Clinical significance of early-diastolic tissue velocity imaging of lateral mitral annulus for prognosis of nonischemic left ventricular dysfunction.

PURPOSE: We explored the potential of tissue velocity imaging (TVI) for prognosis of nonischemic left ventricular (LV) dysfunction (LVD). METHODS: We reviewed 138 nonischemic LVD patients (58 ± 14 years) who underwent both cardiac magnetic resonance (CMR) and echocardiography. Septal and lateral mitral annular TVI data were compared with late gadolinium enhancement (LGE) on CMR. During a mean follow-up of 24 months, recovery (>15%) of LV ejection fraction and clinical outcomes (cardiovascular death and heart failure hospitalization) were assessed. RESULTS: LGE was commonly observed in the basal anteroseptal, inferoseptal, and inferior segments, but infrequently observed in the anterolateral segment. LGE was associated with lower early diastolic, septal (Sep-e' = 5.2 ± 2.0 vs 6.9 ± 2.0 cm/s, P = .031) and lateral (Lat-e' = 7.3 ± 3.0 vs 9.5 ± 2.0 cm/s, P < .001) TVI. The relationship between Lat-e' and anterolateral LGE (area under the curve, AUC 0.834) was much better than that between Sep-e' and inferoseptal LGE (AUC 0.699). The 60 patients with LVD reversibility revealed higher Lat-e' (9.8 ± 2.0 vs 6.7 ± 2.2 cm/s, P < .001) and lower LGE burden (7.3 ± 9.0 vs 22 ± 10%, P < .001), while Lat-e' ≤ 7.8 cm/s appeared unfavorable for 31 events patients. On multivariate analyses, Lat-e' (HR 0.79, 95% CI 0.63-0.99, P = .044) and LVD reversibility (HR 0.53, 95% CI 0.16-0.90, P = .018) were still meaningful together with LGE segments and burden. CONCLUSION: Lat-e' was related with LVD reversibility and a significant predictor of clinical outcomes.

Implication of ultrasound contrast-enhancement of carotid plaques in prevalence of acute coronary syndrome and occurrence of cardiovascular outcomes.

PURPOSE: Ultrasonographic contrast enhancement of carotid plaque (CECP) has been used to detect neovascularization of vasa vasorum and plaque. However, it is uncertain whether CECP can provide risk stratification of coronary artery disease (CAD). This study aimed to evaluate the relationship between CECP and manifestations of acute coronary syndrome (ACS) in established CAD patients and to explore the prognostic implication of CECP for cardiovascular (CV) clinical outcomes. METHODS: A medical record review revealed that contrast-enhanced ultrasonography was performed to evaluate carotid atherosclerosis in 209 coronary artery-stented and 105 non-stented patients. The rate of ACS manifestations was compared depending on contrast uptake patterns: grade 0, absent; grade 1, dot; and grade 2, diffuse pattern. CV primary outcomes were assessed during a mean 7.6 months of follow-up. RESULTS: Male sex, smoking, history of old myocardial infarction, intensive medications, and a favorable lipid profile were common in the stented versus non-stented group. Patients with grade 2 CECP had a higher rate of ACS, greater plaque thickness, and class I-II of Gray-Weale plaque echogenicity. During follow-up, 10 coronary revascularizations (nine ACSs), six strokes, and four heart failures occurred. Grade 2 CECP was more closely related with CV primary outcomes and showed a tendency toward more acute CV outcomes. CONCLUSION: ACS manifestations were proportionate to CECP grade. Diffuse CECP uptake could be a risk factor for acute CV outcomes.

Characteristics of COVID-19 Patients Who Progress to Pneumonia on Follow-Up Chest Radiograph: 236 Patients from a Single Isolated Cohort in Daegu, South Korea.

OBJECTIVE: We investigated the prevalence of pneumonia in novel coronavirus disease 2019 (COVID-19) patients using chest radiographs to identify the characteristics of those with initially negative chest radiographs, who were positive for pneumonia on follow-up. MATERIALS AND METHODS: Retrospective cohort data of 236 COVID-19 patients were reviewed. Chest radiography was performed on admission, with serial radiographs obtained until discharge. The 'positive conversion group' was defined as patients whose initial chest radiographs were negative but were positive for pneumonia during follow-up. Patients with initially positive chest radiographs were defined as the 'initial pneumonia group.' Patients with negative initial and follow-up chest radiographs were defined as the 'non-pneumonia group.' Clinical and laboratory findings were compared between groups, and predictors of positive conversion were investigated. RESULTS: Among 236 patients, 108 (45.8%) were in the non-pneumonia group, 69 (29.2%) were in the initial pneumonia group, and 59 (25%) were in the positive conversion group. The patients in the 'initial pneumonia group' and 'positive conversion group' were older, had higher C-reactive protein (CRP) and lactate dehydrogenase levels, and lower absolute lymphocyte counts than those in the 'non-pneumonia group' (all p < 0.001). Among patients with negative initial chest radiographs, age ≥ 45 years (odds ratio [OR]: 3.93, 95% confidence interval [CI]: 1.76-8.75, p = 0.001), absolute lymphocyte count < 1500 cells/µL (OR: 2.25, 95% CI: 1.03-4.89, p = 0.041), and CRP > 0.5 mg/dL (OR: 3.91, 95% CI: 1.54-9.91, p = 0.004) were independent predictors for future development of pneumonia. CONCLUSION: More than a half of COVID-19 patients initially had normal chest radiographs; however, elderly patients (≥ 45 years of age) with abnormal laboratory findings (elevated CRP and low absolute lymphocyte counts) developed pneumonia on follow-up radiographs.

Clinical impact of diabetes mellitus on 2-year clinical outcomes following PCI with second-generation drug-eluting stents; Landmark analysis findings from patient registry: Pooled analysis of the Korean multicenter drug-eluting stent registry.

BACKGROUND: Patients with diabetes mellitus are at an increased risk for adverse clinical events following percutaneous coronary interventions (PCI). However, the clinical impact of diabetes mellitus (DM) on second-generation drug-eluting stent (DES) implantation is not well-known. The aim of the current analysis was to examine the clinical impact of DM on clinical outcomes and the time sequence of associated risks in patients treated with second-generation DES. METHODS: Using patient-level data from two stent-specific, all-comer, prospective DES registries, we evaluated 1,913 patients who underwent PCI with second-generation DES between Feb 2009 and Dec 2013. The primary outcomes assessed were two-year major cardiac adverse events (MACE), composite endpoints of death from any cause, myocardial infarction (MI), and any repeat revascularization. We classified 0-1 year as the early period and 1-2 years as the late period. Landmark analyses were performed according to diabetes mellitus status. RESULTS: There were 1,913 patients with 2,614 lesions included in the pooled dataset. The median duration of clinical follow-up in the overall population was 2.0 years (interquartile range 1.9-2.1). Patients with DM had more cardiovascular risk factors than patients without DM. In multivariate analyses, the presence of DM and renal failure were strong predictors of MACE and target-vessel revascularization (TVR). After inverse probability of treatment weighting (IPTW) analyses, patients with DM had significantly increased rates of 2-year MACE (HR 2.07, 95% CI; 1.50-2.86; P <0.001). In landmark analyses, patients with DM had significantly higher rates of MACE in the early period (0-1 year) (HR 3.04, 95% CI; 1.97-4.68; P < 0.001) after IPTW adjustment, but these findings or trends were not observed in the late period (1-2 year) (HR 1.24, 95% CI; 0.74-2.07; P = 0.41). CONCLUSIONS: In the second-generation DES era, the clinical impact of DM significantly increased the 2-year event rate of MACE, mainly caused by clinical events in the early period (0-1 year). Careful observation of patients with DM is advised in the early period following PCI with second-generation DES.

NOAC Adherence of Patients with Atrial Fibrillation in the Real World: Dosing Frequency Matters?

BACKGROUND AND OBJECTIVES: Nonvitamin K antagonist oral anticoagulants (NOACs) require stricter medication adherence. We investigated the NOACs adherence in real-world practice. METHODS: We screened all patients in our cardiology department the day before their outpatient appointment, over a 5-month period. We enrolled 719 consecutive patients who were taking NOACs for atrial fibrillation. The patients were contacted by phone or text to bring the remnant pills with them without any information why. Adherence was measured by the percentage of prescribed doses taken (PDT) (number of doses taken/number of doses expected to be taken from the last prescription × 100 [%]) and the Morisky Medication Adherence Scale (MMAS)-8. RESULTS: All 4 NOACs (apixaban 47.8%, dabigatran 21.2%, rivaroxaban 18.4%, and edoxaban 12.6%) were prescribed. The mean duration that the patients had been taking NOACs was 7.2 ± 5.7 months. The PDT was 95.4 ± 9.1% in the once-daily dosing group and 93.4 ± 12.7% in the twice-daily group, and the difference was statistically significant (p = 0.017). The mean MMAS was 2.6 ± 0.8. The proportion of patients with a PDT < 80% was 7.8%. They had a significantly higher MMAS than the PDT ≥ 80% group (3.4 vs. 2.5; p = 0.000). CONCLUSION: Most patients who were taking NOACs had excellent adherence regardless of the dosing frequency. An MMAS ≥ 3 could be used as a simple screening tool for a poor NOAC adherence.

The impact of catheter ablation of atrial fibrillation on the left atrial volume and function: study using three-dimensional echocardiography.

PURPOSE: The exact correlation between the baseline left atrial (LA) volume (LAV) and atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) outcomes and changes to the LA after AF RFCA has not yet been fully understood. We sought to evaluate the serial changes in the LAV and LA function after RFCA using 3D echocardiography. METHODS: Consecutive patients who received RFCA of paroxysmal (PAF) or persistent AF (PeAF) at our center between January 2013 and March 2016 were included. Real-time 3D apical full-volume images were acquired, and a 3D volumetric assessment was performed using an automated three-beat averaging method. The LAV index (LAVI) was calculated and the LA ejection fraction (LAEF) was calculated as [LAVmax - LAVmin]/LAVmax. RESULTS: Ninety-nine total patients were enrolled, and the mean age was 58.0 ± 8.2 years and 75 (74.7%) were male. There were 59 (59.6%) PAF patients and the remaining 40 (40.4%) had PeAF. AF recurred in 5 of 59 (8.5%) PAF and in 10 of 40 (25%) PeAF patients. The LAVImax increased on 1 day, decreased at 3 months, and then increased again at 1 year but was lower than that at baseline. The LAEF changes were similar to the volume changes but were more prominent in PeAF than PAF patients. The baseline 3D LAVImax was an independent predictor of AF recurrence after RFCA and the cut-off value was 44.13 ml/m2. CONCLUSION: In our study, even after 3 months of scar formation due to ablation, structural remodeling of the LA continued. The changes were more prominent in the non-recurrent, PeAF patients.

5-Year Outcomes According to FFR of Left Circumflex Coronary Artery After Left Main Crossover Stenting.

OBJECTIVES: The aim of the current study was to evaluate the long-term clinical impact of fractional flow reserve (FFR) in jailed left circumflex coronary artery (LCx) after left main coronary artery (LM) simple crossover stenting. BACKGROUND: Although the provisional side-branch intervention with FFR guidance has been validated for non-LM bifurcation lesions, the outcome of such a strategy in LM bifurcation disease is not well-known. METHODS: Patients who underwent LM-to-left anterior descending coronary artery simple crossover stenting and who had FFR measurements in the LCx thereafter were enrolled. A low FFR was defined as ≤0.80. The clinical outcomes were assessed by the 5-year rate of target lesion failure (TLF) (a composite of cardiac death, target-vessel myocardial infarction, or target lesion revascularization). RESULTS: In 83 patients, the mean FFR of the LCx after LM stenting was 0.87 ± 0.08, and 14 patients (16.9%) had a low FFR. There was no correlation between the FFR and angiographic % diameter stenosis in jailed LCx (R2 = 0.039; p = 0.071) and there was no difference in the angiographic % diameter stenosis in the high and low FFR groups. At 5 years, the low FFR group had a significantly higher rate of TLF than the high FFR group (33.4% vs. 10.7%; hazard ratio: 4.09, 95% confidence interval: 1.15 to 14.52; p = 0.029). However, there was no difference in the clinical outcomes according to the angiographic % diameter stenosis. In a multivariate analysis, a low FFR was an independent predictor of the risk for a 5-year TLF (hazard ratio: 6.49; 95% confidence interval: 1.37 to 30.73; p = 0.018). CONCLUSIONS: The patients with a high FFR in jailed LCx had better 5-year outcomes than those with a low FFR. The FFR measurement in jailed LCx can be helpful in selecting an adequate treatment strategy and may reduce unnecessary complex procedures.

The incidence of left atrial appendage thrombi on transesophageal echocardiography after pretreatment with apixaban for cardioversion in the real-world practice.

The risk of thromboembolisms during the post-cardioversion period is high. For patients with persistent atrial fibrillation (AF), anticoagulation with warfarin (INR 2.0~3.0) is recommended for at least three weeks prior and four weeks after cardioversion. We aimed to evaluate the efficacy of apixaban in preventing thromboembolic events during post-cardioversion. We enrolled 127 consecutive persistent AF patients (83 persistent, 44 longstanding persistent AF), scheduled to undergo cardioversion and were pretreated with apixaban. All patients underwent transesophageal echocardiography (TEE) to rule out thrombi in the left atrium (LA) or LA appendage (LAA) after anticoagulation with apixaban. The median duration of anticoagulation before the TEE was 37 (interquartile range [IQR] 34, 50) days. There were 7 patients (5.5%) with visible thrombi in the LAA. A spontaneous echo contrast was noted in 24 (18.9%) patients. Cardioversion was attempted in 117 patients, and they were prescribed amiodarone before the elective DC cardioversion. Sinus rhythm was achieved in 37 patients (31.6%) by amiodarone itself. DC cardioversion was attempted in 80 patients and was successful in 73 (91.3%). None of the cardioverted patients had any thromboembolic events within one month. Transient ischemic attacks were observed in one patient during a median follow up period of 202 days (IQR 143, 294). In conclusion, apixaban could be used as an anticoagulant for patients scheduled for cardioversion. However, the incidence of thrombi was not negligible. TEE or other imaging modalities should be considered before cardioversion or other invasive procedures.

Long-term outcomes of intravascular ultrasound-guided implantation of bare metal stents versus drug-eluting stents in primary percutaneous coronary intervention.

BACKGROUND/AIMS: While drug-eluting stents (DESs) have shown favorable outcomes in ST-segment elevation myocardial infarction (STEMI) compared to bare metal stents (BMSs), there are concerns about the risk of stent thrombosis (ST) with DESs. Because intravascular ultrasound (IVUS) guidance may help optimize stent placement and improve outcomes in percutaneous coronary intervention (PCI) patients, we evaluated the impact of IVUS-guided BMS versus DES implantation on long-term outcomes in primary PCI. METHODS: In all, 239 STEMI patients received DES (n = 172) or BMS (n = 67) under IVUS guidance in primary PCI. The 3-year incidence of major adverse cardiac events (MACEs) including death, myocardial infarction (MI), target vessel revascularization (TVR), and ST was evaluated. RESULTS: There was no difference in all cause mortality or MI. However, the incidence of TVR was 23.9% with BMS versus 9.3% with DES (p = 0.005). Thus, the number of MACEs was significantly lower with DES (11.0% vs. 29.9%; p = 0.001). The incidence of definite or probable ST was not different (1.5% vs. 2.3%; p = 1.0). IVUS-guided DES implantation (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.08 to 0.78; p = 0.017), stent length (HR, 1.03; 95% CI, 1.00 to 1.06; p = 0.046), and multivessel disease (HR, 3.01; 95% CI, 1.11 to 8.15; p = 0.030) were independent predictors of MACE. CONCLUSIONS: In patients treated with primary PCI under IVUS guidance, the use of DES reduced the incidence of 3-year TVR versus BMS. However, all cause mortality and MI were similar between the groups. The incidence of ST was low in both groups.

The efficacy of the cystatin C based glomerular filtration rate in the estimation of safe contrast media volume.

BACKGROUND AND OBJECTIVES: The risk of contrast-induced nephropathy (CIN) is significantly influenced by baseline renal function and the amount of contrast media (CM). We evaluated the usefulness of the cystatin C (CyC) based estimated glomerular filtration rate (eGFRCyC) in the prediction of CIN and to determine the safe CM dosage. SUBJECTS AND METHODS: We prospectively enrolled a total of 723 patients who received percutaneous coronary intervention (PCI) and investigated the clinical factors associated with the development of CIN. Renal function was calculated as eGFRCyC and a modified diet in the renal disease (MDRD) equation, respectively. Systemic exposure of CM was calculated as CM volume to eGFR ratio. We conducted a regression analysis to evaluate the predictive role of CM volume to eGFRCyC for the risk of CIN. RESULTS: The incidence of CIN was 4.0% (29/723). The patients with CIN had a lower hemoglobin level, decreased renal function, and a higher CyC value, and had greater CM exposure. Through multivariate regression analyses, hemoglobin {odds ratio (OR) 0.743, p=0.032}, CM volume/eGFRCyC (OR 1.697, p=0.006) and CM volume/MDRD (OR 2.275, p<0.001) were found to be independent predictors for CIN. In the receiver operating characteristic curve analysis, fair discrimination for CIN was found at a CM volume/eGFRCyC level of 4.493 (C-statics=0.814), and at this value, the sensitivity and specificity were 79.3% and 80.0%, respectively. CONCLUSION: Both the CM volume/MDRD and CM volume/eGFRCyC method would be simple, useful indicators for determining the safe CM-dose based on eGFR value before PCI. However, there was no significantly different predictive value between creatinine and CyC based GFR estimations.

Acute Stent Thrombosis and Heparin Induced Thrombocytopenia in a Patient With ST-Segment Elevation Myocardial Infarction.

Heparin is an essential drug in the treatment of acute coronary syndrome and it is used during percutaneous coronary intervention (PCI). Heparin-induced thrombocytopenia (HIT), albeit a serious complication of heparin therapy characterized by thrombocytopenia and high risk for venous and arterial thrombosis, has rarely been previously reported during PCI. We report a case of an acute stent thrombosis due to an unusual cause, HIT during primary PCI, in a patient with acute myocardial infarction.