of risk ratios (RRs) and 95% confidence intervals (CIs) for adverse events at follow-up. After paper retrieval, four studies were included in the meta-analysis, with a total of 123,563 patients. The prevalence of current or previous malignancy among patients admitted with TTS was 6.7% (8258 patients). When compared to control patients, patients with cancer showed an increased risk of clinical events (RR 3.24, 95% CI 3.04–3.45, p

Background Intravenous morphine administration can adversely affect platelet inhibition induced by P2Y 12 receptor inhibitors after acute myocardial infarction. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. The aim of this prospective, randomized MonAMI (Impact of Morphine Treatment With and Without Metoclopramide Coadministration on Platelet Inhibition in Acute Myocardial Infarction) trial was, therefore, to investigate the impact of morphine with or without metoclopramide coadministration on myocardial and microvascular injury. Methods and Results Patients with acute myocardial infarction (n=138) were assigned in a 1:1:1 ratio to ticagrelor 180 mg plus: (1) intravenous morphine 5 mg (morphine group); (2) intravenous morphine 5 mg and metoclopramide 10 mg (morphine+metoclopramide group); or (3) intravenous placebo (control group) administered before primary percutaneous coronary intervention. Cardiac magnetic resonance imaging was performed in 104 patients on day 1 to 4 after the index event. Infarct size was significantly smaller in the morphine only group as compared with controls (percentage of left ventricular mass, 15.5 versus 17.9; P =0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (28% versus 54%; P =0.022) and the extent of microvascular obstruction was smaller (percentage of left ventricular mass, 0 versus 0.74; P =0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio, 0.37; 95% CI, 0.14–0.93 [ P =0.035]). There was no significant difference in infarct size ( P =0.491) and extent ( P =0.753) or presence ( P =0.914) of microvascular obstruction when comparing the morphine+metoclopramide group with the control group. Conclusions In this randomized study, intravenous administration of morphine before primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following acute myocardial infarction. This effect was not observed in the morphine plus metoclopramide group. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02627950.

Little is known about sex differences in elderly patients after out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) and subsequent target temperature management (TTM). Therefore, this study was designed to evaluate sex-specific differences in survival and neurological outcome in elderly patients at 28-day and 180-day follow-up.A total of 468 nontraumatic OHCA survivors with preclinical ROSC and an age of ≥ 65 years were included in this study. Sex-specific differences in survival and a favorable neurological outcome according to the cerebral performance category (CPC) score were evaluated as clinical endpoints.Of all participants included, 70.7% were men and 29.3% women. Women were significantly older (p = 0.011) and were more likely to have a nonshockable rhythm (p = 0.001) than men. Evaluation of survival rate and favorable neurological outcome by sex category showed no significant differences at 28-day and 180-day follow-up. In multiple stepwise logistic regression analysis, age (odds ratio 0.932 [95% confidence interval 0.891-0.951], p = 0.002) and time of hypoxia (0.899 [0.850-0.951], p 0.001) proved to be independent predictors of survival only in male patients, whereas an initial shockable rhythm (4.325 [1.309-14.291], p = 0.016) was associated with 180-day survival in female patients. The majority of patients (93.7%) remained in the same CPC category when comparing 28-day and 180-day follow-up.Our results show no significant sex-specific differences in survival or favorable neurological outcome in elderly patients after having survived OHCA, but sex-specific predictors for 180-day survival. Moreover, the neurological assessment 28 days after the index event also seems to provide a valid indication for the further prognosis in elderly patients.HINTERGRUND: Aktuell existieren nur wenige Daten über geschlechtsspezifische Unterschiede bei älteren Patienten mit überlebtem außerklinischem Herz-Kreislauf-Stillstand (OHCA) und anschließendem Temperaturmanagement (TTM). Daher wurden geschlechtsspezifische Unterschiede im Überleben und im neurologischen Ergebnis bei älteren Patienten nach 28 und 180 Tagen untersucht.Insgesamt wurden 468 Patienten ≥ 65 Jahren mit OHCA sowie präklinischer Rückkehr eines Spontankreislaufs (ROSC) berücksichtigt. Evaluiert wurden die Überlebenswahrscheinlichkeit und der neurologischer Status gemessen mittels Cerebral-Performance-Category(CPC)-Skala.Frauen (29,3 % des Studienkollektivs) waren im Vergleich zu Männern (70,7 %) signifikant älter (p = 0,011) und wiesen häufiger einen nicht schockbaren Rhythmus (p = 0,001) auf. Es wurden kein signifikanter Unterschied beim Überleben und beim neurologischen Outcome festgestellt. In der multiplen Regressionsanalyse wurden bei männlichen Patienten das Alter (Odds-Ratio 0,932 [95 %-Konfidenzintervall 0,891–0,951], p = 0,002) und die Zeit bis zum Beginn der Reanimation (0,899 [0,850–0,951], p 0,001) als unabhängige Prädiktoren für das Überleben nach 6 Monaten identifiziert. Bei Frauen zeigte nur ein initial schockbarer Rhythmus (4,325 [1,309–14,291], p = 0,016) eine unabhängige Assoziation mit dem Überleben nach 6 Monaten. Die Mehrheit der Patienten (93,7 %) wies keine Änderung des neurologischen Status zwischen den Messzeitpunkten auf.Die Ergebnisse zeigen bei älteren Patienten bis 6 Monate nach dem Herz-Kreislauf-Stillstand keinen geschlechtsspezifischen Unterschied beim Überleben und beim neurologischen Status, aber geschlechtsspezifische Prädiktoren für das 180-Tage-Überleben. Zudem war eine valide prognostische Aussage bezüglich des neurologischen Status bereits 28 Tage nach dem Indexereignis möglich.

Funding Acknowledgements Type of funding sources: None. Background Cardiovascular magnetic resonance (CMR) imaging is considered the reference methodology for cardiac morphology and function but requires manual post-processing. Whether novel artificial intelligence (AI) -based automated analyses deliver similar information for risk stratification is unknown. Therefore, this study aimed to investigate feasibility and prognostic implications of AI-based analyses. Methods CMR data (n = 1017 patients) from two myocardial infarction multi-center trials were included. Analyses of biventricular parameters including ejection fraction (EF) were manually and automatically assessed using conventional and AI-based software. Obtained parameters entered regression analyses for prediction of major adverse clinical events (MACE) defined as death, reinfarction or congestive heart failure within one-year after the acute event. Results Both manual and uncorrected automated volumetric assessments showed similar impact on outcome on univariate (LVEF HR 0.93, [95% CI 0.91-0.95]; p < 0.001 for manual and HR 0.94 [0.92-0.96]; p < 0.001 for automated) and multivariable analyses (LVEF HR 0.95, [0.92-0.98]; p = 0.001 for manual and HR 0.95 [CI 0.92-0.98]; p = 0.001 for automated). Manual correction of the automated contours did not lead to improved risk prediction (LVEF AUC 0.67 automated vs. 0.68 automated corrected, p = 0.49). There was acceptable agreement (bias: 2.6%, 95% limits of agreement [LOA] -9.1-14.2%, intraclass correlation coefficient [ICC] 0.88 [0.77-0.93] for LVEF) of manual and automated volumetric assessments. Conclusions User independent volumetric analyses performed by fully automated software are feasible and results are equally predictive of MACE compared with conventional analyses in patients following myocardial infarction.

First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.

IMPORTANCE Takotsubo syndrome (TTS) is an acute, reversible heart failure syndrome featured by significant rates of in-hospital complications. There is a lack of data for risk stratification during hospitalization. OBJECTIVE To derive a simple clinical score for risk prediction of in-hospital complications among patients with TTS. DESIGN, SETTING, AND PARTICIPANTS In this prognostic study, 1007 consecutive patients were enrolled in the German and Italian Stress Cardiomyopathy (GEIST) registry from July 1, 2007, through December 31, 2017, and identified as the derivation cohort; 946 patients were enrolled in the Spanish Registry for Takotsubo Cardiomyopathy (RETAKO) as the external score validation. An admission risk score was developed using a stepwise multivariable regression analysis from 2 registries. Data analysis was performed from March 1, 2018, through July 31, 2018. MAIN OUTCOMES AND MEASURES In-hospital complications were defined as death, pulmonary edema, need for invasive ventilation, and cardiogenic shock. Four variables were identified as independent predictors of in-hospital complications and were used for the score: male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction (LVEF). RESULTS Of the 1007 patients enrolled in the GEIST registry, 107 (10.6%) were male, with mean (SD) age of 69.8 (11.4) years. Overall rate of in-hospital complications was 23.3% (235 of 1007) (death, 4.0%; pulmonary edema, 5.8%; invasive ventilation, 6.4%; and cardiogenic shock, 9.1%). The GEIST prognosis score was derived by providing 20 points each for male sex and history of neurologic disorders and 30 points for right ventricular involvement and then subtracting the value in percent of LVEF (decimal values between 0.15 and 0.70). Score accuracy on area under the receiver operating characteristic curve analysis was 0.71, with a negative predictive power of 87% with scores less than 20. External validation in the RETAKO population (124 [13.1%] male; mean [SD] age, 69.5 [14.9] years) revealed an area under the curve of 0.73 (P = .46 vs GEIST derivation cohort). Stratification into 3 risk groups (40 points) classified 316 patients (40.9%) as having low risk; 342 (44.3%) as having intermediate risk, and 114 (14.8%) as having high risk of complications. The observed in-hospital complication rates were 12.7% for low-risk patients, 23.4% for intermediate-risk patients, and 58.8% for high-risk patients (P < .001 for trend). After 2.6 years of follow-up, patients with in-hospital complications had significantly higher rates of mortality than those without complications (40% vs 10%, P = .01). CONCLUSIONS AND RELEVANCE The GEIST prognostic score may be useful in early risk stratification for TTS. High-risk patients with TTS may require an intensive care unit stay, and low-risk patients with TTS could be discharged within a few days. In-hospital complications in patients with TTS may be associated with increased risk of long-term mortality.

Introduction: Myocardial infarct size (IS) remains one of the strongest predictors of adverse cardiac events following acute myocardial infarction (AMI). Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can precisely quantify the extent of injury but requires manual post-processing. Whether novel user-independent artificial intelligence (AI) based fully-automated analyses may facilitate clinical workflow and deliver similar information for risk stratification is unknown. Methods: 913 AMI patients from two multi-center trials (AIDA-STEMI n = 704 with ST-elevation myocardial infarction [STEMI] and TATORT-NSTEMI n = 245 with non-ST-elevation-infarction [NSTEMI]) were included in this sub-study. IS was quantified manually using conventional software (Medis, Leiden Netherlands) and fully automated AI-based software (NeoSoft). All automatically detected IS were evaluated visually and corrected if necessary. Analyzed data were tested for agreement and prediction of major adverse clinical events (MACE) within one year after AMI. Results: Automated and manual IS were similarly associated with outcome in cox regression analyses (HR 1.05 [95% CI 1-02-1.07] p < 0.001 for automated IS and HR 1.04 [95% CI 1.02-1.06]; p < 0.001 for manual IS). Comparison of C-statistics derived area under the curve (AUC) resulted in equivalent MACE prediction (AUC 0.65 for automated vs. AUC 0.66 for manual, p = 0.53). Manual correction of the automated scar detection did not lead to an improved risk prediction of MACE (AUC 0.65 to 0.66, p = 0.43). There was good agreement of automated and manually derived IS (intraclass correlation coefficient [ICC] 0.75 [0.07-0.89]) which was further improved after manual correction of the underlying contours (ICC 0.98 [0.97-0.98]). Conclusion: AI-based software enables automated scar quantification with similar prognostic value compared to conventional methods in patients following AMI.

Background Right ventricular (RV) involvement complicating myocardial infarction (MI) is thought to impact prognosis, but potent RV markers for risk stratification are lacking. Purpose To assess the frequency and prognostic implications of concomitant structural and functional RV injury in MI. Methods Cardiac magnetic resonance (CMR) was performed in 1235 patients with MI (STEMI: n=795; NSTEMI: n=440) 3 days after reperfusion by primary percutaneous coronary intervention. Central core laboratory-masked analyses included structural (edema representing reversible ischemia, irreversible infarction, microvascular obstruction [MVO]) and functional (ejection fraction, global longitudinal strain [GLS]) RV alterations. The clinical endpoint was the 12-month rate of major adverse cardiac events (MACE). Results RV ischemia and infarction were observed in 19.6% and 12.1% of patients, respectively, suggesting complete myocardial salvage in one-third of patients. RV ischemia was associated with a significantly increased risk of MACE (10.1% versus 6.2%; p=0.035), while patients with RV infarction showed only numerically increased event rates (p=0.075). RV MVO was observed in 2.4% and not linked to outcome (p=0.894). Stratification according to median RV GLS (10.2% versus 3.8%; p Conclusions RV GLS is a predictor of post-infarction adverse events over and above established risk factors, while structural RV involvement was not independently associated with outcome. Funding Acknowledgement Type of funding source: None

Cardiac magnetic resonance (CMR)-derived left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information on various cardiovascular diseases but has not yet been investigated comprehensively in patients with Takotsubo syndrome (TS). This study evaluated the prognostic value of feature tracking (FT) GLS, tissue tracking (TT) GLS, and fast manual long axis strain (LAS) in 147 patients with TS, who underwent CMR at a median of 2 days after admission. Long-term mortality was assessed 3 years after the acute event. In contrast to LV ejection fraction and tissue characteristics, impaired FT-GLS, TT-GLS and fast manual LAS were associated with adverse outcome. The best cutoff points for the prediction of long-term mortality were similar with all three approaches: FT-GLS &minus, 11.28%, TT-GLS &minus, 11.45%, and fast manual LAS &minus, 10.86%. Long-term mortality rates were significantly higher in patients with FT-GLS &gt, &minus, 11.28% (25.0% versus 9.8%, p = 0.029), TT-GLS &gt, 11.45% (20.0% versus 5.4%, p = 0.016), and LAS &gt, 10.86% (23.3% versus 6.6%, p = 0.014). However, in multivariable analysis, diabetes mellitus (p = 0.001), atrial fibrillation (p = 0.001), malignancy (p = 0.006), and physical triggers (p = 0.006) outperformed measures of myocardial strain and emerged as the strongest, independent predictors of long-term mortality in TS. In conclusion, CMR-based longitudinal strain provides valuable prognostic information in patients with TS, regardless of the utilized technique of assessment. Long-term mortality, however, is mainly determined by comorbidities.

BackgroundCardiac magnetic resonance myocardial feature tracking (CMR-FT)-derived global strain assessments provide incremental prognostic information in patients following acute myocardial infarction (AMI). Functional analyses of the remote myocardium (RM) are scarce and whether they provide an additional prognostic value in these patients is unknown.Methods1034 patients following acute myocardial infarction were included. CMR imaging and strain analyses as well as infarct size quantification were performed after reperfusion by primary percutaneous coronary intervention. The occurrence of major adverse cardiac events (MACE) within 12 months after the index event was defined as primary clinical endpoint.ResultsPatients with MACE had significantly lower RM circumferential strain (CS) compared to those without MACE. A cutoff value for RM CS of − 25.8% best identified high-risk patients (p p = 0.003). RM CS provided further risk stratification among patients considered at risk according to established CMR parameters for (1) patients with reduced left ventricular ejection fraction (LVEF) ≤ 35% (p = 0.038 on log-rank testing), (2) patients with reduced global circumferential strain (GCS) > − 18.3% (p = 0.015 on log-rank testing), and (3) patients with large microvascular obstruction ≥ 1.46% (p = 0.002 on log-rank testing).ConclusionCMR-FT-derived RM CS is a useful parameter to characterize the response of the remote myocardium and allows improved stratification following AMI beyond commonly used parameters, especially of high-risk patients.Trial registrationClinicalTrials.gov, NCT00712101 and NCT01612312Graphic abstractDefining remote segments (R) in the presence of infarct areas (I) for the analysis of remote circumferential strain (CS). Remote CS was significantly lower in patients who suffered major adverse cardiac events (MACE) and a cutoff value for remote CS of − 25.8% best identified high-risk patients. In addition, impaired remote CS ≥ − 25.8 % (Remote −) and preserved remote CS

Current evidence regarding the effect of intravenous morphine administration on reperfusion injury and/or cardioprotection in patients with myocardial infarction is conflicting. The aim of this study was to evaluate the impact of morphine administration, on infarct size and reperfusion injury assessed by cardiac magnetic resonance imaging (CMR) in a large multicenter ST-elevation myocardial infarction (STEMI) population. In total, 734 STEMI patients reperfused by primary percutaneous coronary intervention &lt, 12 h after symptom onset underwent CMR imaging at eight centers for assessment of myocardial damage. Intravenous morphine administration was recorded in all patients. CMR was completed within one week after infarction using a standardized protocol. The clinical endpoint of the study was the occurrence of major adverse cardiac events (MACE) within 12 months after infarction. Intravenous morphine was administered in 61.8% (n = 454) of all patients. There were no differences in infarct size (17%LV, interquartile range [IQR] 8&ndash, 25%LV versus 16%LV, IQR 8&ndash, 26%LV, p = 0.67) and microvascular obstruction (p = 0.92) in patients with versus without morphine administration. In the subgroup of patients with early reperfusion within 120 min and reduced flow of the infarcted vessel (TIMI-flow &le, 2 before PCI) morphine administration resulted in significantly smaller infarcts (12%LV, IQR 12&ndash, 19 versus 19%LV, IQR 10&ndash, 29, p = 0.035) and reduced microvascular obstruction (p = 0.003). Morphine administration had no effect on hard clinical endpoints (log-rank test p = 0.74) and was not an independent predictor of clinical outcome in Cox regression analysis. In our large multicenter CMR study, morphine administration did not have a negative effect on myocardial damage or clinical prognosis in acute reperfused STEMI. In patients, presenting early ( &le, 120 min) morphine may have a cardioprotective effect as reflected by smaller infarcts, but this finding has to be assessed in further well-designed clinical studies

Type 2 diabetes predicts outcome following acute myocardial infarction (AMI). Since underlying mechanics are incompletely understood, we investigated left ventricular (LV) and left atrial (LA) pathophysiological changes and their prognostic implications using cardiovascular magnetic resonance (CMR). Consecutive patients (N = 1,147; n = 265 with diabetes, n = 882 without diabetes) underwent CMR 3 days after AMI. Analyses included LV ejection fraction (LVEF); global longitudinal strain (GLS) and circumferential and radial strains; LA reservoir, conduit, and booster pump strains; and infarct size, edema, and microvascular obstruction. Predefined end points were major adverse cardiovascular events (MACE) within 12 months. Patients with diabetes had impaired LA reservoir (19.8% vs. 21.2%, P < 0.01) and conduit (7.6% vs. 9.0%, P < 0.01) strains but not ventricular function or myocardial damage. They were at higher risk of MACE than patients without diabetes (10.2% vs. 5.8%, P < 0.01), with most MACE occurring in patients with LVEF ≥35%. While LVEF (P = 0.045) and atrial reservoir strain (P = 0.024) were independent predictors of MACE in patients without diabetes, GLS was in patients with diabetes (P = 0.010). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with MACE. In conclusion, in patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above that of LVEF.

Background Despite limitations as a standalone parameter, left ventricular ejection fraction (LVEF) is the preferred measure of myocardial function and marker for post-infarction risk stratification. LV myocardial uniformity may provide superior prognostic information after acute myocardial infarction (AMI), which was subject of this study. Methods and Results: Consecutive patients with AMI (n = 1082; median age 63 years; 75% male) undergoing cardiac magnetic resonance (CMR) in median 3 days after infarction were included in this multicenter, observational study. Circumferential and radial uniformity ratio estimates (CURE and RURE) were derived from CMR feature-tracking as markers of mechanical uniformity (values between 0 and 1 with 1 reflecting perfect uniformity). The clinical endpoint was the 12-month rate of major adverse cardiac events (MACE), consisting of all-cause death, re-infarction, and new congestive heart failure. Patients with MACE (n = 73) had significantly impaired CURE [0.76 (IQR 0.67-0.86) versus 0.84 (IQR 0.76-0.89); p 35% (n = 959) even after adjustment for established prognostic markers (hazard ratio 1.99; 95% confidence interval 1.06-3.74; p = 0.033 in stepwise multivariable Cox regression analysis). In contrast, LVEF was not associated with adverse events in this subgroup of AMI patients. Conclusions CMR-derived estimates of mechanical uniformity are novel markers for risk assessment after AMI and CURE provides independent prognostic information in patients with preserved or only moderately reduced LVEF.

The aims of the study were to assess the prognostic significance of cardiac magnetic resonance myocardial feature tracking (CMR-FT) in a large multicenter study and to evaluate the most potent CMR-FT predictor of hard clinical events following myocardial infarction (MI).CMR-FT is a new method that allows accurate assessment of global and regional circumferential, radial, and longitudinal myocardial strain. The prognostic value of CMR-FT in patients with reperfused MI is unknown.The study included 1,235 MI patients (n = 795 with ST-segment elevation MI and 440 with non-ST-elevation MI) at 15 centers. All patients were reperfused by primary percutaneous coronary intervention. Central core laboratory-masked analyses were performed to determine left ventricular (LV) circumferential, radial, and longitudinal strain. The primary clinical endpoint of the study was the occurrence of major adverse cardiac events within 12 months after infarction.Patients with cardiovascular events had significantly impaired CMR-FT strain values (p 0.001 for all). Global longitudinal strain was identified as the strongest CMR-FT parameter of future cardiovascular events and emerged as an independent predictor of poor prognosis following MI even after adjustment for established prognostic markers. Global longitudinal strain provided an incremental prognostic value for all-cause mortality above LV ejection fraction (c-index increase from 0.65 to 0.73; p = 0.04) and infarct size (c-index increase from 0.60 to 0.78; p = 0.002).CMR-FT is a superior measure of LV function and performance early after reperfused MI with incremental prognostic value for mortality over and above LV ejection fraction and infarct size. (Abciximab i.v. Versus i.c. in ST-segment elevation Myocardial Infarction [AIDA STEMI]; NCT00712101; Thrombus Aspiration in ThrOmbus Containing culpRIT Lesions in Non-ST-Elevation Myocardial Infarction [TATORT-NSTEMI]; NCT01612312).

This study assessed the applicability and prognostic value of cardiovascular magnetic resonance (CMR) left ventricular deformation analysis in Takotsubo syndrome (TTS). CMR-feature tracking was performed blinded in a core laboratory to determine circumferential (CS), radial (RS) and longitudinal strain (LS) in 141 TTS patients participating in this cohort study. A subgroup of consecutive TTS patients (n = 20) was compared with age- and sex-matched controls with anterior ST-segment elevation myocardial infarction (STEMI) and non-STEMI as well as healthy subjects. Median global CS, RS and LS were -19%, 19% and -12%, respectively. Apical ballooning was associated with significantly lower global CS (p < 0.01) and LS (p < 0.01) compared with midventricular and basal ballooning. Global RS was lowest in patients with basal ballooning (p < 0.01). Segmental analysis resulted in a reliable discrimination of different ballooning patterns using CS and LS. Strain values were significantly lower in TTS compared with non-STEMI patients and healthy subjects, whereas STEMI patients showed similar values. While global CS and RS were not associated with long-term mortality, global LS (cutoff -14.75%) was identified as a potential parameter for long-term risk stratification (mortality rate 17.9% versus 2.5%; p = 0.02). The transient contraction abnormalities in TTS can be quantitatively assessed with CMR-feature tracking. GLS is a potential determinant of outcome in TTS, which, however, requires further validation. • Cardiovascular magnetic resonance myocardial feature tracking enables accurate assessment of regional and global left ventricular dysfunction in Takotsubo syndrome (TTS). • Global strain in TTS is similar to patients with anterior STEMI and lower compared with non-STEMI and healthy subjects. • Global longitudinal strain is a potential tool for risk prediction in TTS patients.

Takotsubo syndrome (TTS) is a unique nonischemic cardiac disease characterized by acute myocardial dysfunction of the left and/or right ventricle. Patients are predominantly postmenopausal women and usually present with symptoms indistinguishable from acute coronary syndrome. Although the exact pathomechanisms of TTS remain elusive, increasing evidence suggests that sympathetic overdrive and catecholamine excess might play a central role. Despite the complete recovery of ventricular dysfunction within several days to weeks, patients with TTS exhibit considerable short‐ and long‐term mortality rates and ventricular arrhythmias have been identified as key contributor to morbidity and mortality. This article summarizes the prevalence, underlying mechanisms, therapeutic strategies, and prognostic implications of ventricular arrhythmias in TTS. Furthermore, the need for implantable cardioverter‐defibrillators is discussed in view of the transient character of the disease.

Background Potential predictors of clinical complications of Takotsubo syndrome (TTS) are poorly known. Persistent ST-segment elevation (PSTE) may have an impact on outcome similar as previously reported in acute coronary syndrome. The aim of this study was to assess the prevalence and prognostic relevance of PSTE in patients with TTS. Methods Two-hundred-sixty-nine consecutive patients were enrolled in an international multicenter registry. PSTE was defined as the documentation of ST-elevation at least for the first 48h of hospitalization. Long-term mortality was evaluated in median 1.9years after the acute event. Results PSTE was found in 52 TTS patients (19%). Patients with PSTE were characterized by higher admission levels of troponin-I (23±12 vs 8±49ng/L, p p =0.02) and a higher rate of in-hospital complications (31% vs 17% p =0.03). At multivariate analysis including PSTE, age, male sex, admission ejection fraction, PSTE (odds ratio [OR] 4.2; 95% confidence interval [CI] 1.4–13; p =0.01), age (OR 1.05; 95%CI 1.00–1.10; p =0.03) and admission ejection fraction (OR 0.93; 95%CI 0.87–0.99; p =0.02) were independent predictors of in-hospital complications. At long-term follow-up no significant differences in terms of mortality were observed between patients with and without PSTE (19% vs 15%; p =0.5). However, PSTE was a predictor of major cardiac adverse events (MACE) at follow-up (HR 2.32, 95% CI 1.02–5.31, p 0.045). Conclusions In TTS patients, PSTE is a common finding, represents an independent predictor of in-hospital complications and could be associated with MACE at follow-up.

Background The detailed pathomechanism of Takotsubo syndrome (TS) is still elusive. Due to the predominance of postmenopausal females, a potential role of sex hormones has been suggested. However, the limited available data are contradictory. The aim of this study was to comprehensively assess the role of sex hormone levels in a large cohort of TS patients. Methods Serum samples of 57 female TS patients and 57 female patients with myocardial infarction (MI), matched for age (±2years) and repolarization disturbances were analyzed for estradiol (E2), estrone (E1), testosterone and androstenedione using liquid chromatography-tandem mass spectrometry. Results There was no difference concerning the concentrations of E1 [pmol/l (IQR): 89.1 (62.5, 132.0) vs. 98.8 (63.3, 156.0), p =0,441], testosterone [nmol/l (IQR): 0.67 (0.46, 1.00) vs. 0.80 (0.49, 1.08), p =0.382] and androstenedione [nmol/l (IQR): 2.03 (1.57, 3.11) vs. 2.98 (1.48, 5.27), p =0.244] between female TS and MI patients. Regarding E2, the majority of patients demonstrated concentrations below the detection limit of 30pmol/l (TS: n =41/54, 75.9%; MI: n =32/53, 60.4%; p =0.078). The remaining individuals with detectable E2 concentrations did not show a significant difference between TS and MI patients [pmol/l (IQR): 40.5 (33.0, 53.3) vs. 54.1 (37.9, 60.9); p =0.20]. Conclusions Altered sex hormone levels, especially an estradiol deficiency, could not be identified as a risk factor for TS.

Background: Early revascularisation of the culprit lesion is the therapeutic cornerstone in cardiogenic shock complicating acute myocardial infarction. The optimal management of additional non-culprit lesions is unclear. This systematic review and meta-analysis aims to summarise current evidence on the comparison of immediate multivessel percutaneous coronary intervention (MV-PCI) or culprit lesion only PCI with possible staged revascularisation (C-PCI) in patients with cardiogenic shock complicating acute myocardial infarction. Methods: Medical literature databases were screened to identify analyses comparing MV-PCI with C-PCI in patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease. In absence of randomised trials, 10 cohort studies were included in the current meta-analysis. The primary outcome of short-term mortality was assessed at hospital discharge or 30 days after hospital admission. Secondary outcomes were long-term mortality as well as myocardial re-infarction, stroke, acute renal failure, and bleeding at short-term follow-up. Results: Of 6051 patients, 1194 (19.7%) received MV-PCI and 4857 (80.3%) C-PCI. Short-term mortality was 37.5% in patients undergoing MV-PCI compared with 28.8% in C-PCI patients (risk ratio 1.26, 95% confidence interval 1.12–1.41, p=0.001). Long-term mortality ( p=0.77), myocardial re-infarction ( p=0.77), stroke ( p=0.12), acute renal failure ( p=0.17) and bleeding ( p=0.53) did not differ significantly between the two revascularisation groups. Conclusions: Results of this first meta-analysis on the interventional management of patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease do not support MV-PCI over C-PCI. However, possible treatment selection bias in the individual studies must be taken into account.

Primary percutaneous coronary intervention (PCI) is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) presenting within 12 h of symptom onset. A benefit in the subacute stage is less clear. The aim of the present analysis was to compare myocardial salvage and infarct size between patients with early and late reperfusion after STEMI. We compared cardiac magnetic resonance (CMR) data from a randomized controlled trial (RCT) in STEMI patients presenting within 12 h (n = 695) and a RCT of subacute STEMI patients presenting between 12 and 48 h (n = 93) after symptom onset. CMR imaging was performed 3.9 ± 6.3 days after myocardial infarction. Analyses were performed for an unmatched cohort comprising all patients (n = 788) and a cohort matched for area at risk (n = 186). In the overall cohort, area at risk was similar in both groups [37.1 ± 16.1% of left ventricular mass (%LV) vs. 38.3 ± 16.2%LV; p = 0.50]. Compared to STEMI patients with early reperfusion, patients with late PCI demonstrated larger infarct size (18.0 ± 12.5%LV vs. 28.9 ± 16.9%LV; p

Background Previous retrospective analyses have suggested that biventricular (BV) endomyocardial biopsy (EMB) is superior compared to selective left ventricular (LV) or right ventricular (RV) EMB. This study prospectively assessed the feasibility, safety and diagnostic performance of implementing a routine BV-EMB approach in patients with suspected myocarditis. Methods Consecutive patients with clinically suspected myocarditis underwent EMB ( n =136). Myocarditis was defined as ≥14 infiltrating leukocytes/mm 2 in addition to enhanced human leukocyte antigen class II expression in professional antigen-presenting immune cells. The presence of viral genomes was assessed by nested (reverse transcriptase–) polymerase chain reaction. Results BV-EMB was attempted in 132 patients (LV thrombus, n =3; complication during RV-EMB, n =1) and resulted in sufficient samples from both ventricles in 127 patients (96.2%). One major complication (pericardial tamponade requiring surgical revision) was observed during the 136 RV-EMB (0.7%). No severe complications occurred during the 132 LV procedures. Of the 127 patients with BV-EMB, myocarditis was diagnosed in 89 patients (70.1%). While 67 patients (75.3%) fulfilled the diagnostic criteria in both ventricles, the diagnosis of myocarditis was based on the results of LV-EMB only in 16 patients (18%) and of RV-EMB only in 6 patients (6.7%). Viral genomes were found in 45 of the 127 patients (35.4%) with evidence of virus genome only in the left ventricle in 10 patients (22.2%) and only in the right ventricle in 3 patients (6.7%). Conclusions Implementing a routine BV-EMB approach is feasible and safe. In patients with suspected myocarditis, BV-EMB yields superior diagnostic performance compared to selective RV- or LV-EMB.

The current study presents data from a real-world cohort of patients with refractory cardiogenic shock (CS) undergoing extracorporeal life support (ECLS) focusing on the comparison of elderly versus younger patients. One hundred consecutive patients with refractory CS underwent percutaneous ECLS implantation performed by interventional cardiologists. Follow-up was performed at hospital discharge as well as at a median of 18 months [interquartile range 15–36]. Patients were grouped according to median age (≤60 versus >60 years). ECLS could be weaned in more than half of the cohort (n = 56, 56%) with no differences between the age groups (p = 1.00). Despite similar rates of initial haemodynamic stabilisation, in-hospital mortality was higher in patients >60 years (82% versus 58%, p = 0.02). At mid-term follow-up, only three patients were alive in the group of patients >60 years. This resulted in a mortality rate of 94% in the elderly in comparison with 68% in patients aged ≤60 years (p = 0.001). Despite a high rate of initial successful ECLS weaning, mid-term prognosis of patients with CS undergoing ECLS above the age of 60 years is poor with superior results in patients aged ≤60 years.

We thank Prof. Madias for his interest in our work regarding cardiogenic shock (CS) in patients with Takotsubo cardiomyopathy (TTC). He notes the high prevalence of cardiovascular risk factors in our TTC population, particularly hypertension and diabetes mellitus.1 Hypertension has been reported in >50% of TTC patients repeatedly, and the largest registry found a prevalence of 65%.2,3 However, the number of patients with diabetes mellitus (28.1%) is indeed higher than in previous studies, even though the reported data show large variations (1.6–25.5%).1,2 Actually, the rate in our population is perfectly in line with the expected prevalence of diabetes mellitus in the general population aged >65 years.4 Unfortunately, we cannot provide additional data regarding drug therapy, glycemic control or associated comorbidities that might have had an impact on outcome. Nevertheless, a potential protective effect of diabetes mellitus in TTC patients is speculative, since the causative mechanisms of the disease have not been elucidated yet and data supporting a favorable prognosis in diabetic TTC patients are not available. Moreover, Prof. Madias addresses the continuing increased risk of death in TTC patients with CS beyond the acute phase. The mortality curve (Figure 1) indicates that most of these deaths occurred between 28 days and 6 months after hospital admission, when left ventricular function had already significantly improved but not yet fully recovered in all patients.1 Despite normalization of systolic function, three patients died after the 6-month period from cardiac arrest, stroke and unknown cause of death, respectively. We think that an ongoing susceptibility to arrhythmias contributes considerably to fatal events during the convalescent phase of TTC.5 Deterioration of left ventricular function after initial recovery has not been observed. However, the cohort of CS patients who survived the first year after the initial event is small, and long-term echocardiographic data are not available in all patients. Early mechanical circulatory support in TTC patients with CS is definitely a reasonable approach considering the assumed pathophysiological mechanisms. Nevertheless, a potential survival benefit has to be proven in randomized controlled trials before assist devices can be recommended as a first-line therapeutic strategy. Finally, Prof. Madias addresses the increase in vagal tone that has been observed in TTC patients. The heart rate and blood pressure values that have been observed in our cohort of patients with TTC and CS are probably influenced by the administration of catecholamines and other agents prior to admission at our institution. Therefore, these values may be indicative but not appropriate to confirm the concept of vagotonia in the early phase of TTC.

There is an ongoing debate on potential differences in outcome between ST-segment elevation myocardial infarction (STEMI) patients presenting outside of usual hospital working hours (“off-hours”) compared with patients presenting during classical working hours (“on-hours”) [(1,2)][1]. The

Cardiovascular magnetic resonance (CMR) represents the reference standard for cardiac morphology and function assessment. Since introduction in 2009, CMR feature tracking (CMR-FT) has become a frequently used tool in the assessment of myocardial deformation and wall motion on the basis of routinely acquired b-SSFP cine images. Extensive validation has led to excellent intra- and inter-observer as well as inter-study reproducibility. CMR-FT derived myocardial deformation indices such as left ventricular (LV) strain have been shown to be impaired in cardiac diseases such as cardiomyopathies as well as myocardial infarction. Although LV ejection fraction (LVEF) is the routinely and frequently utilized parameter for systolic myocardial function assessment and major adverse clinical event (MACE) prediction, it fails to assess regional differences. Recently, LV strain has emerged as a superior measure for risk assessment and MACE prediction as compared to the established markers e.g., LVEF. This editorial aims to elucidate current discussions in the field of strain assessment in myocardial infarction in the light of recent data from a large prospective multicentre CMR study.

Background The role of left atrial (LA) performance in acute myocardial infarction (AMI) remains controversial. Cardiac MRI myocardial feature tracking (hereafter, MRI-FT) is a method used to quantify myocardial function that enables reliable assessment of atrial function. Purpose To assess the relationship between LA function assessed with MRI-FT and major adverse cardiovascular events (MACE) after AMI. Materials and Methods This secondary analysis of two prospective multicenter cardiac MRI studies (AIDA STEMI [NCT00712101] and TATORT NSTEMI [NCT01612312]) included 1235 study participants with ST-elevation myocardial infarction (n = 795) or non-ST-elevation myocardial infarction (n = 440) between July 2008 and June 2013. All study participants underwent primary percutaneous coronary intervention. MRI-FT analyses were performed in a core laboratory by researchers blinded to clinical status to determine LA performance using LA reservoir function peak systolic strain (es), LA conduit strain (ee), and LA booster pump function active strain (ea). The relationship of LA performance to a MACE within 12 months after AMI was evaluated by using Cox proportional hazards models and area under the receiver operating characteristic curve (AUC). Results Study participants with MACE had worse LA performance parameters compared with study participants without MACE (es = 21.2% vs 16.2%, ee = 8.8% vs 6.9%, ea = 11.8% vs 10%; P < .001 for all). All atrial parameters were strongly associated with MACE (hazard ratio [HR], es = 0.9, ee = 0.88, ea = 0.89; P < .001 for all). For es, a cutoff of 18.8% was identified as the only independent atrial parameter with which to predict MACE after accounting for confounders and established prognostic markers in adjusted analysis (HR, 0.95; P = .02). The es yielded incremental prognostic value above left ventricular ejection fraction, global longitudinal strain, microvascular obstruction, and infarct size (AUC comparisons, P < .04 for all). Conclusion Feature tracking of cardiac MRI to derive left atrial peak reservoir strain provided incremental prognostic value for major adverse cardiovascular events prediction versus established cardiac risk factors after acute myocardial infarction. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Almeida in this issue.

Primary percutaneous coronary intervention is nowadays the preferred reperfusion strategy for patients with acute ST-segment–elevation myocardial infarction, aiming at restoring epicardial infarct-related artery patency and achieving microvascular reperfusion as early as possible, thus limiting the extent of irreversibly injured myocardium. Yet, in a sizeable proportion of patients, primary percutaneous coronary intervention does not achieve effective myocardial reperfusion due to the occurrence of coronary microvascular obstruction (MVO). The amount of infarcted myocardium, the so-called infarct size, has long been known to be an independent predictor for major adverse cardiovascular events and adverse left ventricular remodeling after myocardial infarction. Previous cardioprotection studies were mainly aimed at protecting cardiomyocytes and reducing infarct size. However, several clinical and preclinical studies have reported that the presence and extent of MVO represent another important independent predictor of adverse left ventricular remodeling, and recent evidences support the notion that MVO may be more predictive of major adverse cardiovascular events than infarct size itself. Although timely and complete reperfusion is the most effective way of limiting myocardial injury and subsequent ventricular remodeling, the translation of effective therapeutic strategies into improved clinical outcomes has been largely disappointing. Of importance, despite the presence of a large number of studies focused on infarct size, only few cardioprotection studies addressed MVO as a therapeutic target. In this review, we provide a detailed summary of MVO including underlying causes, diagnostic techniques, and current therapeutic approaches. Furthermore, we discuss the hypothesis that simultaneously addressing infarct size and MVO may help to translate cardioprotective strategies into improved clinical outcome following ST-segment–elevation myocardial infarction.