BackgroundPreliminary semi-quantitative cardiovascular magnetic resonance (CMR) perfusion studies have demonstrated reduced myocardial perfusion reserve (MPR) in patients with angina and risk factors for microvascular disease (MVD), however fully quantitative CMR has not been studied. The purpose of this study is to evaluate whether fully quantitative CMR identifies reduced MPR in this population, and to investigate the relationship between epicardial atherosclerosis, left ventricular hypertrophy (LVH), extracellular volume (ECV), and perfusion.MethodsForty-six patients with typical angina and risk factors for MVD (females, or males with diabetes or metabolic syndrome) who had no obstructive coronary artery disease by coronary angiography and 20 healthy control subjects underwent regadenoson stress CMR perfusion imaging using a dual-sequence quantitative spiral pulse sequence to quantify MPR. Subjects also underwent T1 mapping to quantify ECV, and computed tomographic (CT) coronary calcium scoring to assess atherosclerosis burden.ResultsIn patients with risk factors for MVD, both MPR (2.21 [1.95,2.69] vs. 2.93 [2.763.19], p < 0.001) and stress myocardial perfusion (2.65 ± 0.62 ml/min/g, vs. 3.17 ± 0.49 ml/min/g p < 0.002) were reduced as compared to controls. These differences remained after adjusting for age, left ventricular (LV) mass, body mass index (BMI), and gender. There were no differences in native T1 or ECV between subjects and controls.ConclusionsStress myocardial perfusion and MPR as measured by fully quantitative CMR perfusion imaging are reduced in subjects with risk factors for MVD with no obstructive CAD as compared to healthy controls. Neither myocardial hypertrophy nor fibrosis accounts for these differences.Electronic supplementary materialThe online version of this article (10.1186/s12968-018-0435-1) contains supplementary material, which is available to authorized users.

Dr. Ellis has disclosed speaking, teaching, consulting, or serving on an advisory committee for Medtronic.

The timing and incidence of carotid disease progression depends on the definition of disease progression. Among all three criteria, only severity of disease at initial presentation reliably predicted progression. Based on the results of our ROC curve analysis, we propose that an initial ICA PSV ≥165 cm/s (sensitivity: 90.7%, specificity: 58.7%) represents a reasonable value for defining high progression risk over a 2-year interval.

Methods: Participants underwent a 1.5-day course covering open and endovascular procedures on high-fidelity simulators and cadavers. Before and after the course, participants completed a written test that assessed procedural knowledge concerning index open vascular and endovascular procedures. Participants also assessed their own procedural competence in both open and endovascular procedures on a 5-point Likert scale (1: no ability to perform, 5: performs independently). Postcourse and precourse scores were compared among postgraduate year (PGY) 1 and 2 and PGY 3 to 7 trainees. Participants used a survey to rate the relevance and realism of open and endovascular simulations.Results: Twenty-four vascular integrated residents and vascular fellows (PGY1-7) completed the course and all assessments. After course participation, procedural knowledge scores were significantly improved among PGY1-2 residents (precourse: 51% correct vs postcourse: 63%; P ¼ .002) but not among PGY3-7 residents (precourse: 62% correct vs postcourse: 67%; P ¼ .2). Self-rated procedural competence was significantly improved between PGY 1-2 (precourse: 2.5 6 .2 vs postcourse: 3.4 6 .2; P < .0001) and PGY 3-7 (precourse: 3.2 6 .3 vs postcourse: 4.0 6 .2; P ¼ .003) participants. Self-rated procedural competence significantly improved for both endovascular (precourse: 2.3 6 .2 vs postcourse: 3.3 6 .1; P < .0001) and open procedures (precourse: 2.7 6 .2 vs postcourse: 3.6 6 .1; P ¼ .002). Greater than 90% of participants reported they were "satisfied" or "very satisfied" with the relevance and realism of both open and endovascular simulations. All participants reported they would recommend the course to other trainees.Conclusions: This intensive simulation and surgical skills course improved procedural knowledge concerning index open vascular and endovascular procedures among PGY 1-2 trainees and improved self-rated procedural competence across all levels of training for both open and endovascular procedures. Trainees rated the simulation experience highly. These data support the implementation of similar intensive simulation and surgical skills courses with ongoing objective assessment of their educational effect.

Background Diagnosis of fungal endocarditis can be challenging, especially among cases with negative blood culture results. Of fungal endocarditis cases, histoplasmosis capsulatum constitutes an even smaller proportion with approximately 58 prior cases reported. Due to the rarity of histoplasmosis endocarditis and thus limited data, there is no current diagnostic guideline for testing within culture negative infective endocarditis. Case summary Our patient was a 58-year-old female presenting with worsening dyspnoea, hypotension, and near-syncope. In this case report, we depict the clinical presentation and diagnosis of histoplasma capsulatum endocarditis in a female patient with a prosthetic aortic valve and negative blood cultures. We further demonstrate the rising risk of fungal endocarditis with use of external devices. Discussion Despite the rarity of fungal endocarditis, there has been a recent upward trend in infections given the rising use of external devices, greater number of immunocompromised patients, and rising rates of intravenous drug use (1–3). Recently, more cases of fungal endocarditis have been occurring in patients with prosthetic valves compared to native (4). Although histoplasmosis capsulatum constitutes a smaller proportion of fungal endocarditis cases, patients with appropriate risk factors and those who have been exposed to at-risk areas such as the Ohio and Mississippi River valleys, may benefit from further evaluation.