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De Lazzari, Manuel (2017) Role of cardiac magnetic resonance in clinic and arrhytmic prognostic risk assesment in non-ischemic heart diseases. [Ph.D. thesis]

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Abstract (english)

Currently, many diagnostic tools are available in the clinical arena helping physicians to achieve a diagnosis in non-ischemic heart diseases and now, the main issue is change into prognostic assessment both clinical and, above all, arrhythmic.
Cardiac magnetic resonance (CMR) has emerged as a clinically applicable and highly reproducible non-invasive imaging technique and so used extensively over the last years. Its value in term of diagnosis is well known and recently investigations are aimed at prognostic purposes and risk stratification. Many studies analyzed the impact of a scar as detected in vivo by contrast-CMR in hypertrophic cardiomyopathy in term of death and ventricular arrhythmias. The same concept was proved for dilated cardiomyopathy identifying a midwall stria as an adverse prognostic marker of cardiovascular death, arrhythmias and less robust marker of heart failure hospitalization. Junctional type of scar was investigated in hypertrophic cardiomyopathy and in right ventricle hypertrophy due to pulmonary artery hypertension, no data concerning its value in dilated cardiomyopathy are reported so far. This learning may be transferred into other kind of heart diseases.
Cardiac magnetic resonance tissue characterization doesn’t deal with scar only but also with myocardial tissue edema. Myocardial edema was been strongly studied in acute myocardial infarction in term of area at risk, savage myocardium and to detect hemorrhagic myocardial infarct, but prognostic data regarding other heart diseases are missing.
The aims of our studies were the followings:
1. to evaluate the presence and the prevalence of junctional LGE in patient with dilated cardiomyopathy, the possible relationship between junctional LGE and hemodynamic data and the prognostic significance of this pattern in terms of specific endpoints (arrhythmic and heart failure outcome) in opposite of other type of LGE. In order to investigate this hypothesis, data disclosed in the clinical studio have been proved by ex vivo studies.
2. To evaluate the relationship between myocardial edema as evidenced by CMR and electrocardiographic data (T-wave inversion) in a series of consecutive patients admitted for clinically suspected acute myocarditis. Moreover, to evaluate the prognostic value of T wave inversion (as myocardial edema marker) during the acute/subacute disease phase in predicting LV dysfunction during follow-up.
3. To evaluate the presence of a myocardial substrate underlying life-threatening arrhythmias in young adults with mitral valve prolapse. In order to investigate this hypothesis, data collected in the clinical studio have been proved by pathological (ex vivo) study.
4. Since the proof of the relationship between ventricular arrhythmias and scar in specific area of left ventricle in mitral valve patients, to evaluate the morphological features of mitral valve apparatus underling arrhythmic mitral valve prolapse with fibrosis. In order to confirm these observations, data disclosed by the clinical study have been related by ex vivo results in the pathologic study.

Abstract (italian)

Nella corrente pratica clinica, diversi strumenti diagnostici sono già a disposizione del clinico per aiutarlo nella diagnosi differenziale delle cardiopatie non ischemiche, attualmente però la principale sfida risiede nella capacità di stratificarne prognosticamente il rischio clinico e soprattutto aritmico. La risonanza magnetica cardiaca (RMC) si dimostrata una metodica di imaging non invasivo altamente riproducibile e applicabile nella corrente pratica clinica. La sua utilità nella diagnosi differenziale delle varie malattie cardiache è stata ampiamente validata tant'è che negli ultimi anni l'interesse scientifico si è rivolto a studiarne la valenza prognostica. Molti lavori scientifici hanno analizzato l'impatto di una cicatrice fibrosa evidenziata in vivo dalla RMC nella cardimiopatia ipertrofica sulla mortalità cardiaca. Nella cardiomiopatia dilatativa, la presenza di una stria di fibrosi intramurale si è dimostrata in grado di identificare quei pazienti a più alto rischio di morte cardiaca, di aritmie ventricolari maggiori e, in misura minore, di episodi di scompenso cardiaco. Il significato di una fibrosi giunzionale (ossia localizzata alla giunzione tra i due ventricoli) è stato oggetto di studio nei pazienti con cardiomiopatia ipertrofica e nei pazienti con ipertrofia ventricolare destra da ipertensione arteriosa polmonare, nessuno studio ne ha analizzato il valore nella cardiomiopatia dilatativa. La RMC non è in grado di evidenziare la presenza della sola fibrosi ma è in grado di identificare anche aree di edema miocardico. Se questo è già stato oggetto di numerosi studi nell'infarto miocardico acuto in termini di area a rischio, miocardio salvato e infarto emorragico, pochi invece sono i dati sul suo significato in altre cardiopatie.
Gli scopi dei nostri studi sono:
1. valutare la presenza e la prevalenza della fibrosi giunzionale nei pazienti con cardiopatia dilatativa, studiare un'eventuale relazione con i parametri emodinamici e indagare una sua possibile valenza prognostica sia in termini di instabilità aritmica che meccanica, dispetto gli altri tipo di fibrosi classicamente riscontrati in questi pazienti. Tali dati in-vivo sono inoltre stati confrontati con riscontri post mortem.
2. analizzare la relazione tra edema tissutale visto alla RMC e parametri elettrocardiografici (onde T negative) nei pazienti con diagnosi clinica di miocardite acuta e successivamente valutarne il valore prognostico in termini di disfunzione ventricolare a distanza.
3. valutare la presenza di un substrato anatomico alla base di aritmie ventricolari in pazienti con prolasso valvolare mitralico sia in vivo che ex vivo.
4. dimostrata nei pazienti con prolasso valvolare mitralico una associazione tra fibrosi in specifiche aree del ventricolo sinistro e la presenza di aritmie ventricolari, valutare eventuali caratteristiche dell'apparato valvolare mitralico che possano essere associate alla presenza di fibrosi. Tale studio in vivo è stato confrontato con un analogo studio ex vivo.

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EPrint type:Ph.D. thesis
Tutor:Perazzolo Marra, Martina
Ph.D. course:Ciclo 29 > Corsi 29 > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI
Data di deposito della tesi:31 January 2017
Anno di Pubblicazione:30 January 2017
Key Words:cardiac magnetic resonance, dilated cardiomyopathy, mitral valve prolapse, curling, junctional late gadolinium enhancement, myocardial edema, acute myocarditis.
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/11 Malattie dell'apparato cardiovascolare
Struttura di riferimento:Dipartimenti > Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari
Codice ID:10169
Depositato il:17 Nov 2017 09:24
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