Combined Evaluation of ST-segment Elevation in lead AVR and ST-segment Depression in other Leads Enhances Prediction of in-hospital Cardiovascular Death in Patients with Non ST-segment Elevation Acute Coronary Syndrome

Objective: To investigate the prognostic significance of ST-segment elevation (STE) in aVR associated with ST-segment depression (STD) in other leads in patients with non-STE acute coronary syndrome (NSTE-ACS). Background: In NSTE-ACS patients, STD has been extensively associated with severe coronary lesions and poor outcomes. The prognostic role of STE in aVR is uncertain. Methods: We enrolled 888 consecutive patients with NSTE-ACS. They were divided into two groups according to the presence or not on admission ECG of aVR STE≥ 1mm and STD (defined as high risk ECG pattern). The primary and secondary endpoints were: in-hospital cardiovascular (CV) death and the rate of culprit left main disease (LMD). Results: Patients with high risk ECG pattern (n=121) disclosed a worse clinical profile compared to patients (n=575) without [median GRACE (Global-Registry-of-Acute-Coronary-Events) risk score =142 vs. 182, respectively]. A total of 75% of patients underwent coronary angiography. The rate of in-hospital CV death was 3.9%. On multivariable analysis patients who had the high risk ECG pattern showed an increased risk of CV death (OR=2.88, 95%CI 1.05-7.88) and culprit LMD (OR=4.67,95%CI 1.86-11.74) compared to patients who had not. The prognostic significance of the high risk ECG pattern was maintained even after adjustment for the GRACE risk score (OR = 2.28, 95%CI:1.06-4.93 and OR = 4.13, 95%CI:2.13-8.01, for primary and secondary endpoint, respectively). Conclusions: STE in aVR associated with STD in other leads predicts in-hospital CV death and culprit LMD. This pattern may add prognostic information in patients with NSTE-ACS on top of recommended scoring system.

Portal hypertension: a comparison between portal-venous pressure measurement and ARFI measurement of liver and spleen stiffness

PURPOSE. Portal pressure is measured invasively as Hepatic Venous Pressure Gradient (HVPG) in the angiography room. Liver stiffness measured by Fibroscan was shown to correlate with HVPG values below 12 mmHg. This is not surprising, since in cirrhosis the increase of portal pressure is not directly linked with liver fibrosis and consequently to liver stiffness. We hypothesized that, given the spleen’s privileged location upstream to the whole portal system, splenic stiffness could provide relevant information about portal pressure. Aim of the study was to assess the relationship between liver and spleen stiffness measured by Virtual Touch™ (ARFI) and HVPG in cirrhotic patients. METHODS. 40 consecutive patients (30 males, mean age 62y, mean BMI=26, mean Child-Pugh A6, mean platelet count=92.000/mmc, 19 HCV+, 7 with ascites) underwent to ARFI stiffness measurement (10 valid measurements in right liver lobe both surface and centre, left lobe and 20 in the spleen) and HPVG, blindly to each other. Median ARFI values of 10 samplings on every liver area and of 20 samplings on spleen were calculated. RESULTS. Stiffness could be easily measured in all patients with ARFI, resulting a mean of 2,61±0,76, 2,5±0,62 and 2,55±0,66 m/sec in the liver areas and 3.3±0,5 m/s in the spleen. Median HPVG was 14 mmHg (range 5-27); 28 patients showed values ≥10 mmHg. A positive significant correlation was found between spleen stiffness and HPVG values (r=0.744, p<0.001). No significant correlation was found between all liver stiffness and HVPG (p>0,05). AUROC was calculated to test spleen stiffness ability in discriminating patients with HVPG ≥10. AUROC = 0.911 was obtained, with sensitivity of 69% and specificity of 91% at a cut-off of 3.26 m/s. CONCLUSION. Spleen stiffness measurement with ARFI correlates with HVPG in patients with cirrhosis, with a potential of identifying patients with clinically significant portal hypertension.

Automated Segmentation and Non-Rigid Registration for the Quantitative Evaluation of Myocardial Perfusion from Magnetic Resonance Images

Myocardial perfusion quantification by means of Contrast-Enhanced Cardiac Magnetic Resonance images relies on time consuming frame-by-frame manual tracing of regions of interest. In this Thesis, a novel automated technique for myocardial segmentation and non-rigid registration as a basis for perfusion quantification is presented. The proposed technique is based on three steps: reference frame selection, myocardial segmentation and non-rigid registration. In the first step, the reference frame in which both endo- and epicardial segmentation will be performed is chosen. Endocardial segmentation is achieved by means of a statistical region-based level-set technique followed by a curvature-based regularization motion. Epicardial segmentation is achieved by means of an edge-based level-set technique followed again by a regularization motion. To take into account the changes in position, size and shape of myocardium throughout the sequence due to out of plane respiratory motion, a non-rigid registration algorithm is required. The proposed non-rigid registration scheme consists in a novel multiscale extension of the normalized cross-correlation algorithm in combination with level-set methods. The myocardium is then divided into standard segments. Contrast enhancement curves are computed measuring the mean pixel intensity of each segment over time, and perfusion indices are extracted from each curve. The overall approach has been tested on synthetic and real datasets. For validation purposes, the sequences have been manually traced by an experienced interpreter, and contrast enhancement curves as well as perfusion indices have been computed. Comparisons between automatically extracted and manually obtained contours and enhancement curves showed high inter-technique agreement. Comparisons of perfusion indices computed using both approaches against quantitative coronary angiography and visual interpretation demonstrated that the two technique have similar diagnostic accuracy. In conclusion, the proposed technique allows fast, automated and accurate measurement of intra-myocardial contrast dynamics, and may thus address the strong clinical need for quantitative evaluation of myocardial perfusion.

Anatomic study of the feline bronchial and vascular structures with a 64 detector-row computed tomography

Multidetector row computed tomography over the last decade is commonly used in veterinary medicine. This new technology has an increased spatial and temporal resolution, could evaluate wider scanning range in shorter scanning time, providing an advanced imaging modality. Computed tomography angiographic studies are commonly used in veterinary medicine in order to evaluate vascular structures of the abdomen and the thorax. Pulmonary pathology in feline patients is a very common condition and usually is further evaluating with computed tomography. Up to date few references of the normal computed tomographic aspects of the feline thorax are reported. In this study a computed tomographic pulmonary angiography (CTPA) protocol is reported in normal cats and is compared with the up to date anatomical references. A CTPA protocol using a 64 MDCT in our study achieved high resolution images of the pulmonary arteries, pulmonary veins and bronchial lumen till the level of minor segmental branches. Feline pulmonary bronchial parenchyma demonstrates an architecture of mixed type with a monopedial model observed in the most anatomical parts and the dichotomic aspect is seen at the accessory lobe. The arterial and venous architecture is similar to the bronchial. Statistical analysis demonstrates the linear correlation of tracheal diameter to the felines weight. Vascular variations were noticed. The pulmonary venous system enters into the left atrium through three ostia (left cranial ostia: consisted of the anastomosis of the cranial and caudal portion of the left cranial pulmonary vein; right ostia: consisted of the anastomosis of the right cranial and middle pulmonary vein; and the caudal ostia: consisted of the anastomosis of the right and left caudal pulmonary vein). In conclusion CTPA is applicable in feline patients and provides an excellent imaging of the pulmonary arterial, venous and bronchial system till the level of minor segmental branches.

The medical management after surgery for advanced heart failure

The aim of the Research of this Ph D Project is to improve the medical management after surgery for advanced heart failure, both after left ventricular assist devices (LVAD) implantation, and after heart transplantation in the long-term. Regarding heart transplantation (HTx), the Research Project is focused on diagnostics, classification, prevention and treatment of cardiac allograft vasculopathy (CAV), and on treatment of post-HTx cancers; the results are presented in the first part of this Thesis. In particular, the main aspect investigated are the prognostic role of information derived from coronary angiography, coronary tomography and intravascular ultrasound, and the different sensitivity of these techniques in predicting outcomes and in diagnosing CAV. Moreover, the role of mTOR inhibitors on CAV prevention or treatment is investigated, both alone and in combination with different anti-CMV prevention strategies, as well as the impact of mTOR inhibitors on clinical outcomes in the long term. Regarding LVAD, the main focus is on the role of transthoracic echocardiography in the management of patients with a continuous-flow, centrifugal, intrapericardial pump (HVAD, Heartware); this section is reported in the second part of this Thesis. The main aspects investigated are the use of echocardiography in patients with HVAD device and its interaction with the information derived from pump curves' analysis in predicting aortic valve opening status, a surrogate of the condition of support provided by the LVAD.