Assessment of mitral apparatus in patients with acute inferoposterior myocardial infarction and ischaemic mitral regurgitation with two-dimensional echocardiography from anatomically correct imaging planes.

BACKGROUND: Ischaemic mitral regurgitation (IMR) is associated with adverse prognosis after myocardial infarction (MI) as a result of left ventricular remodelling and geometric deformation of the mitral apparatus (MA). AIM: The aim of this study was to assess MA from anatomically correct imaging planes in acute inferoposterior MI and IMR. METHODS: Ninety-three patients with no structural cardiac valve abnormalities and the first acute inferoposterior MI were prospectively enrolled into the study. Two-dimensional transthoracic echocardiography for MA assessment was performed within 48 h of presentation after reperfusion therapy. Based on the degree of mitral regurgitation (MR), patients were divided into either a no significant MR (NMR) group (n = 52 with no or mild, grade 0-I MR) or an IMR group (n = 41 with grade ≥ 2 MR). The control group consisted of 45 healthy individuals. RESULTS: Ischaemic MR was related with dilatation of the left ventricle chambers, decrease in ejection fraction, increase in mitral annulus diameter and area, and changes in subvalvular apparatus when compared with the NMR group or healthy individuals. CONCLUSIONS: Ischaemic MR in acute inferoposterior MI is related with worse lesions in MA geometry that cause insufficiency of mitral valve function.

Left atrial mechanics in patients with acute STEMI and secondary mitral regurgitation: A prospective pilot CMR feature tracking study.

BACKGROUND AND OBJECTIVE: Left atrium (LA) is an important biomarker of adverse cardiovascular outcomes and cerebrovascular events. This study aimed to evaluate LA myocardial deformation using cardiac magnetic resonance feature tracking (CMR-FT) in patients with acute ST-segment elevation myocardial infarction (STEMI) and secondary mitral regurgitation (MR). Additionally, to assess interobserver and intraobserver variability of the technique. MATERIALS AND METHODS: Twenty patients with STEMI underwent CMR with a 1.5Tesla MRI scanner. According to the presence of MR patients were divided into two groups: MR(+) and MR(-). Total LA strain (ɛs), passive LA strain (ɛe), and active LA strain (ɛa) were obtained. Additionally, total, passive and active strain rates (SRs, SRe, and SRa) were calculated. To assess interobserver agreement data analysis was performed by second independent observer. RESULTS: LA volumetric and functional parameters were similar in both groups. All LA strain values were significantly higher in patients with MR: ɛs (27.67±10.25 for MR(-) vs. 32.80±6.95 for MR(+); P=0.01), ɛe (15.29±7.30 for MR(-) vs. 19.22±6.04 for MR(+); P=0.01) and ɛa (12.38±4.23 for MR(-) vs. 14.44±5.19 for MR(+); P=0.03). Only SRe significantly increased in patients with MR (-0.57±0.24 for MR(-) vs. -0.70±0.20 for MR(+); P=0.01). All LA deformation parameters demonstrated high interobserver and intraobserver agreement. CONCLUSIONS: Conventional volumetric and functional LA parameters do not detect early changes in LA performance in patients with STEMI and secondary MR. In contrast, LA reservoir, passive and active strain are significantly higher in patients with MR. Only peak early negative strain rate substantially increases during secondary MR. LA deformation parameters derived from conventional cine images using CMR-FT technique are highly reproducible.

Comparison of the ipsi-lateral versus contra-lateral retrograde approach of percutaneous coronary interventions in chronic total occlusions.

BACKGROUND: Retrograde recanalization of coronary chronic total occlusions (CTO) via contralateral (CL) collateral connections (CCs) is successful in 60-70% of patients in whom conventional antegrade approach fails or is unpromising. This study describes our experience with retrograde CTO-PCI via ipsi-lateral (IL) CCs in patients with unfavorable CL CCs. METHODS: Between January 2013 and September 2015, 392 consecutive CTO procedures were performed by two high volume CTO-operators and the relevant data were fed into an online registry (ERCTO® EuroCTO-club). Most patients (222/392; 57%) were approached antegradely, whereas 43% were attempted retrogradely (170/392). After exclusion of all procedures performed via bypass-grafts (n = 12), PCI via CL CCs, the CL-group (n = 114/158; 72%), was compared with the IL-group that was attempted via IL CCs (n = 44/158; 28%). RESULTS: Both groups were similar with respect to risk factors and morphologic criteria of CTO-severity. The initial primary strategy was successful in 78% in the CL-group and in 68% in the IL-group. In both patient groups, the initial strategy had to be switched in five patients from CL toward IL (4.4%, n = 5/114) and from IL to CL (11.3% n = 5/44). The rate of major complications was 7% (CL) and 5% (IL), respectively (n.s.). After retrograde failure and cross-over to an antegrade controlled re-entry strategy the overall success rates increased to 92% (CL) and 93% (IL). CONCLUSIONS: In experienced hands retrograde CTO-PCI via IL CCs appears as safe and successful as the CL approach. © 2016 Wiley Periodicals, Inc.

Ionizing radiation exposure in interventional cardiology: current radiation protection practice of invasive cardiology operators in Lithuania.

Ionizing radiation management is among the most important safety issues in interventional cardiology. Multiple radiation protection measures allow the minimization of x-ray exposure during interventional procedures. Our purpose was to assess the utilization and effectiveness of radiation protection and optimization techniques among interventional cardiologists in Lithuania. Interventional cardiologists of five cardiac centres were interviewed by anonymized questionnaire, addressing personal use of protective garments, shielding, table/detector positioning, frame rate (FR), resolution, field of view adjustment and collimation. Effective patient doses were compared between operators who work with and without x-ray optimization. Thirty one (68.9%) out of 45 Lithuanian interventional cardiologists participated in the survey. Protective aprons were universally used, but not the thyroid collars; 35.5% (n = 11) operators use protective eyewear and 12.9% (n = 4) wear radio-protective caps; 83.9% (n = 26) use overhanging shields, 58.1% (n = 18)-portable barriers; 12.9% (n = 4)-abdominal patient's shielding; 35.5% (n = 11) work at a high table position; 87.1% (n = 27) keep an image intensifier/receiver close to the patient; 58.1% (n = 18) reduce the fluoroscopy FR; 6.5% (n = 2) reduce the fluoro image detail resolution; 83.9% (n = 26) use a 'store fluoro' option; 41.9% (N = 13) reduce magnification for catheter transit; 51.6% (n = 16) limit image magnification; and 35.5% (n = 11) use image collimation. Median effective patient doses were significantly lower with x-ray optimization techniques in both diagnostic and therapeutic interventions. Many of the ionizing radiation exposure reduction tools and techniques are underused by a considerable proportion of interventional cardiology operators. The application of basic radiation protection tools and techniques effectively reduces ionizing radiation exposure and should be routinely used in practice.

Left Ventricular Mechanics in Functional Ischemic Mitral Regurgitation in Acute Inferoposterior Myocardial Infarction.

UNLABELLED: Ischemic mitral regurgitation (MR) is an established adverse prognostic factor after myocardial infarction (MI). Functional ischemic mitral regurgitation in acute phase of MI remains under-investigated due to its often transient and dynamic nature. We aimed to assess left ventricular (LV) mechanics by speckle-tracking echocardiography in acute inferoposterior MI and ischemic mitral regurgitation (MR). METHODS: Sixty-nine patients with no structural cardiac valve abnormalities and first acute inferoposterior MI were prospectively enrolled into the study. Two-dimensional transthoracic echocardiography for regional myocardial function and valve assessment was performed within 48 hours of presentation after reperfusion therapy (percutaneous coronary intervention). Based on degree of MR, patients were divided into no significant MR (NMR) group (N = 34, with no or mild (grade 0-I) MR) and ischemic MR (IMR) group (N = 35, with grade ≥2 MR). Thirty-five age- and gender-matched healthy individuals served as a normal reference group. Offline 2D speckle tracking analysis was performed with GE EchoPAC software. RESULTS: LV ejection fraction and longitudinal myocardial deformation parameters were significantly better in healthy subjects, but did not differ between both study groups. All circumferential myocardial deformation parameters were significantly worse in IMR group compared to healthy subjects and NMR group. Global, basal, and mid-ventricular radial strain was significantly lower in IMR group compared to both-healthy subjects and NMR group. CONCLUSION: Ischemic mitral regurgitation in acute inferoposterior MI is associated with worse radial and circumferential LV deformation parameters assessed by 2D speckle tracking echocardiography.

"Spiral stenting"-creating a subintimal neo-luminal helix around a massively calcified ostial chronic total occlusion of the right coronary artery in a patient with recurrent ventricular tachycardia.

This case report describes a successful percutaneous coronary intervention (PCI) of a severely calcified aorto-ostial chronic total occlusion (CTO) of the right coronary artery (RCA). The lesion was treated by a retrograde approach implementing long spiral subintimal wire tracking and final coronary stenting creating a subintimal neo-luminal helix around the natively occluded RCA. After 6 months of follow-up valuable angiographic results were proven.

Predicting ischemic mitral regurgitation in patients with acute ST-elevation myocardial infarction: Does time to reperfusion really matter and what is the role of collateral circulation?

BACKGROUND/OBJECTIVES: Ischemic mitral regurgitation (MR) is an adverse prognostic factor. We aimed to assess the role of time delay from symptom onset to reperfusion, and the impact of collateral circulation to incidence of MR in relation to established echocardiographic and clinical risk factors. METHODS: Patients with STEMI presenting within 12 h from symptom onset and treated with primary percutaneous coronary intervention (PPCI) at Hospital of Lithuanian University of Health Sciences were enrolled. Echocardiography was performed after PPCI. Based on MR grade, patients were divided into no significant MR (NMR, grade 0-I MR, N = 102) and ischemic MR (IMR, grade ≥ 2 MR, N = 71) groups. Well-developed collaterals were defined as grade ≥ 2 by Rentrop classification. Continuous variables were compared by independent samples Student's T-test. Multivariate logistic regression analysis was used to identify independent predictors of ischemic MR. RESULTS: Time to reperfusion, MI localization, TIMI flow before/after PCI was similar between the groups. IMR group patients were elder, more often females and non-smokers, had lower body mass index, higher prevalence of multi-vessel coronary artery disease (CAD), better-developed collateral supply, greater left ventricular end-diastolic diameter index, left atrial index, pulmonary artery systolic pressure and lower ejection fraction. Multivariate logistic regression analysis revealed that ischemic MR is predicted by female gender, well-developed collateral supply, presence of multi-vessel CAD, and lower EF. CONCLUSION: In acute STEMI significant MR is unrelated to ischemic time and is predicted by female gender, lower EF, multi-vessel CAD and well-developed collateral supply to the infarct region.

Functional (ischemic) mitral regurgitation in acute phase of myocardial infarction: Associated clinical factors and in-hospital outcomes.

BACKGROUND AND OBJECTIVE: Mitral regurgitation (MR) after myocardial infarction (MI) carries adverse prognosis. The objective of this study was to assess the impact of functional MR on adverse in-hospital outcomes in acute MI. MATERIALS AND METHODS: A total of 569 patients with first ever acute MI were divided into three groups: no MR, mild MR (regurgitant orifice area <0.2 cm(2)) and moderate-severe MR group (regurgitant orifice area more or equal >0.2 cm(2)). Clinical profile and in-hospital outcomes were compared among the groups. RESULTS: Patients with increasing grade of MR were elder (P<0.001), more likely to be female (P=0.003), have atrial fibrillation (P<0.001), higher peak C-reactive protein values (P=0.001), multivessel coronary artery disease (P<0.001), and less likely to have dyslipidemia (P=0.029). Ejection fraction, age, atrial fibrillation and left ventricular end diastolic diameter index were independent predictors of moderate and severe MR (P<0.001). In hospital cardiac death and decompensated heart failure was more prevalent in moderate-severe MR group. CONCLUSIONS: Moderate and severe MR in acute MI is related to age, atrial fibrillation, increased left ventricular diastolic dimensions and decreased ejection fraction. Moderate and severe, but not mild MR is an important clinical contributor to in-hospital cardiac death.

Left anterior descending coronary artery spasm and "accordion effect" mimicking coronary artery dissection.

We present an illustrative case report of the mid-vessel left anterior descending (LAD) coronary artery spasm, which has been enhanced by straightening of the tortuous LAD segment with a guidewire ("accordion effect") thus resistant to intracoronary nitroglycerine and mimicking a coronary artery dissection. Dynamic appearance of this iatrogenic pseudo-lesion upon administration of intracoronary nitrates and recognition of these angiographic phenomena prevented from unnecessary further intervention.

'Mirroring' the ethics of biobanking: what should we learn from the analysis of consent documents[corrected]?

Biobanks have been recognized as a key research infrastructure and how to approach ethical questions has been a topic of discussion for at least a decade by now. This article explores the characteristics of donors' participation in European biobanks as reflected in the consent documents of a selection of different biobanks from various European countries. The primary aim of this study is to understand how donors are informed about their participation in biobanking. Also the paper discusses what the most important thematic issues of information are to be given to the biobank participants and how this information should be presented in the consent documents. For these purposes, we analyse consent documents from 14 biobanks in 11 countries for six ethically relevant issues: (1) model of consent, (2) scope of future research, (3) access to medical data, (4) feedback to the participants, (5) consent withdrawal, and (6) role of research ethics committee. In order to compare different trends of informing donors of human biological material and medical data, we interpret the six analysed issues in the context of respect to donor's autonomy paradigm. Although the results of the paper reflect the heterogeneity of biobank consent document policies applied in different European countries, we uncovered some trends and suggested several examples of good practices to balance the interests of the donors with those of the researchers and future patients.

Impaired renal function impacts negatively on vascular stiffness in patients with coronary artery disease.

BACKGROUND: Chronic kidney disease (CKD) and coronary artery disease (CAD) are independently associated with increased vascular stiffness. We examined whether renal function contributes to vascular stiffness independently of CAD status. METHODS: We studied 160 patients with CAD and 169 subjects without CAD. The 4-variable MDRD formula was used to estimate glomerular filtration rate (eGFR); impaired renal function was defined as eGFR <60 mL/min. Carotid-femoral pulse wave velocity (PWV) was measured with the SphygmoCor® device. Circulating biomarkers were assessed in plasma using xMAP® multiplexing technology. RESULTS: Patients with CAD and impaired renal function had greater PWV compared to those with CAD and normal renal function (10.2 [9.1;11.2] vs 7.3 [6.9;7.7] m/s; P < 0.001). In all patients, PWV was a function of eGFR (ß = -0.293; P < 0.001) even after adjustment for age, sex, systolic blood pressure, body mass index and presence or absence of CAD. Patients with CAD and impaired renal function had higher levels of adhesion and inflammatory molecules including E-selectin and osteopontin (all P < 0.05) compared to those with CAD alone, but had similar levels of markers of oxidative stress. CONCLUSIONS: Renal function is a determinant of vascular stiffness even in patients with severe atherosclerotic disease. This was paralleled by differences in markers of cell adhesion and inflammation. Increased vascular stiffness may therefore be linked to inflammatory remodeling of the vasculature in people with impaired renal function, irrespective of concomitant atherosclerotic disease.