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The increasing prevalence of patients with aortic stenosis worldwide highlights a clinical need for improved and accurate prediction of clinical outcomes following surgery. We investigated patient demographic and cardiovascular magnetic resonance (CMR) characteristics to formulate a dedicated risk score estimating long-term survival following surgery. We recruited consecutive patients undergoing CMR with gadolinium administration prior to surgical aortic valve replacement from 2003 to 2016 in two UK centres. The outcome was overall mortality. A total of 250 patients were included (68 ± 12 years, male 185 (60%), with pre-operative mean aortic valve area 0.93 ± 0.32cm2, LVEF 62 ± 17%) and followed for 6.0 ± 3.3 years. Sixty-one deaths occurred, with 10-year mortality of 23.6%. Multivariable analysis showed that increasing age (HR 1.04, P = 0.005), use of antiplatelet therapy (HR 0.54, P = 0.027), presence of infarction or midwall late gadolinium enhancement (HR 1.52 and HR 2.14 respectively, combined P = 0.12), higher indexed left ventricular stroke volume (HR 0.98, P = 0.043) and higher left atrial ejection fraction (HR 0.98, P = 0.083) associated with mortality and developed a risk score with good discrimination. This is the first dedicated risk prediction score for patients with aortic stenosis undergoing surgical aortic valve replacement providing an individualised estimate for overall mortality. This model can help clinicians individualising medical and surgical care.Trial Registration ClinicalTrials.gov Identifier: NCT00930735 and ClinicalTrials.gov Identifier: NCT01755936.

This article aims to reflect on the evaluation of potential and emergent learning environments. Learning environments are considered as potential sources of development where learners, as integral members of these contexts, act in a constructivist perspective. It is concluded that the assessment of learning environments should seek to overcome the limitation associated with the excessive focus on the efficiency of teaching, which can be achieved through the effective inclusion of the student in the context. The importance of agency in learning environments is also recognised and it is suggested that potential or emerging learning environments should seek to integrate a holistic and inclusive conception of participants. Reflecting on the potential that contexts bring to learning and knowledge construction, can trigger new ways of perceiving the dynamics of social relationships, learning and education.

No presente artigo se aborda a aprendizagem a partir de uma perspetiva construtivista e o potencial que ambientes híbridos e imersivos podem ter no processo de ensino-aprendizagem, nos quais se assume de significativa relevância considerar o envolvimento ativo e o estímulo da agência do estudante no processo de construção de conhecimento. Neste sentido, os autores apresentam considerações teóricas e reflexões que visam consciencializar para ambientes emergentes de aprendizagem, diferentes modelos de ensino híbrido e para várias mídias imersivas, assim como, contribuir para a reflexão e consolidação dos fundamentos da aprendizagem nesses contextos. Enfatizar a aprendizagem situacional, integrando ambientes híbridos e imersivos, pode conduzir o estudo da educação e da aprendizagem a novos rumos.

In this work, we describe the CRIMSON (CardiovasculaR Integrated Modelling and SimulatiON) software environment. CRIMSON provides a powerful, customizable and user-friendly system for performing three-dimensional and reduced-order computational haemodynamics studies via a pipeline which involves: 1) segmenting vascular structures from medical images; 2) constructing analytic arterial and venous geometric models; 3) performing finite element mesh generation; 4) designing, and 5) applying boundary conditions; 6) running incompressible Navier-Stokes simulations of blood flow with fluid-structure interaction capabilities; and 7) post-processing and visualizing the results, including velocity, pressure and wall shear stress fields. A key aim of CRIMSON is to create a software environment that makes powerful computational haemodynamics tools accessible to a wide audience, including clinicians and students, both within our research laboratories and throughout the community. The overall philosophy is to leverage best-in-class open source standards for medical image processing, parallel flow computation, geometric solid modelling, data assimilation, and mesh generation. It is actively used by researchers in Europe, North and South America, Asia, and Australia. It has been applied to numerous clinical problems; we illustrate applications of CRIMSON to real-world problems using examples ranging from pre-operative surgical planning to medical device design optimization., Author summary We provide the first full presentation in the literature of CRIMSON, the Cardiovascular Integrated Modelling and Simulation Package. CRIMSON consists of a graphical user interface desktop computer program for creating geometric models of blood vessels from medical imaging scans, specifying parameters such as the stiffness of the artery walls, the resistance of connected vessels which are not visible on the scans, and determining the appropriate parameters for all aspects of the model. CRIMSON additionally consists of the Flowsolver, a high-performance computing package which simulates the flow of blood through the models created in the graphical user interface. Whilst several packages which can simulate blood flow exist, most target general fluid simulations, and this lack of specialisation means that blood flow simulation is harder to perform, and can require ad hoc (and potentially scientifically-limiting) workflow decisions. CRIMSON’s specialisation deals with these problems, as well as presenting a number of unique features which are unavailable elsewhere.

BackgroundCMRA in pediatrics remains challenging due to the smaller vessel size, high heart rates (HR), potential image degradation caused by limited patient cooperation and long acquisition times. High-relaxivity contrast agents have been shown to improve coronary imaging in adults, but limited data is available in children. We sought to investigate whether gadobenate dimeglumine (Gd-BOPTA) together with self-navigated inversion-prepared coronary magnetic resonance angiography (CMRA) sequence design improves coronary image quality in pediatric patients.MethodsForty consecutive patients (mean age 6 ± 2.8 years; 73% males) were prospectively recruited for a 1.5-T MRI study under general anesthesia. Two electrocardiographic-triggered free breathing steady-state free precession (SSFP) angiography sequences (A and B) with isotropic spatial resolution (1.3 mm3) were acquired using a recently developed image-based self-navigation technique. Sequence A was acquired prior to contrast administration using T2 magnetization preparation (T2prep). Sequence B was acquired 5–8 min after a bolus of Gd-BOPTA with the T2prep replaced by an inversion recovery (IR) pulse to null the signal from the myocardium. Scan time, signal-to noise and contrast-to-noise ratios (SNR and CNR), vessel wall sharpness (VWS) and qualitative visual score for each sequence were compared.ResultsScan time was similar for both sequences (5.3 ± 1.8 vs 5.2 ± 1.5 min, p = .532) and average heart rate (78 ± 14.7 vs 78 ± 14.5 bpm, p = .443) remained constant throughout both acquisitions. Sequence B resulted in higher SNR (12.6 ± 4.4 vs 31.1 ± 7.4, p p p = .001; and visual scoring A = 3.8 ± 0.59 vs B = 4.1 ± 0.53, p p = .002], and contrary to the pre-contrast sequence, never involved a proximal segment. These results were independent of the patients' age, body surface area and HR.ConclusionsThe use of Gd-BOPTA with a 3D IR SSFP CMRA sequence results in improved coronary visualization in small infants and young children with high HR within a clinically acceptable scan time.AbbreviationsBP-CA, blood pool contrast agent; BSA, body surface area; SSFP, steady state free precession; CHD, congenital heart disease; CMR, cardiovascular magnetic resonance; CMRA, coronary magnetic resonance angiography; CNR, contrast-to-noise ratio; CoA, aortic coarctation; EC-GBCA, extra-cellular gadolinium-based contrast agent; ECG, electrocardiogram; Gd-BOPTA, gadobenate dimeglumine; HR, heart rate; iNAV, image-based navigator; IR, inversion recovery; LAD, left anterior descending artery; LCx, left circumflex artery; MRI, magnetic resonance imaging; RCA, right coronary artery; SNR, signal-to-noise ratio; VWS, vessel wall sharpness.

ObjectiveMitral valve anatomy has a significant impact on potential surgical options for patients with hypoplastic or borderline left ventricle. Papillary muscle morphology is a major component regarding this aspect. The purpose of this study was to use cardiac magnetic resonance to describe the differences in papillary muscle anatomy between normal, borderline, and hypoplastic left ventricles.MethodsWe carried out a retrospective, observational cardiac magnetic resonance study of children (median age 5.36 years) with normal (n=30), borderline (n=22), or hypoplastic (n=13) left ventricles. Borderline and hypoplastic cases had undergone an initial hybrid procedure. Morphological features of the papillary muscles, location, and arrangement were analysed and compared across groups.ResultsAll normal ventricles had two papillary muscles with narrow pedicles; however, 18% of borderline and 46% of hypoplastic cases had a single papillary muscle, usually the inferomedial type. In addition, in borderline or hypoplastic ventricles, the supporting pedicle occasionally displayed a wide insertion along the ventricular wall. The length ratio of the superolateral support was significantly different between groups (normal: 0.46±0.08; borderline: 0.39±0.07; hypoplastic: 0.36±0.1; p=0.009). No significant difference, however, was found when analysing the inferomedial type (0.42±0.09; 0.38±0.07; 0.39±0.22, p=0.39). The angle subtended between supports was also similar among groups (113°±17°; 111°±51° and 114°±57°; p=0.99). A total of eight children with borderline left ventricle underwent biventricular repair. There were no significant differentiating features for papillary muscle morphology in this subgroup.ConclusionsThe superolateral support can be shorter or absent in borderline or hypoplastic left ventricle cases. The papillary muscle pedicles in these patients often show a broad insertion. These changes have important implications on surgical options and should be described routinely.

OBJECTIVES Hypertrophic cardiomyopathy (HCM) is associated with left atrial (LA) functional abnormalities. The determinants and the degree of LA dysfunction in the course of HCM are not fully understood. We aimed to characterize LA mechanics in HCM, according to the extent of left ventricular (LV) hypertrophy and fibrosis. METHODS AND RESULTS Seventy-three HCM patients and 23 age- and sex-matched controls underwent cardiovascular magnetic resonance imaging including late gadolinium enhancement (LGE). LA reservoir, conduit, and contractile functions were quantified by fractional volume changes and cardiovascular magnetic resonance feature-tracking-derived strain and strain rate. In multivariable regression, LA mechanics were associated with the extent of LV LGE (P = 0.033 to P < 0.001), but not with the LV mass extent or maximum wall thickness (P = 0.108 to P = 0.964). Left atrial function decreased according to the increase in extent of LV fibrosis (non-LGE; mild LGE ≤ 10%; intermediate LGE 11%-19%; severe LGE ≥ 20%). Compared with healthy controls, LA conduit function was impaired in HCM with no LGE already (LA emptying fraction conduit: 32% ± 7% vs 26 ± 14, P = 0.037). Conversely, LA contractile booster pump function was impaired in HCM with severe LGE only (LA emptying fraction booster: 40% ± 8% vs 20% ± 10%, P < 0.001; for controls vs LGE ≥ 20%, respectively). CONCLUSIONS Left atrial functional abnormalities are associated with LV fibrosis, but not with LV hypertrophy. While LA conduit function is impaired in early HCM stages as represented by mild or absent LV fibrosis, LA contractile function is impaired later in the course of disease progression as demonstrated by the presence of severe LV fibrosis only. These novel markers of LA performance may potentially proof useful for disease staging and early detection of cardiac deterioration.

Despite the volume increase of electronic data collection in the health area, there is still much medical information that is recorded without any systematic pattern. For instance, besides the structured admission notes format, there are free text fields for clinicians’ patient evaluation observation. Intelligent Decisions Support Systems can benefit from cross-referencing and interpretation of these documents. In the Intensive Care Units, several patients are admitted daily, and several discharge notes are written. To support real-time decision-making and to increase the quality of its process, is crucial to have all relevant patient clinical data available. Since there is no writing pattern followed by all medical doctors, its analysis becomes quite difficult to do. This project aims to make qualitatively and quantitatively analysis of clinical information focusing on the stroke or cerebrovascular accident diagnosis using text analysis tools, namely Natural Language Processing and Text Mining. Our results revealed a set of related words in the clinician’ patient diaries that can reveal patterns., This work has been supported by COMPETE: POCI-01-0145-FEDER-007043 and FCT – Fundação para a Ciência e Tecnologia within the Project Scope: UID/CEC/00319/2013. This work is also supported by the Deus ex Machina (DEM): Symbiotic technology for societal efficiency gains - NORTE-01-0145-FEDER-000026.

The segmentation of the left ventricle (LV) from CINE MRI images is essential to infer important clinical parameters. Typically, machine learning algorithms for automated LV segmentation use annotated contours from only two cardiac phases, diastole, and systole. In this work, we present an analysis work-flow for fully-automated LV segmentation that learns from images acquired through the cardiac cycle. The workflow consists of three components: first, for each image in the sequence, we perform an automated localization and subsequent cropping of the bounding box containing the cardiac silhouette. Second, we identify the LV contours using a Temporal Fully Convolutional Neural Network (T-FCNN), which extends Fully Convolutional Neural Networks (FCNN) through a recurrent mechanism enforcing temporal coherence across consecutive frames. Finally, we further defined the boundaries using either one of two components: fully-connected Conditional Random Fields (CRFs) with Gaussian edge potentials and Semantic Flow. Our initial experiments suggest that significant improvement in performance can potentially be achieved by using a recurrent neural network component that explicitly learns cardiac motion patterns whilst performing LV segmentation.

Summary Aquagenic urticaria (AU) is a rare form of chronic inducible urticaria elicited by water at any temperature. We describe the case of a 25-year-old atopic woman who presented to our unit with a 4-year history of recurrent urticarial rashes, highly pruritic, confined to the neck and lower part of the face, occurring solely on contact with sea water. The lesions were reproduced by challenge tests with aqueous 3.5% NaCl and other hypertonic aqueous solutions but not with 20% glucose neither tap water. Our case supports the existence of a distinct salt-dependent subtype of aquagenic urticaria (SDAU), which seems to be triggered mostly by sea bathing, affects young women and has a characteristic localization on the inferior facial contours and neck. To the best of our knowledge, only eight cases of SDAU have been reported in the literature.

Objectives Cardiac output (CO) response to dobutamine can identify Alagille's syndrome (ALGS) patients at higher risk of cardiovascular complications during liver transplantation. We propose a novel patient-specific computational methodology to estimate the coronary autoregulatory responses during different hemodynamic conditions, including those experienced in a post-reperfusion syndrome (PRS), to aid cardiac risk-assessment. Material and methods Data (pressure, flow, strain and ventricular volumes) from a 6-year-old ALGS patient undergoing catheter/dobutamine stress MRI (DSMRI) were used to parameterize a closed-loop coupled-multidomain (3D-0D) approach consisting of image-derived vascular models of pulmonary and systemic circulations and a series of 0D-lumped parameter networks (LPN) of the heart chambers and the distal arterial and venous circulations. A coronary microcirculation control model (CMCM) was designed to adjust the coronary resistance to match coronary blood flow (and thus oxygen delivery) with MVO2 requirements during Rest, Stress and a virtual PRS condition. Results In all three simulated conditions, diastolic dominated right coronary artery (RCA) flow was observed, due to high right ventricle (RV) afterload. Despite a measured 45% increase in CO, impaired coronary flow reserve (CFR) (~1.4) at Stress was estimated by the CMCM. During modeled PRS, a marked vasodilatory response was insufficient to match RV myocardial oxygen requirements. Such exhaustion of the RCA autoregulatory response was not anticipated by the DSMRI study. Conclusion Impaired CFR undetected by DSMRI resulted in predicted myocardial ischemia in a computational model of PRS. This computational framework may identify ALGS patients at higher risk of complications during liver transplantation due to impaired coronary microvascular responses.

Background The purpose of this study was to evaluate a recently developed two-dimensional (2D) image-based navigation approach (iNAVG+C) combined with respiratory bellows gating for CMRA in patients with congenital heart disease. Methods Nine healthy volunteers (mean age 32 ± 6 years [standard deviation]) and 29 patients (28 ± 9 years) were scanned on a 1.5 Tesla clinical scanner using iNAVG+C motion compensated T2prepared CMRA, and the conventional 1D NAV approach. Scan time was recorded for each CMRA scan. An image quality score was given to each coronary artery from (0, uninterpretable; to 4, excellent image quality). Additionally, vessel sharpness of each coronary artery was measured. Results Average scan time was significantly shorter (P < 0.01) using the proposed iNAVC+G approach (7:57 ± 1:34) compared with 1D NAV (9:15 ± 3:02). Improved visual scores of the right coronary artery (iNAVG+C: 4,3,4 (median, 25th percentile, 75th percentile) versus 1D NAV: 3,3,4; P < 0.001) and left anterior descending artery (iNAVG+C: 3,3,4 versus 1D NAV: 3,2,3; P < 0.001) were obtained using iNAVG+C compared with 1D NAV as well as an increased vessel sharpness of the right coronary artery (iNAVG+C: 65.3% ± 6.6% (mean ± standard deviation) versus 1D NAV: 60.2% ± 11.4%; P < 0.05) and left anterior descending artery (iNAVG+C: 63.2% ± 6.7% versus 1D NAV: 58.3% ± 9.5%; P < 0.05). Conclusion Image-based navigation in combination with respiratory bellows gating allows for more robust suppression of respiratory motion artifacts for whole-heart CMRA compared with conventional 1D NAV as images can be acquired in a shorter time and with improved image quality. J. Magn. Reson. Imaging 2015

AimsVascular ageing is characterized by arterial stiffening, dilation, and arterial wall thickening. We investigated the extent to which these changes are related and their heritability during 5 year follow-up in the Twins UK cohort.Methods and resultsCarotid-femoral pulse wave velocity (PWVcf), carotid diameter, carotid distensibility, and carotid intima-media thickness (IMT) were measured in 762 female twins (mean age 57.9 ± 8.6 years) at two time-points over an average follow-up of 4.9 ± 1.5 years. Magnetic resonance imaging (MRI) was performed in a sub-sample of 38 women to measure aortic pulse wave velocity (PWVaorta), diameter, and wall thickness. Heritability of changes in arterial wall properties was estimated using structural equation modelling. Annual increases in PWVcf, carotid diameter, distensibility, and IMT were 0.139 m/s, 0.028 mm, −0.4 kPa−1, and 0.011 mm per year, respectively. In regression analysis, predictors of progression in PWVcf included age, mean arterial pressure (MAP), and heart rate (HR) at baseline, and progression in MAP, HR, and body mass index (BMI). Predictors of progression in IMT included progression in MAP, BMI, and triglyceride levels. Progression of PWV and distensibility correlated with progression in carotid diameter but not with IMT. Heritability of progression of PWVcf, diameter, and IMT was 55%, 21%, and 8%, respectively. In a sub-sample of women that underwent MRI, aortic wall thickness increased by 0.19 mm/year, but aortic wall thickening was not correlated with an increase in lumen diameter or PWVaorta.ConclusionArterial stiffening, as measured by PWVcf, and dilation are heritable but independent of arterial wall thickening. Genetic and cardiovascular risk factors contribute differently to progression of PWV and IMT.

BACKGROUND: The use of coronary MR angiography (CMRA) in patients with coronary artery disease (CAD) remains limited due to the long scan times, unpredictable and often non-diagnostic image quality secondary to respiratory motion artifacts. The purpose of this study was to evaluate CMRA with image-based respiratory navigation (iNAV CMRA) and compare it to gold standard invasive x-ray coronary angiography in patients with CAD.METHODS: Consecutive patients referred for CMR assessment were included to undergo iNAV CMRA on a 1.5 T scanner. Coronary vessel sharpness and a visual score were assigned to the coronary arteries. A diagnostic reading was performed on the iNAV CMRA data, where a lumen narrowing >50% was considered diseased. This was compared to invasive x-ray findings.RESULTS: Image-navigated CMRA was performed in 31 patients (77% male, 56 ± 14 years). The iNAV CMRA scan time was 7 min:21 s ± 0 min:28 s. Out of a possible 279 coronary segments, 26 segments were excluded from analysis due to stents or diameter less than 1.5 mm, resulting in a total of 253 coronary segments. Diagnostic image quality was obtained for 98% of proximal coronary segments, 94% of middle segments, and 91% of distal coronary segments. The sensitivity and specificity was 86% and 83% per patient, 80% and 92% per vessel and 73% and 95% per segment.CONCLUSION: In this study, iNAV CMRA offered a very good diagnostic performance when compared against invasive x-ray angiography. Due to the short and predictable scan time it can add clinical value as a part of a comprehensive CAD assessment protocol.

BACKGROUND: Pulse wave velocity (PWV) is a biomarker for the intrinsic stiffness of the aortic wall, and has been shown to be predictive for cardiovascular events. It can be assessed using cardiovascular magnetic resonance (CMR) from the delay between phase-contrast flow waveforms at two or more locations in the aorta, and the distance on CMR images between those locations. This study aimed to investigate the impact of different distance measurement methods on PWV. We present and evaluate an algorithm for automated centreline tracking in 3D images, and compare PWV calculations using distances derived from 3D images to those obtained from a conventional 2D oblique-sagittal image of the aorta.METHODS: We included 35 patients from a twin cohort, and 20 post-coarctation repair patients. Phase-contrast flow was acquired in the ascending, descending and diaphragmatic aorta. A 3D centreline tracking algorithm is presented and evaluated on a subset of 30 subjects, on three CMR sequences: balanced steady-state free precession (SSFP), black-blood double inversion recovery turbo spin echo, and contrast-enhanced CMR angiography. Aortic lengths are subsequently compared between measurements from a 2D oblique-sagittal plane, and a 3D geometry.RESULTS: The error in length of automated 3D centreline tracking compared with manual annotations ranged from 2.4 [1.8-4.3] mm (mean [IQR], black-blood) to 6.4 [4.7-8.9] mm (SSFP). The impact on PWV was below 0.5m/s (CONCLUSIONS: Automatic aortic centreline tracking in three commonly used CMR sequences is possible with good accuracy. The 3D length obtained from such sequences can differ considerably from lengths obtained from a 2D oblique-sagittal plane, depending on aortic curvature, adequate planning of the oblique-sagittal plane, and patient motion between acquisitions. For accurate PWV measurements we recommend using 3D centrelines.

Three-dimensional (3D) whole heart techniques form a cornerstone in cardiovascular magnetic resonance imaging of congenital heart disease (CHD). It offers significant advantages over other CHD imaging modalities and techniques: no ionizing radiation; ability to be run free-breathing; ECG-gated dual-phase imaging for accurate measurements and tissue properties estimation; and higher signal-to-noise ratio and isotropic voxel resolution for multiplanar reformatting assessment. However, there are limitations, such as potentially long acquisition times with image quality degradation. Recent advances in and current applications of 3D whole heart imaging in CHD are detailed, as well as future directions.

Coronary artery stent thrombosis is an uncommon but potentially catastrophic complication. The risk of very late stent thrombosis (VLST) raises important safety issues regarding the first generation of drug-eluting stents (DES). Although several complex mechanisms for VLST have been suggested and various predictors have been described, its pathophysiology is not completely understood and it is not known whether longer-term dual antiplatelet therapy reduces the risk. We present a rare case of simultaneous very late DES thrombosis in the three vascular territories, following discontinuation of antiplatelet therapy seven years after stent placement, presenting as cardiogenic shock. Resumo: A trombose de stent coronário é uma complicação rara mas potencialmente catastrófica. O risco de trombose muito tardia de stent (TMTS) tem levantado questões importantes sobre a segurança do uso de stents revestidos com fármacos (SRF) de primeira geração. Embora sejam vários e complexos os mecanismos da TMTS e vários os preditores que têm sido descritos, a sua fisiopatologia ainda não está totalmente esclarecida e desconhece-se se o prolongar da terapêutica antiagregante dupla reduz esse risco. Descrevemos um caso raro de trombose muito tardia de SRF ocorrendo em simultâneo nos três territórios vasculares, após interrupção da terapêutica antiagregante, sete anos após implantação dos stents, apresentando-se como choque cardiogénico. Keywords: Very late stent thrombosis, Drug-eluting stents, Palavras-chave: Trombose muito tardia de stent, Stents revestidos

Background Left atrium (LA) size and function are powerful biomarkers of cardiovascular outcomes in many diseases. We sought to determine if the expected age-associated increase in arterial stiffness (AS) and left ventricular (LV)-LA afterload leads to corresponding effects on LA function and this can be measured with cardiovascular magnetic resonance (CMR). Additionally, we investigated the significance of these markers in asymptomatic individuals with cardiovascular risk factors (CRF).

Resumo: As anomalias coronárias congénitas são uma das causas de isquemia miocárdica e morte súbita em jovens, principalmente durante a prática desportiva. A origem da artéria coronária direita na descendente anterior é muito rara, com uma prevalência de 0,015% e correspondendo a 1,2% das anomalias coronárias congénitas. Os autores apresentam o caso clínico de um homem de 22 anos, consumidor de cocaína, internado por enfarte agudo do miocárdio sem supradesnivelamento de ST. O cateterismo mostrou a presença desta anomalia coronária rara e a ausência de lesões ateroscleróticas luminais, pelo que se assumiu tratar-se de um enfarte agudo do miocárdio tipo II secundário a vasospasmo do vaso anómalo induzido pela cocaína. Abstract: Congenital coronary artery anomalies are one of the causes of myocardial ischemia and sudden death in the young, mainly during sports. Origin of the right coronary artery from the left anterior descending artery is very rare, with a prevalence of 0.015%, corresponding to 1.2% of all coronary artery anomalies. The authors present the case of a 22-year-old man, with a history of cocaine use, admitted to hospital with a non-ST elevation acute myocardial infarction. Coronary angiography revealed the presence of this rare coronary anomaly and the absence of atherosclerotic luminal stenosis, and so it was assumed to be a type II infarction caused by cocaine-induced vasospasm of the anomalous vessel. Palavras-chave: Coronárias, Congénito, Enfarte, Cocaína, Keywords: Coronary, Congenital, Infarction, Cocaine

CAV remains one of the main limiting factors for survival in children after heart transplantation. In this study, we explored the incremental value of routine CMR for evaluation and detection of CAV using qualitative and quantitative analysis of regional and global myocardial function and strain. This was a prospective imaging biomarker validation trial. Twenty-two patients (11 male), aged between 10 and 17 years (median 14 years) post-heart transplantation, were prospectively enrolled and underwent CMR in addition to their biennial review workup with Echo, angiography, and IVUS. Nine healthy control patients were enrolled to undergo CMR alone. Echo was used to analyze WMAs and systolic function. CMR images were analyzed qualitatively for RWMA and quantitatively for volumetric analysis, S and SR. All results were compared to IVUS and angiography assessments. Qualitatively, CMR detected RWMA corresponding to angiographic disease in 3 patients that were not detected on Echo. However, quantitative strain analysis suggested RWMA in an extra 9 patients. Detection of regional wall motion abnormality using quantitative strain analysis was associated with a higher mean stenosis grade (P=.04) and reduced graft survival (P=.04) compared to those with no quantitative wall motion abnormality. Overall, only longitudinal stain was abnormal in patients compared with controls, but there was no correlation between any of the global indices of S or SR and IVUS measurements. CMR is more sensitive than Echo for the visual detection of significant WMAs. Quantitative CMR strain analysis at rest may give additional information to discriminate those at greatest risk.

Neuromediated stunned myocardium is a well-known complication of subarachnoid hemorrhage but has rarely been reported in association with other central nervous system disorders. The pathophysiology of this entity remains unclear, but a catecholamine-induced neurocardiogenic injury has been proposed as a causal factor. Typically, patients have rapid full cardiovascular recovery within a few days. We report a case of ischemic stroke, coexisting with ischemic electrocardiographic changes, increased cardiac-specific necrosis biomarkers, regional wall motion abnormalities and a cardiac SPECT consistent with inferior myocardial infarction despite normal coronary arteries. Interestingly, left-ventricular dysfunction in this case persisted longer than usually described despite full neurologic recovery. This case also illustrates the diagnostic challenges posed by this entity which frequently mimics acute myocardial infarction and emphasizes the investigation needed in this area.

A 42-year-old man presented to his local hospital with sepsis. He was cyanotic and had finger clubbing with oxygen saturation of 85% to 90%. A computed tomographic pulmonary angiogram led to an initial diagnosis of left-sided superior vena cava and partial anomalous pulmonary venous drainage. He had been generally well but always had limited exercise capacity (New York Heart Association class 2) and mild cyanosis and finger clubbing had been noted previously but had never been investigated. He was reviewed at an adult congenital center, and his symptoms were thought to be inconsistent with partial anomalous pulmonary venous drainage and left-sided superior vena cava. An echocardiogram raised suspicion for abnormal drainage of the SVC, and bubble echocardiography showed early and complete opacification of the left atrium and left ventricle after contrast injection in the left arm. There was late but significant filling of the right atrium and right ventricle, but this was less dense, signifying a right to left shunt. A cardiac magnetic resonance imaging demonstrated complete occlusion of the right SVC (Figure [A]). The brachiocephalic vein and other head and neck veins drained via tortuous venous collaterals to the left upper and right upper pulmonary veins (Figure [B]; …

This article proposes a schema for meta‐information about MARC that can express at a fairly comprehensive level the syntactic and semantic aspects of MARC formats in XML, including not only rules but also all texts and examples that are conveyed by MARC documentation. It can be thought of as an XML version of the MARC or UNIMARC manuals, for both machine and human usage. The article explains how such a schema can be the central piece of a more complete framework, to be used in conjunction with “slim” record formats, providing a rich environment for the automated processing of bibliographic data.

A 72-year-old man was admitted to the local hospital with non-ST elevation myocardial infarction. In the first 24 hours, a new onset apical murmur was heard. Transthoracic and transesophageal echocardiography showed interventricular septal (IVS) rupture and dissection of the right ventricle (RV) wall forming an echolucent pseudocavity that partially occupied the RV and communicated with the true RV cavity. Multislice computed tomography characterized in detail the IVS and RV wall dissection, and further showed the right coronary artery in the outer border of the RV and pseudocavity, excluding pericardial fluid. Despite surgical correction, progression to cardiogenic shock and death occurred 33 days after admission. (Echocardiography 2012;29:E112-E114)

(0.91 cm 2 and 0.94 cm 2 respectively, p = 0.17), and significantly higher during SE (1.1 cm 2 ) compared to both RE and CMR (p < 0.001 and p = 0.002, respectively). Differences in AVA between the modalities after stratification by EF and by flow rate are presented in table 1 and table 2, respectively. In patients with low EF, although higher by CMR, there was no significant difference in AVA when compared to RE. In low EF, AVA was similar between SE and CMR. However, in the presence of low flow rate, CMR AVA was significantly higher than RE AVA, but similar to SE AVA. In preserved EF and normal flow rate groups, there were no significant differences between RE and CMR AVA - however, SE AVA remained significantly higher than CMR AVA.

Intramyocardial dissecting haematoma (IDH) is a rare complication of myocardial infarction, with very scarce reports in medical literature. Before the advent of non-invasive imaging techniques, the diagnosis of IDH was only made by necropsy. It can develop in the left ventricular free wall, the right ventricle, or the interventricular septum. We present a case of a patient with an IDH after acute anterolateral myocardial infarction, focusing on the utility of echocardiography in the diagnosis and follow-up of this unusual complication. By this imaging modality, it was possible to see the various acoustic densities of the progressive clotting of the intramyocardial haematoma, its extension through the haemorrhagic dissection, as well as its independency in relation to ventricular cavities and extracardiac space by confirming intact epicardial and endocardial layers. Based on this report, we believe that serial two-dimensional echocardiography, added, when necessary, by the use of contrast agents is the non-invasive method ideally suited to confirm the diagnosis and monitor its evolution at the patient's bedside.

The titingene ( TTN ) is a major determinant of myocardial function, its importance in both familial and ‘idiopathic’ Dilated Cardiomyopathy (DCM) has recently been ascertained. In some instances a second genetic mutation or a physiological perturbation (e.g. pregnancy) may reveal otherwise latent TTN mutation effects. We hypothesise that patients with pronounced LV dysfunction following MI, when controlling for infarct parameters and coronary anatomy, may have a high burden of TTN truncating variants (TTNtvs). We studied a large cohort of post-MI patients prospectively recruited at the Royal Brompton and Harefield NHS Foundation Trust. Gadolinium-enhanced Cardiac Magnetic Resonance was used to characterise cardiac dimensions, function and tissue properties. The size and thickness of MI, wall motion and number of hibernating segments were quantified by two experts blinded to genotype using a standard 17-segment model. Targeted re-sequencing of TTN and other key DCM genes was performed. Genetic variation in DCM genes in 530ethnically matchedhealthy volunteers along with public repositories was used for variant annotation and comparison. Our initial analyses show that out of the 336 post-MI patients, nine (2.7%) had a TTNtv. As hypothesised, TTNtv were significantly enriched in patients with LV ejection fraction (LVEF) TTNtv , in post-MI systolic dysfunction. Based on these findings it will be important to explore if genetic stratification of the post-MI patient can inform medical or revascularisation strategies.

Submitted by José Pereira (jro.pereira@gmail.com) on 2014-11-04T16:34:28Z No. of bitstreams: 1 Pulmonary embolism with thromboembolus in transit.pdf: 480541 bytes, checksum: 591f6b98a53d7a1cb0a79708ada69017 (MD5) Made available in DSpace on 2014-11-04T16:34:28Z (GMT). No. of bitstreams: 1 Pulmonary embolism with thromboembolus in transit.pdf: 480541 bytes, checksum: 591f6b98a53d7a1cb0a79708ada69017 (MD5) Previous issue date: 2013

A 76-year-old woman was admitted to the emergency department with a squeezing severe chest pain starting at rest, 1h before. Previous medical history was unremarkable. An electrocardiogram showed rapidly evolving ST-segment changes ( Panels A–C ). The rapid troponin I assay was positive (1.4 ng/mL). Unknown renal dysfunction was also noted (creatinine of 1.7 mg/dL). Apical akinesia was present on bedside echocardiogram (TEE). Urgent coronary angiography due to unremitting chest pain and hypotension excluded obstructive coronary disease. Ventriculography showed a striking pattern of apical akinesia ( Panels D and E …

Cardiac metastases from testicular tumors are rare. We report a case of a 42-year-old man with a cardiac mass incidentally found in a computed tomography-scan included in the workup for lumbago and a suspicious neoformation in the right testicle. Transthoracic echocardiography showed a large multilobular ill-defined mass infiltrating the right ventricle free wall, protruding to, and partially obstructing the right ventricular outflow tract resulting in considerable outflow obstruction. Cardiac magnetic resonance imaging favored a malignant nature, which was confirmed by marked regression of the tumor mass with chemotherapy and anatomopathologic study.

Submitted by José Pereira (jro.pereira@gmail.com) on 2014-11-04T16:53:27Z No. of bitstreams: 1 Coronary artery fistula.pdf: 959694 bytes, checksum: c123b0684f099977d231e1c557e4a1bd (MD5) Made available in DSpace on 2014-11-04T16:53:27Z (GMT). No. of bitstreams: 1 Coronary artery fistula.pdf: 959694 bytes, checksum: c123b0684f099977d231e1c557e4a1bd (MD5) Previous issue date: 2013

A 72-year-old man was admitted to the local hospital with non-ST elevation myocardial infarction. In the first 24 hours, a new onset apical murmur was heard. Transthoracic and transesophageal echocardiography showed interventricular septal (IVS) rupture and dissection of the right ventricle (RV) wall forming an echolucent pseudocavity that partially occupied the RV and communicated with the true RV cavity. Multislice computed tomography characterized in detail the IVS and RV wall dissection, and further showed the right coronary artery in the outer border of the RV and pseudocavity, excluding pericardial fluid. Despite surgical correction, progression to cardiogenic shock and death occurred 33 days after admission.