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A 78-year-old female patient with a medical history of severe aortic stenosis and metastatic ovarian cancer with liver and right iliac bone metastases was admitted for dyspnoea that started during the same day. Six months ago, she was diagnosed with acute heart failure with a B-type natriuretic peptide (BNP) level at 682 pg/mL. Upon presentation, she was hypotensive (85/55 mmHg) and tachycardic (114 b.p.m.). Her BNP level was 278 pg/mL. A bedside echocardiogram showed a large pericardial effusion that was successfully drained. Ten days later, BNP was repeated and was 1147 pg/mL. The pseudonormalization of BNP level was due to the impaired ventricular stretching caused by the chronic cardiac tamponade.

Background Linear accelerator–based stereotactic radiosurgery delivered to cardiac arrhythmogenic foci could be a promising catheter‐free ablation modality. We tested the feasibility of in vivo atrioventricular ( AV ) node ablation in swine using stereotactic radiosurgery. Methods and Results Five Large White breed swine (weight 40–75 kg; 4 females) were studied. Single‐chamber St Jude pacemakers were implanted in each pig. The pigs were placed under general anesthesia, and coronary/cardiac computed tomography simulation scans were performed to localize the AV node. Cone beam computed tomography was used for target positioning. Stereotactic radiosurgery doses ranging from 35 to 40 Gy were delivered by a linear accelerator to the AV node, and the pigs were followed up with weekly pacemaker interrogations to observe for potential electrocardiographic changes. Once changes were observed, the pigs were euthanized, and pathology specimens of various tissues, including the AV node and tissues surrounding the AV node, were taken to study the effects of radiation. All 5 pigs had disturbances of AV conduction with progressive transition into complete heart block. Macroscopic inspection did not reveal damage to the myocardium, and pigs had preserved systolic function on echocardiography. Immunostaining revealed fibrosis in the target region of the AV node, whereas no fibrosis was detected in the nontargeted regions. Conclusions Catheter‐free radioablation using linear accelerator–based stereotactic radiosurgery is feasible in an intact swine model.

Patients with advanced chronic kidney disease (CKD) have increased risk of myocardial infarction (MI). Silent MIs (SMIs) are common in CKD patients and carry increased mortality risk. The prevalence and prognostic value of SMI in advanced CKD has not been evaluated.We identified consecutive patients with advanced CKD who were evaluated for renal transplantation at the University of Alabama at Birmingham between June 2004 and January 2006. Clinical MI (CMI) was determined by review of medical records. SMI was defined as ECG evidence of MI without clinical history of MI. The primary end-point was a composite of death, MI, or coronary revascularization censored at time of renal transplantation.The cohort included 1007 patients with advanced CKD aged 48±12years (58% men, 43% diabetes, 75% on dialysis). The prevalence of SMI and CMI was 10.7% and 6.7%, respectively. The only independent predictor of SMI was older age (odds ratio for age ≥50yrs. 2.32, p0.001). During a median follow-up of 28months, 376 (37%) patients experienced the primary outcome (33% death, 2% MI, 5% coronary revascularization). In a multivariable adjusted Cox-regression model, both SMI (adjusted HR 1.58, [1.13-2.20], p=0.007) and CMI (adjusted HR 1.67 [1.15-2.43], p=0.007) were independently associated with the primary outcome. Further, both SMI (HR 2.37 [1.15-4.88], p=0.02) and CMI (HR 4.02 [1.80-8.98], p=0.001) were associated with increased risk after renal transplantation.SMI is more common than CMI in patients with advanced CKD. Both SMI and CMI are associated with increased risk of future cardiovascular events.

A 38-year-old healthy male presented with vomiting and profuse diarrhea, associated with blurry and yellow coloration of the vision (xanthopsia). Laboratory workup was unremarkable, except for hyperkalemia (K 5.2 mEq/L) and mildly elevated troponin level 0.11 ng/mL (cut-off value 0.08). An electrocardiogram showed sinus bradycardia with deep scooping of the T waves. Although the patient denied intake of any drugs, herbs, consumption of plants, a digoxin level was drawn and was significantly elevated > 5 ng/mL (therapeutic range 0.8–2.0). Further questioning revealed that the patient was a pharmacist mixing raw material to fabricate medication, and that he could have incidentally ingested contaminated water. His symptoms improved with parallel improvement in the electrocardiogram T wave abnormalities. An echocardiogram was normal. The positive troponin was felt to be secondary to severe digoxin toxicity. Review of the literature however showed no report of elevated troponin in the setting of digoxin toxicity.

Several original articles and editorials have been published in the Journal of Nuclear Cardiology last year. It has become a tradition at the beginning of each year to summarize some of these key articles (AlJaroudi and Hage in J Nucl Cardiol 22:507-512, 2015, 23:122-130, 2016; Hage and AlJaroudi in J Nucl Cardiol 22:714-719, 2015; 23:493-498, 2016). In this part one, we will discuss some of the progress made in patients with infiltrative disease, cardiomyopathies (non-ischemic, ischemic, and diabetic), hybrid and molecular imaging, using advancement in positron emission tomography, computed tomography, and magnetic resonance imaging.

The ratio of early transmitral flow velocity (E) to mitral annular velocity (E') is considered a predictor of pulmonary capillary wedge pressure (PCWP). In a previous small study, the paradoxical relation between PCWP and E/E' ratio has been described in patients with constrictive pericarditis (CP). We sought to test this paradoxical relation in a larger cohort. We retrospectively identified 49 patients with surgically confirmed CP (40 men; mean age 61 ± 10 years) who underwent right-sided cardiac catheterization with PCWP measurement, preceded by an echocardiographic study. Of these, 48 patients underwent either computed tomography or magnetic resonance imaging to measure pericardial thickness on the lateral side of the left ventricular wall. Mean interval time between echocardiogram and right-sided cardiac catheterization was 1.5 ± 3.8 days. There were no significant correlations between mean, medial, or lateral E/E' and PCWP (r = -0.17, 95% confidence interval [CI] -0.43 to -0.12; r = -0.17, 95% CI -0.43 to -0.12; and r = -0.12, 95% CI -0.39 to -0.17, respectively). Similarly, there was no correlation between mean E/E' and brain natriuretic peptide (Spearman r = -0.17, p = NS). Patients with increased pericardial thickness (defined as >4 mm) had both lower lateral peak systolic annular velocity (S') and lower lateral S' integral (7.8 ± 2.4 vs 9.6 ± 2.4, p = 0.02 and 13.2 ± 4.2 vs 15.9 ± 4.7, p = 0.04, respectively). In patients with CP, there were no correlations between septal, lateral, or mean E/E' and PCWP. In conclusion, E/E' is not predictive of filling pressures in patients with CP, and perhaps the "annulus paradoxus" phenomenon should be revisited. The relation between the mitral annular velocity and thickness of the parietal pericardium may affect this phenomenon.

Prior studies show that left ventricular mechanical dyssynchrony (LVD), measured by gated SPECT myocardial perfusion imaging (MPI), identifies patients with end-stage renal disease (ESRD) at higher risk for all-cause mortality but these were in small number of patients. We sought to assess the interaction between LVD and LV perfusion pattern in risk-stratification of a large sample size of patients with ESRD. From the renal transplantation database maintained at the University of Alabama at Birmingham, we identified consecutive patients with ESRD who had gated SPECT MPI between 2003 and 2007. MPIs were reprocessed to derive LV ejection fraction (EF), perfusion defect size, and LVD [phase bandwidth (BW) and phase standard deviation (SD)]. The primary end-point was all-cause mortality, which was prospectively collected and verified against the social security death index database. There were 828 patients aged 52.6 ± 0.36 years (45% were women and 60% had diabetes mellitus). The LVEF was 54.8 ± 0.4% and the perfusion pattern was abnormal in 334 patients (41%). During a follow-up period of 61 ± 0.9 months, 230 patients (28%) received renal transplants and 290 patients (35%) died. The phase BW (73.1 ± 2.6° vs 66.3 ± 1.8°, P = .02) and SD (25.2 ± 0.8° vs 23.4 ± 0.5°, P = .06) were greater in patients who died than those who survived indicating greater dyssynchrony. Patients with phase BW >56° or SD ≥21° (median values) had worse 5-year survival (64% vs 72%, and 66% vs 71%, log-rank P = .005 and P = .07, respectively). After adjusting for demographics, co-morbidities, LVEF, and perfusion pattern, phase BW was associated with worse outcome (hazard ratio 1.289 95% CI 1.010-1.644, P = .04). LVD by phase analysis of gated SPECT MPI provides prognostic value in ESRD beyond myocardial perfusion and EF.

Over the last decade, cardiovascular magnetic resonance (CMR) imaging has emerged as a powerful non-invasive imaging modality with pivotal role in the evaluation and management of patients with coronary artery disease. In particular, it quantifies ventricular function, detects myocardial ischemia and scar, visualizes myocardial edema and hemorrhage. CMR provides high resolution images that are not limited by acoustic window, and without the use of radiation or iodine contrast, hence being an attractive alternative to other non-invasive modalities. In this paper we present four different cases illustrating the role of CMR in the diagnosis of patients with known or suspected coronary artery disease, how it provides prognostic information and may guide or alter the management.

Left ventricular diastolic dysfunction (DD) is recognized as an important contributor to diastolic heart failure and is associated with increased morbidity and mortality. The evaluation of diastolic function has become an integral part of a full echocardiographic study and is recommended by the current guidelines of the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Recent data show that diastolic function is not static, but rather a dynamic phenomenon; worsening of diastolic function is associated with worse outcomes, whereas its improvement is associated with better survival. The purpose of this article is to review the echocardiographic assessment of diastolic function with an integrative clinical practical approach, discuss plausible mechanistic links between DD and clinical outcomes, summarize the prognostic value of left ventricular and right ventricular DD in various patient cohorts, the strengths and limitations of the data, and finally, give insight into future directions.

ObjectivesThis study tested the diagnostic and prognostic utility of a rapid, visual T1 assessment method for identification of cardiac amyloidosis (CA) in a “real-life” referral population undergoing cardiac magnetic resonance for suspected CA.BackgroundIn patients with confirmed CA, delayed-enhancement cardiac magnetic resonance (DE-CMR) frequently shows a diffuse, global hyperenhancement (HE) pattern. However, imaging is often technically challenging, and the prognostic significance of diffuse HE is unclear.MethodsNinety consecutive patients referred for suspected CA and 64 hypertensive patients with left ventricular hypertrophy (LVH) were prospectively enrolled and underwent a modified DE-CMR protocol. After gadolinium administration a method for rapid, visual T1 assessment was used to identify the presence of diffuse HE during the scan, allowing immediate optimization of settings for the conventional DE-CMR that followed. The primary endpoint was all-cause mortality.ResultsAmong patients with suspected CA, 66% (59 of 90) demonstrated HE, with 81% (48 of 59) of these meeting pre-specified visual T1 assessment criteria for diffuse HE. Among hypertensive LVH patients, 6% (4 of 64) had HE, with none having diffuse HE. During 29 months of follow-up (interquartile range: 12 to 44 months), there were 50 (56%) deaths in patients with suspected CA and 4 (6%) in patients with hypertensive LVH. Multivariable analysis demonstrated that the presence of diffuse HE was the most important predictor of death in the group with suspected CA (hazard ratio: 5.5, 95% confidence interval: 2.7 to 11.0; p < 0.0001) and in the population as a whole (hazard ratio: 6.0, 95% confidence interval 3.0 to 12.1; p < 0.0001). Among 25 patients with myocardial histology obtained during follow-up, the sensitivity, specificity, and accuracy of diffuse HE in the diagnosis of CA were 93%, 70%, and 84%, respectively.ConclusionsAmong patients suspected of CA, the presence of diffuse HE by visual T1 assessment accurately identifies patients with histologically-proven CA and is a strong predictor of mortality.

Amyloidosis is an infiltrative disease characterized by deposition of amyloid fibrils within the extracellular tissue of one or multiple organs. Involvement of the heart, cardiac amyloidosis, is recognized as a common cause of restrictive cardiomyopathy and heart failure. The two major types of cardiac amyloidosis are cardiac amyloid light-chain (AL) and transthyretin-related cardiac amyloidosis (ATTR, mutant and wild types) (Nat Rev Cardiol 2010;7:398-408). While early recognition of cardiac amyloidosis is of major clinical importance, so is the ability to differentiate between subtypes. Indeed, both prognosis and therapeutic options vary drastically depending on the subtype. While endomyocardial biopsy with immunostaining is considered the gold standard, advances in imaging provide an attractive non-invasive alternative. Currently, electrocardiography, echocardiography, and cardiac magnetic resonance imaging are all used in the evaluation of cardiac amyloidosis with varying diagnostic and prognostic accuracy. Yet, none of these modalities can effectively differentiate the cardiac amyloid subtypes. Recent data with (99m)Tc-phosphate derivatives, previously used as bone seeking radioactive tracers, have shown promising results; these radiotracers selectively bind ATTR, but not AL subtype, and can differentiate subtypes with high diagnostic accuracy. This review will initially present the non-radionuclide imaging techniques and then focus on the radionuclide imaging techniques, particularly (99m)Tc-DPD and (99m)Tc-PYP, mechanism of action, performance and interpretation of the study, diagnostic accuracy, prognostic value, future clinical perspective, and outlook.

Background— American College of Cardiology/American Heart Association appropriate use criteria recommend performing stress myocardial perfusion imaging (MPI) for intermediate- to high-risk patients presenting with syncope but not for low-risk patients. However, there are limited data to support these recommendations. We investigated the yield of stress MPI for the evaluation of syncope in patients at risk but without known coronary artery disease. Methods and Results— Using the Cleveland Clinic Institutional Review Board–approved MPI database, we identified consecutive patients without known coronary artery disease who underwent stress MPI between 2006 and 2012 for diagnostic workup of syncope. Patients were stratified into low-, intermediate-, and high-risk groups using the Framingham risk score. For patients with abnormal MPI, left heart catheterization were reviewed if performed. There were 700 patients (mean age, 62±15 years; 55% female) who had undergone stress MPI for syncope; 659 patients (94%) had normal perfusion. Of the 41 patients with abnormal MPI, 18 had left heart catheterization (9 were false-positive); there were 23 remaining patients with abnormal MPI (16 having moderate to severe perfusion defect size) but who did not have a left-side angiogram and could have undiagnosed significant coronary artery disease. The diagnostic yield of stress MPI was similarly low among all cardiovascular risk categories. Conclusions— Stress MPI for evaluation of syncope in patients without known coronary artery disease has a low-diagnostic yield among all risk categories; thus, reaffirmation and revision of the appropriateness criteria should be considered.

Chronic kidney disease (CKD) is associated with worse survival in patients with implantable cardiac defibrillators (ICDs). This study examined the association of outcomes with CKD in patients receiving an ICD for primary versus secondary prevention.The study included 696 patients who underwent ICD placement for clinical reasons (59% primary, 41% secondary prevention) at the University of Alabama at Birmingham between January 2002 and September 2007. CKD was defined as an estimated glomerular filtration rate60 ml/min/1.73 m(2) but not on dialysis. Outcomes of interest included overall mortality and first appropriate ICD therapy (shocks or anti-tachycardia pacing).After a follow-up of 50 ± 24 months, 213 patients died (31%) and 111 (16%) received appropriate ICD therapy. Patients with CKD had higher mortality than patients with no CKD in the primary (43% vs. 15%, p0.001) and secondary prevention (37% vs. 23%, p = 0.003) groups. Patients with CKD were at higher risk of receiving an appropriate ICD therapy than patients without CKD in the primary (p0.001) but not secondary prevention (p = 0.9) cohort. After adjusting for age, gender and multiple risk factors, CKD was independently associated with all-cause mortality and ICD therapy in the primary prevention group (HR 2.08 [1.34-3.23] and 3.53 [1.75-7.10], p = 0.001 and0.0001, respectively) but not in the secondary prevention group (HR 1.27 [0.81-2.00], and 0.63 [0.35-1.13], p=0.3 and 0.2, respectively).CKD is independently associated with increased mortality and appropriate ICD therapy in patients undergoing ICD implantation for primary but not secondary prevention.

Diabetic autonomic neuropathy is a possible link between abnormal metabolism in type 2 diabetes mellitus (T2DM) and risk for atrial fibrillation (AF) and heart failure (HF). The aim of this study was to elucidate the association between attenuated heart rate recovery (HRR) and these manifestations of myocardial dysfunction in T2DM. Nine hundred fourteen consecutive patients with T2DM (mean age 56 ± 11 years, 508 men) without diabetes mellitus complications, with negative results on stress echocardiography, were enrolled. Patients with known cardiac disease were excluded. Demographics, clinical assessment, co-morbidities, and insulin use were collected prospectively. The association of HRR with new-onset HF and AF was sought using a Cox proportional-hazards model. There were 47 events (22 HF and 25 AF) during a median follow-up period of 7.8 years. Events were associated with age, exercise capacity, HRR, and left atrial volume index but not with baseline glycosylated hemoglobin, left ventricular mass index, or standard markers of diastolic function. In sequential Cox models for the combined outcomes, the model based on clinical data (age and gender; overall chi-square = 5.5) was not significantly improved by left atrial volume index (chi-square = 8.6, p = 0.10) or maximum METs (chi-square = 8.7, p = 0.07) but was significantly improved by adding HRR (chi-square = 19.7, p = 0.004). In addition, HRR provided significant incremental prognostic value regarding the composite end point (net reclassification improvement 19.2%, p = 0.04; integrated discrimination improvement 1.58%, p = 0.004). In conclusion, the association of HRR with subsequent HF and AF, independent of and incremental to left atrial volume index and other markers of abnormal cardiac structure and function, indicates a role for autonomic neuropathy as the link between metabolic and cardiac risk in patients with T2DM.

Left bundle branch block (LBBB) causes an abnormal pattern of cardiac activation and affects regional myocardial function. Although recognition of LBBB on the surface electrocardiogram is straightforward, dissecting its effect on patient treatment and outcome can be more challenging. The altered pattern of cardiac activation in LBBB causes electrical and mechanical ventricular dyssynchrony, influences ischemia detection on the surface electrocardiogram, and affects stress testing and imaging modalities dependent on wall motion and thickening. Restoration of synchrony by biventricular pacing can improve symptoms and longevity in carefully selected patients. The diagnostic, prognostic, and therapeutic implications of LBBB across this spectrum are discussed in this review.

The safety of regadenoson (Reg) during low-level exercise testing has been established. However, its administration at peak exercise for patients who do not reach target heart rate (THR) on standard exercise treadmill stress testing (ETT) needs to be established, particularly among patients with known coronary artery disease (CAD) METHODS: From our stress myocardial perfusion imaging (MPI) database, we identified all patients between 2009 and 2012 who underwent standard ETT and received Reg at peak exercise for failure to reach THR. Hemodynamics, side effects, and adverse events were entered prospectively into the database at the time of testing and were subsequently retrieved for analysis.There were 514 patients, mean age 60 ± 12 years, 34 % female gender, and 51 % with prior CAD. There were 218 (42 %) and 297 (57 %) patients who underwent standard or modified Bruce and Cornell protocols, respectively, and with a mean exercise time of 5.8 ± 2.1 min. The mean percentage of peak heart rate achieved was 71 ± 8 %, and mean maximal metabolic equivalent (MET) was 6.7 ± 1.8. There were 63 (12 %) patients who developed ≥30 mmHg drop in systolic blood pressure (SBP) after 2 min of Reg administration, and 10 (2 %) had SBP100 mmHg at 2 min and were younger and achieved higher METs; 8 and 2 patients were symptomatic, respectively. The most common side effects reported were shortness of breath (12 %), chest pain/discomfort (13 %), and dizziness (7 %). There was one syncopal event, but no high-degree heart block, cardiac or respiratory arrest. Four patients received aminophylline. Women were more likely to have shortness of breath or gastrointestinal symptoms, while diabetics were less likely to have chest discomfort. There was otherwise no significant difference in adverse events between different groups including those with and without CAD.Among patients undergoing standard treadmill stress testing for MPI who do not reach THR, the administration of Reg at peak exercise is safe and without major adverse events. Future large prospective studies are warranted to further evaluate the off-label use of Reg in this setting.

In patients presenting with non-ST-elevation myocardial infarction (NSTEMI), left anterior descending (LAD) coronary artery and three-vessel disease are the most commonly encountered culprit lesions in the presence of ST depression, while one third of patients with left circumflex (LCX) artery related infarction have normal ECG. We sought to determine the predictors of presence of culprit lesion in NSTEMI patients based on ECG, echocardiographic, and clinical characteristics.Patients admitted to the coronary care unit with the diagnosis of NSTEMI between June 2012 and December 2013 were retrospectively identified. Admission ECG was interpreted by an electrophysiologist that was blinded to the result of the coronary angiogram. Patients were dichotomized into either normal or abnormal ECG group. The primary endpoint was presence of culprit lesion. Secondary endpoints included length of stay, re-hospitalization within 60 days, and in-hospital mortality.A total of 118 patients that were identified; 47 with normal and 71 with abnormal ECG. At least one culprit lesion was identified in 101 patients (86%), and significantly more among those with abnormal ECG (91.5% vs. 76.6%, P=0.041).The LAD was the most frequently detected culprit lesion in both groups. There was a higher incidence of two and three-vessel disease in the abnormal ECG group (P=0.041).On the other hand, there was a trend of higher LCX involvement (25% vs. 13.8%, P=0.18) and more normal coronary arteries in the normal ECG group (23.4% vs. 8.5%, P=0.041). On multivariate analysis, prior history of coronary artery disease (CAD) [odds ratio (OR) 6.4 (0.8-52)], male gender [OR 5.0 (1.5-17)], and abnormal admission ECG [OR 3.6 (1.12-12)], were independent predictors of a culprit lesion. There was no difference in secondary endpoints between those with normal and abnormal ECG.Among patients presenting with NSTEMI, prior history of CAD, male gender and abnormal admission ECG were independent predictors of a culprit lesion. An abnormal ECG was significantly associated with two and three-vessel disease, while normal ECG was more associated with LCX involvement or normal angiogram. Admission ECG did not impact secondary outcomes.

In 2015, the Journal of Nuclear Cardiology (®) published many high-quality articles. In this series, we will summarize key articles that have appeared in the Journal last year to provide for the interested reader a quick review of the advancements that have recently occurred in the field. In the first article of this 2-part series, we concentrated on publications dealing with plaque imaging, cardiac positron emission tomography, computed tomography, and magnetic resonance. This review will focus on myocardial perfusion imaging summarizing advances in the field including in diagnosis, prognosis, and appropriate use.

Phase analysis of gated myocardial perfusion imaging (MPI) provides automated and reproducible assessment of left ventricular (LV) mechanical dyssynchrony (LVMD) (phase standard deviation [SD]). Many patients undergoing gated MPI have history of prior coronary artery bypass graft surgery (CABG). The latter is often associated with paradoxical septal wall motion (PSM). The effect of prior CABG and PSM on LVMD has not been evaluated. From the single-photon emission computed tomography (SPECT) and positron emission tomography (PET) MPI clinical database maintained at the Cleveland Clinic, we identified 200 consecutive patients with SPECT (100 control with normal LV ejection fraction [EF], MPI, and QRS

LV mechanical dyssynchrony (LVMD) is a risk marker in narrow QRS cardiomyopathy, but its association with treatment outcome is not well defined. We determined the incremental prognostic value of LVMD in ischemic cardiomyopathy, and assessed its interaction with scar, myocardium in jeopardy and subsequent revascularization. Stress and rest 82Rb gated PET were performed in 486 consecutive patients (66 ± 11 years of age, 82 % men, LV ejection fraction 26 ± 6 %) with ischemic cardiomyopathy and QRS

The study sought to investigate whether there is stress-induced worsening of left ventricular mechanical dyssynchrony (LVMD) in patients with ischemic cardiomyopathy (ICM), determine the predictors of LVMD response (LVMDR) and its incremental prognostic value. The effect of stress physiology on LVMD in patients with ICM has not been adequately evaluated, and the prognostic value of abnormal LVMDR beyond traditional predictors of mortality remains uncertain. 489 consecutive patients with ICM, LV ejection fraction (EF)

Background— Diastolic dysfunction is an independent predictor of mortality in patients with normal left ventricular ejection fraction. There are limited data, however, on whether worsening of diastolic function is associated with worse prognosis. Methods and Results— We reviewed clinical records and echocardiograms of consecutive patients who had baseline echocardiograms between January 1, 2005, and December 31, 2009, that showed left ventricular ejection fraction ≥55% and who subsequently had a follow-up echocardiogram within 6 to 24 months. Diastolic function was labeled as normal, mild, moderate, or severe dysfunction. All-cause mortality was determined by use of the Social Security Death Index. Kaplan-Meier survival analysis and Cox regression analysis with a proportional hazard model were performed to assess outcomes. A total of 1065 outpatients were identified (mean±SD age, 67.9±13.9 years; 58% male). Baseline diastolic dysfunction was present in 770 patients (72.3%), with mild being the most prevalent. On follow-up testing (mean±SD, 1.1±0.4 years), 783 patients (73%) had stable, 168 (16%) had worsening, and 114 (11%) had improved baseline diastolic function. Eighty-eight patients (8.3%) had a decrease in left ventricular ejection fraction to P =0.002). After a mean±SD follow-up (from the second study) of 1.6±0.8 years, 142 patients (13%) died. On multivariate analysis, a decrease in left ventricular ejection fraction to P =0.02; and hazard ratio, 1.78; 95% confidence interval, 1.21–2.59; P =0.003, respectively). Conclusion— In patients with normal baseline left ventricular ejection fraction, worsening of diastolic function is an independent predictor of mortality.

There are limited data on whether differences exist in left ventricular (LV) mechanical dyssynchrony indices derived from stress versus rest gated positron emission tomography (PET) in patients with normal myocardial perfusion imaging (MPI).Stress/rest (82)Rb gated PET was performed in consecutive patients with normal MPI between 2006 and 2010. Patients were divided into two groups: group 1 [LV ejection fraction (EF) ≥ 55% and QRS120 ms] and group 2 (LVEF ≤35%). Images were acquired on a dedicated PET scanner prior to and on a hybrid PET/CT system after November 2008. LV dyssynchrony indices [phase standard deviation (SD)° and SD (ms)] were derived from stress and rest gated images.There were 91 patients in group 1 (age 61 ± 13, LVEF 66 ± 8%, normal QRS) and 126 in group 2 (age 66 ± 12, LVEF 25 ± 7%). The stress derived LVEF were significantly higher than rest for either group (p0.0001). Patients with cardiomyopathy had significantly higher dyssynchrony indices compared to those with normal LVEF (rest SD° 49.2 ± 21.5° vs 16.8 ± 7.8° and stress SD° 42.5 ± 19.4° vs 12.4 ± 3.7°, respectively, p0.0001 for both). The dyssynchrony indices derived from rest gated images were significantly higher than those derived from stress in both groups (p0.001 by unpaired and paired t test) and irrespective of the type of PET scanner utilized. Finally, 20/87 (23%) patients with normal LVEF and 27/66 (41%) of those with cardiomyopathy but without dyssynchrony based on stress indices were recategorized as having significant dyssynchrony given their resting indices.LV mechanical dyssynchrony indices by phase analysis are smaller when derived from peak stress versus rest gated PET imaging in patients with normal MPI, irrespective of the resting LVEF.

Multiple novel studies were presented at the 2015 American Heart Association Scientific Sessions which was considered a successful conference at many levels. In this review, we will summarize key studies in nuclear cardiology, cardiac magnetic resonance, echocardiography, and cardiac computed tomography that were presented at the Sessions. We hope that this bird's eye view will keep readers updated on the newest imaging studies presented at the meeting whether or not they were able to attend the meeting.

BACKGROUND: Sedentary lifestyle has become prevalent in our community. Recent data showed controversy on the effect of regular exercise on left ventricular compliance and myocardial relaxation. HYPOTHESIS: We sought to assess whether physical inactivity is an independent predictor of diastolic dysfunction in or community, after adjustment for several covariates. METHODS: Consecutive outpatients presenting to the echocardiography laboratory between July 2013 and June 2014 were prospectively enrolled. Clinical variables were collected prospectively at enrollment. Patients were considered physically active if they exercised regularly ≥3× a week, ≥30 minutes each time. The primary endpoint was presence of diastolic dysfunction. RESULTS: The final cohort included 1356 patients (mean age [SD] 52.9 [17.4] years, 51.3% female). Compared with physically active patients, the 1009 (74.4%) physically inactive patients were older, more often female, and had more comorbidities and worse diastolic function (51.3% vs 38.3%; P < 0.001). On univariate analysis, physical inactivity was associated with 70% increased odds of having diastolic dysfunction (odds ratio: 1.70, 95% confidence interval: 1.32‐2.18, P < 0.001). There was significant interaction between physical activity and left ventricular mass index (LVMI; P = 0.026). On multivariate analysis, patients who were physically inactive and had LVMI ≥ median had significantly higher odds of having diastolic dysfunction (odds ratio: 2.82, 95% confidence interval: 1.58‐5.05, P < 0.001). CONCLUSIONS: In a large, prospectively enrolled cohort from a single tertiary center in the Middle East, physically inactive patients with increased LVMI had 2‐ to 3‐fold increased odds of having diastolic dysfunction after multivariate adjustment.

In patients with heart failure and prolonged QRS duration, randomized clinical trials have shown that cardiac resynchronization therapy (CRT) is associated with improvement in quality of life, left ventricular (LV) remodeling, and survival.1–3 The improvements are believed to be mediated by more effective synchronized contraction in the presence of a wide QRS, but mechanical and electrical dyssynchrony are not equivalent.4,5 Although the concept of CRT response remains problematic,6 20% to 40% of patients who receive CRT based on electrical dyssynchrony criteria (ie, QRS duration) do not derive symptom improvement or demonstrate reverse remodeling.7–10 Scar burden11–13 and failure to place the LV pacing lead at the site of latest onset of contraction14–17 have been linked to a poor response. Thus, optimal clinical decision-making for CRT must include a comprehensive evaluation of all these factors to identify patients with heart failure who will benefit. The standard echocardiographic parameters of LV mechanical dyssynchrony have been extensively reviewed,18 with >600 published articles. Most of this work has been done using tissue Doppler imaging, with more recent work using speckle tracking,19,20 3D echocardiography,21 echocardiographic contrast imaging,22 and intracardiac echocardiography.23 Despite the important benefits of high temporal resolution, success in individual centers, and ability to assess the impact of scar burden and concordance of LV lead with latest activation site,14 fundamental limitations of tissue Doppler imaging include the inability to measure over a sufficient number of cardiac cycles to overcome beat-to-beat variation, poor image quality, and measurement error.24 In the only randomized trial of CRT in patients with wide QRS,25 the failure of 12 different echocardiographic dyssynchrony parameters to improve outcome was most likely related to the large interobserver and …

Limited published data suggested that patients with end-stage liver disease (ESLD) might have "cirrhotic cardiomyopathy," which could have an earlier stage manifested by mechanical dyssynchrony before left ventricular (LV) dysfunction.We studied consecutive patients with ESLD who had a stress-gated Tc-99m sestamibi myocardial perfusion imaging between 2008 and 2010 prior to liver transplant. Patients with LVEF 50%, abnormal perfusion, or QRS ≥ 120 ms were excluded. Baseline demographics, co-morbidities, model for ESLD (MELD) score, LV volumes, mass, ejection fraction (EF), and dyssynchrony indices (standard deviation and bandwidth) were extracted. The phase indices were compared to a normal cohort. There were 179 patients with a mean age 53 ± 8 years, LVEF 72 ± 10%. Hepatitis C, non-alcoholic steatohepatitis, and alcohol abuse were the most common cause of liver cirrhosis (40%, 18%, and 14%, respectively). Patients with ESLD had similar standard deviation (14 ± 8° vs 15 ± 6°, P = NS) and bandwidth (41 ± 25° vs 42 ± 14°, P = NS) to the normal cohort. Only four patients (2%) had a standard deviation27° (mean + 2 SD of the control group). The phase standard deviations and bandwidth similar in patients with MELD scores of ≤10, 11-18, 19-24, and ≥25 (P = NS for both). There was no correlation between the MELD score and standard deviation or bandwidth (r = -0.044 and -0.068, respectively, P = NS for both). Also, there was no correlation between the QTc and dyssynchrony indices. After 1-year follow-up, 22 patients died (12%). The dyssynchrony indices were similar among those who died and those who survived.Patients with ESLD and normal EF have no evidence for LV dyssynchrony.

The effect of heart rate (HR) on left ventricular (LV) mechanical dyssynchrony has not been studied by phase analysis of myocardial perfusion imaging and has yielded conflicting results by echocardiography. We measured indexes of LV dyssynchrony by automated analysis of gated single-photon emission computed tomography in 140 patients with end-stage renal disease (ESRD) and 133 subjects with normal renal function (control group). Patients with abnormal perfusion pattern or QRS duration120 ms were excluded. HR at time of acquisition of gated images was recorded. LV ejection fraction (EF), volumes, mass, and 2 indexes of dyssynchrony, phase SD and bandwidth, were derived. Almost 50% of patients in each group had an abnormal LVEF (50%). HR at rest ranged from 48 to 113 beats/min (75 ± 13). Patients with abnormal LVEF had a higher phase SD (30 ± 13° vs 22 ± 11° and 28 ± 16° vs 15 ± 6° for the ESRD and control groups, respectively, p0.001 each) and higher histographic bandwidth (88 ± 44° vs 62 ± 33° and 80 ± 49° vs 43 ± 14° for the ESRD and control groups, p0.001 each). Patients with ESRD and normal LVEF had higher SD and bandwidth than the control group (22 ± 11° vs 15 ± 6° and 62 ± 33° vs 43 ± 14°, respectively, p0.001 each). The control and ESRD groups were divided into tertiles based on HR. The phase SD and bandwidth were similar in the first (slowest HR) and third (highest HR) tertiles in every group (p = NS). There were no significant correlations between phase SD or bandwidth and HR in either group. In conclusion, within the HR range examined in this cross-sectional study, there was no relation between HR at rest and LV dyssynchrony.

Glucagon-like peptide-1 (GLP-1) is an incretin hormone secreted from intestinal L cells upon nutrients ingestion, and is currently used for treating diabetes mellitus. It plays an important role in receptor modulation and cross talk with insulin at the coronary endothelium (CE) and cardiomyocytes (CM) in diabetic type 1 rat heart model. We studied the effects of insulin, GLP-1 analogues (exendin-4), and dipeptidyl peptidase-IV (DPP-IV) inhibitor on GLP-1 cardiac receptor modulation. The binding affinity of GLP-1 to its receptor on CE and CM was calculated using a rat heart perfusion model with [(125)I]-GLP-1(7-36). Tissue samples from the heart were used for immunostaining and Western blot analyses. GLP-1 systemic blood levels were measured using ELISA. GLP-1 binding affinity (τ) increased on the CE (0.33 ± 0.01 vs. 0.25 ± 0.01 min; p < 0.001) and decreased on the CM (0.29 ± 0.02 vs. 0.43 ± 0.02 min; p < 0.001) in the diabetic non-treated rats when compared to normal. There was normalization of τ back to baseline on the CE and CM levels with insulin and DPP-IV inhibitor treatment, respectively. Histological sections and immunofluorescence showed receptor up-regulation in diabetic rats with significant decrease and even normalization with the different treatment strategies. Systemic GLP-1 levels increased after 14 days of diabetes induction (10 ± 3.7 vs. 103 ± 58 pM; p = 0.0005). In conclusion, there is a significant GLP-1 receptor affinity modulation on the CE and CM levels in rats with diabetes type 1, and a cross talk with GLP-1 analogues in early prevention of cardiac remodeling.

There is increasing awareness of the value of phase analysis of gated tomographic myocardial perfusion imaging in assessing left ventricular (LV) dyssynchrony. A concern repeatedly raised in many studies is whether reversible defects in the stress images "ischemia" could affect the phase-derived standard deviation and bandwidth, the two commonly used dyssynchrony indices. We hypothesized that the stress and rest images should provide comparable information because the images are acquired 1 hour after the tracer injection.We studied two groups of patients with normal LV ejection fraction and no fixed perfusion defects. In group-1 (N = 20), the patients had reversible perfusion defects involving10% of the LV myocardium and in group-2 (N = 20), the patients had normal images. All patients underwent stress/rest-gated single photon emission computed tomography sestamibi imaging (the stress study was acquired with the lower dose) between January and March 2010. Patients with left bundle branch block or ventricular pacing were excluded. The patients in group-1 had a mean age of 61 ± 9 years, 65% were men, 75% Caucasians, and 70% had known prior coronary artery disease. The size of the reversible perfusion defect was 20 ± 13% (range 11%-50%) of the LV myocardium. The rest and stress phase-derived standard deviation (16 ± 6° vs 18 ± 8° and 16 ± 7° vs. 19 ± 6°) and the rest and stress bandwidth (42 ± 14° vs 46 ± 16° and 45 ± 17° vs 52 ± 12°), respectively, (P = NS for all) were similar in the two groups. The change (stress-rest) in standard deviation and bandwidth in groups 1 and 2 were not statistically significant (0.2 ± 3.1° vs 1.4 ± 4.7°, and 2 ± 13° vs 5 ± 13°, respectively, P = NS). There was no significant change from rest to stress in the standard deviation and the bandwidth in group-1 (P = .8 and .4, respectively) and group-2 (P = .2 and .08, respectively). There was no correlation between the size of the reversible perfusion defect and the change in phase standard deviation or bandwidth (r = 0.07 and 0.12, respectively, P = NS).The presence of even a large reversible perfusion defect does not alter the indices of mechanical dyssynchrony by phase analysis. Further, comparable information is obtained whether using a low dose or a high dose of the radiotracer.

The presence and degree of left ventricular (LV) dyssynchrony in patients with end-stage renal disease (ESRD) has not been well studied. We hypothesized that these patients would be more likely to have mechanical dyssynchrony than a control cohort. The indexes of LV mechanical dyssynchrony were measured by automated analysis of gated single photon emission computed tomography myocardial perfusion imaging in 290 patients with ESRD and 109 control patients. Only patients with normal myocardial perfusion imaging findings and a narrow QRS duration were included. The following variables were derived: LV ejection fraction (EF), volume, mass, and 2 indexes of dyssynchrony, the standard deviation and bandwidth. The standard deviation and bandwidth were significantly greater in those with ESRD (23° ± 13° vs 15° ± 6° and 65° ± 40° vs 42° ± 14°, respectively, p0.001 for each). The LV volumes and LV mass were significantly lower and LVEF significantly greater in the control group than in the patients with ESRD (p0.001 for each). The subgroup of 217 patients with ESRD and normal LVEF also had a significantly greater standard deviation and bandwidth than did the control group (21° ± 12° and 57° ± 35°, p0.001 for each). However, their values were lower than those of the 73 patients with ESRD and a LVEF50% (30° ± 13° and 90° ± 45°, p0.001 for each). Finally, 25 patients (9%) with ESRD and none of the control group had a standard deviation43° (p = 0.01). In conclusion, patients with ESRD had significantly more mechanical dyssynchrony than did the control group, even in absence of electrical dyssynchrony and abnormal LV perfusion or function.

Regadenoson is a selective A(2A) receptor agonist that is used for vasodilator stress myocardial perfusion imaging (MPI). Since the drug is partially metabolized by the liver, its safety in patients with end-stage liver disease (ESLD) needs to be determined.We studied 168 consecutive patients with ESLD who had regadenoson stress gated single photon emission computed tomography MPI between January 2008 and March 2010 before planned orthotopic liver transplantation and compared the hemodynamic responses and safety profile to 168 control patients. There were 72 women (43%) in ESLD versus 87 (52%) in the control group (P = .1). The patients with ESLD were younger (58 ± 7 vs 62 ± 12 years, P = .0002), but more likely to be Caucasians (P = .002). The MPI images were normal in 161 patients (96%) in each group. The left ventricular ejection fraction was 72 ± 10% in ESLD and 66 ± 11% in the control patients (P = .0001). The heart rate increase in response to regadenoson was lower in patients with ESLD than in the control group (16 ± 11 vs 23 ± 16 bpm, P = .0001), but the changes in systolic and diastolic blood pressures were similar (-9 ± 12 vs -11 ± 14 mmHg and -6 ± 8 vs -7 ± 10 mmHg, respectively, P = NS). There were no deaths or medication-related adverse events that required hospitalization in either group within 30 days of the study.This is the first study to document the tolerability and safety profile of regadenoson in patients with ESLD.

Left-ventricular (LV) dyssynchrony could be measured by gated SPECT myocardial perfusion imaging (MPI). This study examined the relation between the degree of dyssynchrony and outcome in patients with implantable cardiac defibrillators (ICDs). We studied 70 patients with ICD and LV ejection fraction (EF)

Background— Metabolic syndrome (MetSyn) is associated with increased cardiovascular risk in the general population. Its prognostic implications are less well defined in patients with coronary artery disease. Methods and Results— We analyzed patients in the Duke Database for Cardiovascular Disease with a diagnosis of incident obstructive coronary artery disease. Diabetes mellitus (DM) was classified as a clinical history of DM, use of hypoglycemic drugs, or fasting glucose of ≥126 mg/dL. MetSyn was defined as having 3 of 5 characteristics: fasting glucose ≥100 and 150 mg/dL, blood pressure ≥130/85 mm Hg, or use of antihypertensive therapy, or body mass index ≥27. Death, myocardial infarction, or stroke was assessed at 6 months, 1 year, then annually. Cox proportional hazards models were generated to compare mortality and cardiovascular events between groups. The primary cohort consisted of 5744 patients; 1831 (31.9%) had DM, 2491 (43.4%) had MetSyn, and 1422 (24.7%) had no DM/MetSyn. Median follow-up was 5 years. Compared with no DM/MetSyn patients, DM patients had a higher adjusted risk for mortality (hazard ratio, 1.47; 95% CI, 1.28 to 1.69) but MetSyn patients did not (hazard ratio, 0.94; 95% CI, 0.81 to 1.08). Similar results were found for the combined end points of death or myocardial infarction, and death, myocardial infarction, or stroke. Conclusions— In a population of consecutive patients with a new diagnosis of coronary artery disease by angiography, MetSyn without DM was not an independent predictor of mortality or cardiovascular events.

Prior studies show that ischemic cardiomyopathy (ICM) patients with substantial viable myocardium have better survival with coronary revascularization (CR) than medical therapy (MT). When myocardial perfusion imaging (MPI) is used, the analysis is often based on visual scoring. We sought to determine the value of automated quantitative viability analysis in guiding management and predicting outcome.We identified 246 consecutive ICM patients who had rest-redistribution gated SPECT thallium-201 MPI. Size and severity of perfusion defects were assessed by automated method. Regions with50% activity vs normal were considered nonviable. Mortality was verified against the social security death index database.Of the 246 patients, 37% underwent CR within 3 months of MPI. The initial images showed a total perfusion defect size of 32 +/- 17%, redistribution of 3.5 +/- 4.6% and nonviable myocardium of 13 +/- 14%LV. Using multivariate logistic regression analysis, independent predictors of CR included chest pains (OR 2.74) and rest-delayed transient ischemic dilatation (OR 4.49), while a prior history of CR or ventricular arrhythmias favored MT. The cohort was followed-up for 41 +/- 30 m during which 111 patients (45%) died. Survival was better with CR than MT (P.0001). For CR, survival was better for those with a smaller area of nonviable myocardium (risk of death increased by 5%/1% increase in size of nonviable myocardium, P = .009) but this was not seen in MT. CR had a mortality advantage over MT when the area of nonviable myocardium wasor=20%LV but not larger.Automated quantitative analysis of MPI is useful in predicting survival in ICM, but the decision for or against CR is a complex one as it depends on multiple other factors and "viability testing" is just one variable that needs to be incorporated in the decision-making process.

A 9-year-old boy with hypereosinophilic syndrome (HES) was referred for cardiac magnetic resonance (CMR) imaging following an abnormal echocardiogram that showed a large mass layered on the inferolateral wall of the left ventricle, causing secondary severe mitral regurgitation. Cardiac involvement in HES usually affects the ventricular apex. In our case, CMR confirmed the presence of a large mural thrombus of 0.9 cm × 4.2 cm. This unusual cardiac involvement in HES was diagnosed in its intermediate thrombotic stage. CMR is very sensitive and specific in staging the disease. It explained the etiology of mitral regurgitation and guided therapy, especially when echocardiography was nonconclusive.

Myocardial infarct (MI) size is a well-established prognostic marker but the association of serum markers with MI size, as measured by myocardial perfusion imaging (MPI), has not been well studied in patients with hypertrophic cardiomyopathy (HC) after alcohol septal ablation (ASA). Creatine kinase (CK), CK-MB, troponin I, and brain natriuretic peptide were measured before and at multiple points after ASA in patients with HC and were correlated with MI size measured by MPI. MPI at rest was performed in 54 patients with HC at a median of 2 days after ASA. CK, CK-MB, and troponin I increased after ASA to peak levels at 12 hours and their cumulative levels (area under the curve) showed significant correlation with size of MI by MPI (r = 0.544, 0.408, and 0.477, p

A 38-year-old male presented with heart failure symptoms and was diagnosed with aortic valve endocarditis and underlying aortic stenosis in the absence of concentric hypertrophy or bicuspid aortic valve and underwent aortic valve replacement but continued to have symptoms which were then attributed to hypertrophic cardiomyopathy with dynamic left ventricular outflow tract obstruction. He was determined to be unsuitable for myomectomy and underwent successful alcohol septal ablation using transthoracic echocardiographic Doppler and continuous wave velocity monitoring without requiring to cross the aortic valve or to perform transatrial septostomy and left ventricular pressure monitoring. When crossing the aortic valve is a relative or absolute contraindication like in our index case, continuous Doppler velocity recording is a safe and effective alternative approach to monitor the outflow gradient while performing alcohol septal ablation.

A 61-year-old white female, a Jehovah's Witness, with severe pulmonary hypertension, presented with worsening heart failure symptoms. She had a pericardial effusion with left ventricular (LV) diastolic collapse on transthoracic echocardiography. She was not a candidate for surgical pericardial window and therefore underwent pericardiocentesis and percutaneous balloon pericardiotomy with remarkable improvement in her clinical condition and with no recurrence of the effusion. LV diastolic collapse, an atypical presentation of cardiac tamponade, is commonly seen in postoperative patients with localized pericardial effusions. However, outside the surgical setting, isolated LV diastolic collapse is rare. Our case is one of the first cases described in the literature of LV diastolic collapse in the setting of severe pulmonary hypertension treated successfully with pericardiocentesis and percutaneous balloon pericardiotomy.

In 2015, many original articles pertaining to cardiovascular imaging with impressive quality were published in the Journal of Nuclear Cardiology. In a set of 2 articles, we provide an overview of these contributions to facilitate for the interested reader a quick review of the advancements that occurred in the field over this year. In this first article, we focus on arterial plaque imaging, cardiac positron emission tomography, computed tomography, and magnetic resonance imaging.

Perioperative risk assessment is essential in screening patients before noncardiac surgery. Cardiovascular complications such as fatal and non-fatal myocardial infarction (MI), ventricular arrhythmia, pulmonary edema, and stroke are important in-hospital causes of morbidity and mortality intra and post-operatively. The optimal approach is to identify patients at increased risk so that appropriate testing and therapeutic interventions are undertaken a priori to minimize such risk. The initial preoperative evaluation includes identification of surgery-specific risk, patient exercise functional capacity and clinical risk profile. Patients with major predictors of events such as acute coronary syndromes, recent MI, unstable arrhythmia, and severe valvular disease warrant further management and optimization that often lead to delaying surgery. Those with three or more predictors (history of ischemic heart disease, compensated heart failure, diabetes, renal insufficiency, or history of cerebrovascular disease) undergoing high- risk surgery often require stress testing. Although data from randomized prospective trials are lacking, numerous studies have demonstrated the utility of myocardial perfusion imaging (MPI) for determination of perioperative cardiac risk. The goal of this chapter is to review the use of MPI for preoperative risk assessment and the recommendations from the current guidelines. The focus will be on short-term and long-term prognosis including special groups such as after coronary stenting and before vascular surgery, liver and renal transplantation.

Coronary artery disease (CAD) remains the leading cause of morbidity and mortality worldwide. While the burden of the disease remains high, the rates of death attributable to CAD have declined by almost a third between 1998 and 2008. In patients with stable ischemic heart disease (SIHD), data supporting survival benefit from coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) versus no revascularization are outdated with the recent advancement in medical therapy. Over the years, myocardial perfusion imaging (MPI) has played a significant role in detecting ischemic burden, risk stratifying patients and guiding physicians to the best treatment strategy. Contrary to data from other trials, the role of stress MPI has been downplayed in more contemporary randomized clinical trial that failed to show that ischemic burden identifies the ideal candidate for revascularization or carries incremental prognostic value. Hence, there is an equipoise on the role of MPI in the management of patients prior to revascularization. The role of stress MPI post-revascularization has also been evaluated in multiple studies, mostly done in the last decade or prior. The guidelines advocate against routine stress MPI in asymptomatic patients (unless 5 years or more post-CABG), but allows it in the presence or recurrence of symptoms. The current chapter will review the data on survival benefit from revascularization, complementary role of stress MPI in selecting the appropriate candidate for revascularization, prognostic value of ischemic versus atherosclerotic burden, role of MPI post revascularization, updated guidelines and proposed algorithms to guide the treating physicians.

In this new feature of The Journal of Nuclear Cardiology we will summarize key articles that were published in the Journal in the previous year. In the first article of this 2-part series we concentrated on publications dealing with cardiac positron emission tomography, computed tomography, and neuronal imaging. This review will focus on myocardial perfusion imaging summarizing advances in the field including in diagnosis, prognosis, appropriateness, and safety of testing.

Blunted heart rate response (HRR) to regadenoson has been shown to be predictive of poor outcome in patients undergoing SPECT myocardial perfusion Imaging (MPI). The predictive value of this marker has not been evaluated in high risk patients with end stage renal disease (ESRD). ESRD patients

Cardiac magnetic resonance imaging (CMRI) is a novel non-invasive modality with many potential indications, and was recently introduced in Lebanon. We sought to assess the appropriateness and diagnostic yield of CMR studies performed at a tertiary referral center from the Middle East since the inception of the program.All patients who underwent CMR studies between January 1(st) 2013 and June 18(th) 2014 were enrolled in this study. CMR reports were retrospectively reviewed. The study indication, clinical history, and findings were extracted and analyzed. The appropriateness of the study was judged according to the 2010 updated Asian Society of Cardiac Imaging guidelines.There were a total of 142 patients [mean age 42.1 (SD: 18) years, 24.6% females] that underwent CMR study. Two-thirds of studies were performed on an outpatient basis, and outside referrals constituted 16.2% of the entire cohort. The cardiologists referred 122 cases (86%) with main contribution from electrophysiology and imaging specialists. Of the 142 cases, 12 (8.4%) were not indicated and added little value. Of the remaining 130 appropriate studies (appropriateness level A8-A9), one-third had an incorrect diagnosis prior to CMR, and 8% had relevant findings that were missed on other studies but captured by CMR. Furthermore, CMR confirmed the diagnosis in 28% of the cases, provided relevant information on scar burden, shunt quantification, and ruled out infiltrative disease in the remaining patients. Also, CMR demonstrated the presence of scar in 45 of patients, among whom 20 (44%) had significant scar volume quantification (5% of left ventricular myocardium). Finally, 9% of patients had a relevant extra-cardiac finding that needed further investigation.Despite the recent launch of the CMR program at our institution, the majority of studies were appropriately indicated, provided relevant data and were clinically useful. Inappropriate or uncertain studies did not provide relevant data, and should be further minimized to avoid unnecessary costs and downstream testing. Large prospective CMR database with clinical follow-up is needed to provide more insight about cardiovascular disease and outcomes in our population.

Coronary computed tomography angiography (CCTA) has many advantages over invasive coronary angiography. It allows the detection of anomalous vessels and their relationship to heart structures. Dual left anterior descending coronary artery (LAD) anomaly is defined by the presence of two LADs. It is categorized on the basis of a long and short LAD. We present a novel type in which one long LAD branches from the right coronary artery (RCA) and the other LAD, a long vessel as well, branches from the left main coronary artery (LMCA). They course in parallel to terminate at the apex. This pattern defies the current short-long classification. We suggest it to be a novel pattern.