Incremental value of normal adenosine perfusion cardiac magnetic resonance: Long-term outcome.

BACKGROUND: The purpose of the study was to determine the long-term prognostic value of normal adenosine stress cardiac magnetic resonance imaging (CMR) in patients referred for evaluation of myocardial ischemia. METHODS: We reviewed 300 consecutive patients (age 65 ± 11 years, 74% male) with suspected or known coronary disease and normal wall motion who had undergone adenosine stress CMR negative for ischemia and scar. Most patients were at intermediate risk of coronary artery disease. The end points studied were all causes of mortality and major adverse cardiac events, including cardiac death, myocardial infarction, revascularization, and hospitalization for unstable angina. RESULTS: During a mean follow-up of 5.5 years (mean = 5.4 ± 1.1), 16 patients died because of various causes (cardiac death in 5 patients). Three patients had a nonfatal myocardial infarction, 7 patients were hospitalized for revascularization, and 11 were medically treated for unstable angina. The annual cardiac event rate was 1.3% (0.78% in the first 3 years and 1.9% between the fourth and sixth years). The predictors of major adverse cardiac events in a multivariate analysis model were as follows: advanced age (hazard ratio [HR] 1.15, 95% confidence interval [95% CI] 1.02-1.30), diabetes (HR 17.5, 95% CI 2.2-140), and the habit of smoking (HR 5.9, 95% CI 1.0-35.5). For all causes of mortality, the only predictor was diabetes (HR 11.4, 95% CI 1.76-74.2). Patients with normal stress CMR had an excellent outcome during the 3 years after the study. The cardiac event rate was higher between the fourth and sixth years. CONCLUSION: Over a 5.5-year period, a low event rate and excellent prognosis occurred in patients with normal adenosine stress CMR. Low- to intermediate-risk patients with a normal CMR are at low risk for subsequent cardiac events.

Endoventricular circular patch repair: the "Dor procedure".

Although during recent decades the prompt clinical management of myocardial infarction has significantly reduced the incidence of mechanical complications, post-infarction heart failure is still an open issue. The surgical ventricular reconstruction technique, also called the "Dor procedure", was introduced as a surgical strategy to reduce left ventricular volume and restore its shape and function by performing an endoventricular circular patch plasty. Although its use was not clearly beneficial, there is growing evidence from specialized centres suggesting its safety and efficacy, thus bringing this technique back to a leading role in the surgical armamentarium to treat patients with heart failure. The objective of this work was to present a step-by-step explanation of the Dor procedure as a landmark for all surgeons who want to perform it.

Contrast-enhanced magnetic resonance imaging guided decision making after primary percutaneous coronary intervention for acute ST-elevation inferior myocardial infarction.

Coronary occlusion of large epicardial branches leads to profound ischemia at the infarct core, resulting in simultaneous necrosis of myocytes and endothelial cells. This process leads to microvascular obstruction in the infarct core, described as the no-reflow region in basic studies and documented in humans by contrast-enhanced magnetic resonance imaging and ultrasound. After coronary occlusion, contrast-enhanced magnetic resonance identifies myocardial infarction as a hyperenhanced region containing a hypoenhanced core. There is growing interest in incorporating its assessment into the evaluation of acute myocardial infarction because it is the key in defining specific therapeutic strategies and in directing the interventional therapy. We report a rare case of right ventricular infarction where contrast-enhanced magnetic resonance produced detailed images of myocardial perfusion pattern and tissue damage and directed the treatment after acute myocardial infarction.

Quantitative assessment of primary mitral regurgitation using left ventricular volumes obtained with new automated three-dimensional transthoracic echocardiographic software: A comparison with 3-Tesla cardiac magnetic resonance.

BACKGROUND: Quantitative assessment of primary mitral regurgitation (MR) using left ventricular (LV) volumes obtained with three-dimensional transthoracic echocardiography (3D TTE) recently showed encouraging results. Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time consuming. AIMS: To investigate the accuracy and reproducibility of new automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for the quantification of LV volumes and MR severity in patients with isolated degenerative primary MR; and to compare regurgitant volume (RV) obtained with 3D TTE with a cardiac magnetic resonance (CMR) reference. METHODS: Fifty-three patients (37 men; mean age 64±12 years) with at least mild primary isolated MR, and having comprehensive 3D TTE and CMR studies within 24h, were eligible for inclusion. MR RV was calculated using the proximal isovelocity surface area (PISA) method and the volumetric method (total LV stroke volume minus aortic stroke volume) with either CMR or 3D TTE. RESULTS: Inter- and intraobserver reproducibility of 3D TTE was excellent (coefficient of variation≤10%) for LV volumes. MR RV was similar using CMR and 3D TTE (57±23mL vs 56±28mL; P=0.22), but was significantly higher using the PISA method (69±30mL; P<0.05 compared with CMR and 3D TTE). The PISA method consistently overestimated MR RV compared with CMR (bias 12±21mL), while no significant bias was found between 3D TTE and CMR (bias 2±14mL). Concordance between echocardiography and CMR was higher using 3D TTE MR grading (intraclass correlation coefficient [ICC]=0.89) than with PISA MR grading (ICC=0.78). Complete agreement with CMR grading was more frequent with 3D TTE than with the PISA method (76% vs 63%). CONCLUSION: 3D TTE RV assessment using the new generation of automated software correlates well with CMR in patients with isolated degenerative primary MR.

Performance of new automated transthoracic three-dimensional echocardiographic software for left ventricular volumes and function assessment in routine clinical practice: Comparison with 3 Tesla cardiac magnetic resonance.

BACKGROUND: Three-dimensional (3D) transthoracic echocardiography (TTE) is superior to two-dimensional Simpson's method for assessment of left ventricular (LV) volumes and LV ejection fraction (LVEF). Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time-consuming. AIMS: To evaluate the feasibility, accuracy and reproducibility of new fully automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for quantification of LV volumes and LVEF in routine practice; to compare the 3D LV volumes and LVEF obtained with a cardiac magnetic resonance (CMR) reference; and to optimize automated default border settings with CMR as reference. METHODS: Sixty-three consecutive patients, who had comprehensive 3D TTE and CMR examinations within 24hours, were eligible for inclusion. Nine patients (14%) were excluded because of insufficient echogenicity in the 3D TTE. Thus, 54 patients (40 men; mean age 63±13 years) were prospectively included into the study. RESULTS: The inter- and intraobserver reproducibilities of 3D TTE were excellent (coefficient of variation<10%) for end-diastolic volume (EDV), end-systolic volume (ESV) and LVEF. Despite a slight underestimation of EDV using 3D TTE compared with CMR (bias=-22±34mL; P<0.0001), a significant correlation was found between the two measurements (r=0.93; P=0.0001). Enlarging default border detection settings leads to frequent volume overestimation in the general population, but improved agreement with CMR in patients with LVEF≤50%. Correlations between 3D TTE and CMR for ESV and LVEF were excellent (r=0.93 and r=0.91, respectively; P<0.0001). CONCLUSION: 3D TTE using new-generation fully automated software is a feasible, fast, reproducible and accurate imaging modality for LV volumetric quantification in routine practice. Optimization of border detection settings may increase agreement with CMR for EDV assessment in dilated ventricles.

Usefulness of 3-Tesla cardiac magnetic resonance imaging in the assessment of aortic stenosis severity in routine clinical practice.

BACKGROUND: Recently, 1.5-Tesla cardiac magnetic resonance imaging (CMR) was reported to provide a reliable alternative to transthoracic echocardiography (TTE) for the quantification of aortic stenosis (AS) severity. Few data are available using higher magnetic field strength MRI systems in this context. AIMS: To evaluate the feasibility and reproducibility of the assessment of aortic valve area (AVA) using 3-Tesla CMR in routine clinical practice, and to assess concordance between TTE and CMR for the estimation of AS severity. METHODS: Ninety-one consecutive patients (60 men; mean age 74±10years) with known AS documented by TTE were included prospectively in the study. RESULTS: All patients underwent comprehensive TTE and CMR examination, including AVA estimation using the TTE continuity equation (0.81±0.18cm2), direct CMR planimetry (CMRp) (0.90±0.22cm2) and CMR using Hakki's formula (CMRhk), a simplified Gorlin formula (0.70±0.19cm2). Although significant agreement with TTE was found for CMRp (r=0.72) and CMRhk (r=0.66), CMRp slightly overestimated (bias=0.11±0.18cm2) and CMRhk slightly underestimated (bias=-0.11±0.17cm2) AVA compared with TTE. Inter- and intraobserver reproducibilities of CMR measurements were excellent (r=0.72 and r=0.74 for CMRp and r=0.88 and r=0.92 for peak aortic velocity, respectively). CONCLUSION: 3-Tesla CMR is a feasible, radiation-free, reproducible imaging modality for the estimation of severity of AS in routine practice, knowing that CMRp tends to overestimate AVA and CMRhk to underestimate AVA compared with TTE.

Surgical ventricular restoration improves mechanical intraventricular dyssynchrony in ischemic cardiomyopathy.

BACKGROUND: In ischemic cardiomyopathy, dyssynchrony of left ventricular (LV) mechanical contraction produces adverse hemodynamic consequences. This study tests the capacity of geometric rebuilding by surgical ventricular restoration (SVR) to restore a more synchronous contractile pattern after a mechanical, rather than electrical, intervention. METHODS AND RESULTS: A prospective study of the global and regional components of dyssynchrony was conducted in 30 patients (58+/-8 years of age) undergoing SVR at the Cardiothoracic Center of Monaco. The protocol used simultaneous measurements of ventricular volumes and pressure to construct pressure/volume (P/V) and pressure/length (P/L) loops. Angiograms were done before and after SVR to study a 600-ms cycle during atrial pacing at 100 bpm. Mean QRS duration was similar, at 100+/-17 ms preoperatively and 114+/-28 ms postoperatively (NS). Preoperative LV contraction was highly asynchronous, because P/V loops showed abnormal isometric phases with a right shifting. Endocardial time motion was either early or delayed at the end-systolic phase so that P/L loops were markedly abnormal in size, shape, and orientation. Postoperatively, SVR resulted in leftward shifting of P/V loops and increased area; endocardial time motion and P/L loops almost normalized to allow a better contribution of single regions to global ejection. The hemodynamic consequences of SVR were improved ejection fraction (30+/-13% to 45+/-12%; P=0.001); reduced end-diastolic and end-systolic volume index (202+/-76 to 122+/-48 and 144+/-69 to 69+/-40 mL/m(2); P=0.001); more rapid peak filling rate (1.75+/-0.7 to 2.32+/-0.7 EDV/s; P=0.0001); peak ejection rate (1.7+/-0.7 to 2.6+/-0.9 Sv/s; P=0.0002), and mechanical efficiency (0.56+/-0.15 to 0.65+/-0.18; P=0.04). CONCLUSIONS: SVR produces a mechanical intraventricular resynchronization that improves LV performance.

Surgical ventricular restoration in the treatment of congestive heart failure due to post-infarction ventricular dilation.

OBJECTIVES: The purpose of this study was to test how surgical ventricular restoration (SVR) affects early and late survival in a registry of 1,198 post-anterior infarction congestive heart failure (CHF) patients treated by the international Reconstructive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ventricle (RESTORE)team. BACKGROUND: Congestive heart failure may be caused by late left ventricular (LV) dilation after anterior infarction. The infarcted segment is often akinetic rather than dyskinetic because early reperfusion prevents transmural necrosis. Previously, only dyskinetic areas were treated by operation. Surgical ventricular restoration reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. METHODS: The RESTORE group applied SVR to 1,198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined, and risk factors were identified. RESULTS: Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair; p < 0.001). Perioperative mechanical support was uncommon (<9%). Global systolic function improved postoperatively. Ejection fraction (EF) increased from 29.6 +/- 11.0% preoperatively to 39.5 +/- 12.3% postoperatively (p < 0.001). The left ventricular end-systolic volume index (LVESVI) decreased from 80.4 +/- 51.4 ml/m(2) preoperatively to 56.6 +/- 34.3 ml/m(2) postoperatively (p < 0.001). Overall five-year survival was 68.6 +/- 2.8%. Logistic regression analysis identified EF or=80 ml/m(2), advanced New York Heart Association (NYHA) functional class, and age >or=75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were NYHA functional class III or IV and postoperatively, 85% were class I or II. CONCLUSIONS: Surgical ventricular restoration improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent five-year outcome.

Surgical remodeling of left ventricle.

In the future, we can certainly expect better assessment of myocardial wall, LV morphology, and performance, with careful approach and analysis of CMR allowing us to check exactly the morphology and volume performances of the LV, and chiefly the wall itself (Fig. 6). Perhaps it will be possible to have a hope of recovery for dilated but nonscarred myocardium, through a combination of currently existing surgical treatment (LVR + myocardial revascularization + mitral repair) and new techniques such as LVAD in appraisal, to help the nondiseased and tired myocardium, and suppress the immune or the autogenous hormonal reaction and let antagonist drugs be efficient. Analysis of some results published by the Berlin Heart Center in Berlin, Germany and others from Magdi Yacoub, MD (personal communication, 2002) showed improvement in LV wall thickness and contraction after months of left ventricular assistance, allowing weaning the idiopathic cardiomyopathy patient from assistance (bridge to recovery). Similar management may be possible in ischemic cardiomyopathy, where the LV wall is not uniformly diseased--one part is a scar and one part is dilated with living perfused myocardium. The synthesis of surgery (LVR) for the scarred area and medical treatment and mechanical support for the dilated portion can become the future method to treat severe end-stage ischemic congestive heart failure. The potential of adding cellular therapy to stimulate growth in the viable distended myocardium is perhaps a further promising complement of this treatment.

Favorable effects of left ventricular reconstruction in patients excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial.

OBJECTIVE: We sought to examine the hemodynamic effects at 1 month and 1 year of left ventricular reconstruction by means of endoventricular patch plasty for patients with acute or chronic, very severe post-myocardial infarction heart failure who would have been systematically excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial. METHODS: From 2002 to May 2008, 274 patients underwent left ventricular reconstruction for post-myocardial infarction scarring; 117 of these patients would not have been eligible for the STICH trial. The pertinent criteria for exclusion included 12 patients with no coronary vessel suitable for coronary artery bypass grafting; 17 patients within a month of myocardial infarction, including 11 with acute heart failure (8 septal ruptures and 3 cases of ventricular tachycardia); 48 patients receiving intravenous inotropes, intra-aortic balloon pumping, or both; 15 patients with bifocal or posterior scarring; 4 patients scheduled for heart transplantation; and 21 patients meeting 5 other exclusion criteria. These patients (mean age, 64 years; age range, 34-83 years) preoperatively had a mean 49% (range, 35%-75%) scarred left ventricular circumference, as determined by means of magnetic resonance imaging assessment. In the patients with chronic heart failure, the preoperative ejection fraction was 26% ± 4% (range, 9%-34%), the end-diastolic volume index was 130 ± 43 mL/m(2) (range, 62-343 mL/m(2)), and the end-systolic volume index was 95 ± 37 mL/m(2) (range, 45-289 mL/m(2)). Mitral regurgitation was mild to severe in 56 patients and associated with annular dilatation (≥35 mm) in 51 patients. A strategy of left ventricular reconstruction by means of endoventricular circular suturing and patching excluded the scarred left ventricular wall and was balloon sized to provide a diastolic volume of 50 mL/m(2). Circular patches were used for anteroseptoapical lesions, and triangular patches were used for posterior lesions. The mitral valve was repaired in 51 patients, and coronary revascularization was performed in 105 patients (arterial grafts in 95 and mixed in 12). Seventy-eight patients had endocardectomy, and cryotherapy was used in 39 patients for ventricular tachycardia. RESULTS: Four in-hospital and 2 delayed deaths occurred during the first year. In 101 patients with chronic heart failure, magnetic resonance imaging revealed that ejection fraction improved from 26% ± 4% preoperatively to 40% ± 8% at 1 month and 44% ± 11% at 1 year postoperatively. At these same time points, the end-diastolic volume index was reduced from 130 ± 43 mL/m(2) to 81 ± 27 and 82 ± 25 mL/m(2), respectively, and the end-systolic volume index was reduced from 96 ± 45 mL/m(2) to 50 ± 21 and 47 ± 20 mL/m(2), respectively. CONCLUSIONS: With minimal associated mortality, left ventricular reconstruction produces durable improvement in left ventricular function in patients with a large scarred ventricular wall. Considering that this patient cohort would have been systematically excluded from the STICH trial, care should be taken not to extrapolate that study's results too widely so as to inappropriately deny selected patients an effective treatment for ischemic cardiomyopathies with an injured ventricle.

Long-term follow-up of patients with first-time chest pain having 64-slice computed tomography.

A paucity of data on outcome of coronary multislice computed tomography (CT) is available. The aim of this study was to assess the long-term follow-up of 64-slice CT in a homogenous patient group. In total 222 patients (136 men, 61%, 59 ± 11 years of age) with chest pain at intermediate risk of coronary artery disease (CAD) and no previous CAD underwent 64-slice CT. Coronary lesions were considered significant or not based on a threshold of 50% luminal narrowing. Plaques were classified as calcified, noncalcified, and mixed based on type. End point during follow-up was major adverse cardiac events (nonfatal myocardial infarction, unstable angina requiring hospitalization, myocardial revascularization). Coronary plaques were detected in 162 patients (73%). Coronary artery stenosis was significant in 62 patients. Normal arteries were found in 59 patients (27%). During a mean follow-up of 5 ± 0.5 years, 30 cardiac events occurred. Annualized event rates were 0% in patients with normal coronary arteries, 1.2% in patients with nonsignificant stenosis, and 4.2% in patients with significant stenosis (p <0.01). Predictors of cardiac events were presence of significant stenosis, proximal stenosis, and multivessel disease. Noncalcified and mixed plaques had the worse prognosis (p <0.05). In conclusion, 64-CT provides long-term incremental value in patients at intermediate risk of CAD.

Tumor thrombus in right atrium from lung adenocarcinoma.

We report a case referred for elective surgery to remove an intra-atrial extension of a tumor thrombus. The patient underwent surgical excision of the mass because he would have a high risk of sudden death, pulmonary embolism, or tricuspid obstruction. A histologic examination established the diagnosis of lung adenocarcinoma metastases.