The effect of vitamin d on aldosterone and health status in patients with heart failure.

BACKGROUND: Vitamin D deficiency is associated with heart failure (HF) events, and in animal models vitamin D down-regulates renin-angiotensin-aldosterone system hormones. METHODS: Patients with New York Heart Association (NYHA) functional class II-IV HF and a 25OH-D level ≤37.5 ng/mL received 50,000 IU vitamin D3 weekly (n = 31) or placebo (n = 33) for 6 months. Serum aldosterone, renin, echocardiography, and health status were determined at baseline and 6 months. RESULTS: Mean age of participants was 65.9 ± 10.4 years, 48% were women, 64% were African American, mean ejection fraction was 37.6 ± 13.9%, 36% were in NYHA functional class III, and 64% were in class II. The vitamin D group increased serum 25OH-D (19.1 ± 9.3 to 61.7 ± 20.3 ng/mL) and the placebo group did not (17.8 ± 9.0 to 17.4 ± 9.8 ng/mL). Aldosterone decreased in the vitamin D group (10.0 ± 11.9 to 6.2 ± 11.6 ng/dL) and not in the placebo group (8.9 ± 8.6 to 9.0 ± 12.4 ng/dL; P = .02). There was no difference between groups in renin, echocardiographic measures, or health status from baseline to 6 months. Modeling indicated that variables which predicted change in aldosterone included receiving vitamin D, increasing age, African American race, and lower glomerular filtration rate. CONCLUSIONS: Vitamin D3 repletion decreases aldosterone in patients with HF and low serum vitamin D. Vitamin D may be an important adjunct to standard HF therapy. Further study will assess if vitamin D provides long-term benefit for patients with HF.

Imaging a spiral dissection of the superficial femoral artery in high resolution with optical coherence tomography-seeing is believing.

Optical coherence tomography (OCT) offers an alternative to intravascular ultrasound (IVUS) for endovascular imaging. Clinical and research applications for OCT have emerged in percutaneous coronary intervention (PCI), however, OCT has not found similar utility in peripheral arterial interventions. Early generation time-domain OCT systems required arterial occlusion to create the blood free environment needed for image acquisition and could not reliably scan vessel diameters encountered in the peripheral circulation. However, the frequency-domain OCT (FD-OCT) system currently FDA approved for use in the United States does not require arterial occlusion to generate images and permits a greater scan diameter allowing for exploratory use in peripheral arteries. To our knowledge, this is the first report using non-occlusive OCT imaging to serve as an adjunct to endovascular intervention for femoropopliteal disease. We illustrate the feasibility of acquiring high resolution images of a spiral dissection of the superficial femoral artery following balloon angioplasty that was not adequately visualized by angiography.

Volumetric characterization of human coronary calcification by frequency-domain optical coherence tomography.

BACKGROUND: Coronary artery calcification (CAC) presents unique challenges for percutaneous coronary intervention. Calcium appears as a signal-poor region with well-defined borders by frequency-domain optical coherence tomography (FD-OCT). The objective of this study was to demonstrate the accuracy of intravascular FD-OCT to determine the distribution of CAC. METHODS AND RESULTS: Cadaveric coronary arteries were imaged using FD-OCT at 100-µm frame interval. Arteries were subsequently frozen, sectioned and imaged at 20-µm intervals using the Case Cryo-Imaging automated system(TM). Full volumetric co-registration between FD-OCT and cryo-imaging was performed. Calcium area, calcium-lumen distance (depth) and calcium angle were traced on every cross-section; volumetric quantification was performed offline. In total, 30 left anterior descending arteries were imaged: 13 vessels had a total of 55 plaques with calcification by cryo-imaging; FD-OCT identified 47 (85%) of these plaques. A total of 1,285 cryo-images were analyzed and compared with corresponding co-registered 257 FD-OCT images. Calcium distribution, represented by the mean depth and the mean calcium angle, was similar, with excellent correlation between FD-OCT and cryo-imaging respectively (mean depth: 0.25±0.09 vs. 0.26±0.12mm, P=0.742; R=0.90), (mean angle: 35.33±21.86° vs. 39.68±26.61°, P=0.207; R=0.90). Calcium volume was underestimated in large calcifications (3.11±2.14 vs. 4.58±3.39mm(3), P=0.001) in OCT vs. cryo respectively. CONCLUSIONS: Intravascular FD-OCT can accurately characterize CAC distribution. OCT can quantify absolute calcium volume, but may underestimate calcium burden in large plaques with poorly defined abluminal borders.

Assessment of echocardiographic left atrial size: accuracy of M-mode and two-dimensional methods and prediction of diastolic dysfunction.

BACKGROUND: Despite the American Society of Echocardiography recommendation to use left atrial volume indexed for body surface area (LAVI) for quantification of left atrial size, a variety of methods are used in clinical practice. Our objectives were to evaluate the accuracy of M-mode and two-dimensional (2D) echocardiographic LA size estimates to LAVI and to determine their ability to predict left ventricular diastolic dysfunction. METHODS: In 150 consecutive patients, LA diameter (LAD), LA diameter indexed for body surface area (LADI), LA area in the apical two- and four-chamber views (LAA 2c and LAA 4c), biplane area-length LA volume (LAV), and LAVI were obtained. The accuracy of these methods to quantify LA enlargement by LAVI, correlation with clinical parameters, and ability to act as a surrogate for diastolic dysfunction were determined using Pearson correlation coefficients along with univariate and multiple logistic analysis. RESULTS: The true degree of LA size (with LAVI as standard) was identified by LAD in 45%, LADI in 42%, LAA 4c in 43%, and LAA 2c in 41%. All methods showed positive correlation with age, E/E', mitral regurgitation, and right atrial size and negative correlation with ejection fraction. LAVI was the strongest method to predict any (c = 0.655, P = 0.012) or moderate-severe (P = 0.856 and P < 0.001) diastolic dysfunction. All methods have greater capacity to identify moderate or severe diastolic dysfunction than any degree of diastolic dysfunction alone. CONCLUSIONS: One-dimensional and 2D methods inaccurately quantify LA size and are inferior to LAVI to predict diastolic dysfunction.

Unrestricted utilization of frequency domain optical coherence tomography in coronary interventions.

Frequency domain optical coherence tomography (FD-OCT) has shown promise to evaluate coronary devices in clinical trials, however, little is known about its application in clinical practice. This prospective, single center initiative planned for 100 % FD-OCT utilization in all patients undergoing coronary interventions during a 60-day period. Operators pre-specified the planned intervention based on angiography alone. FD-OCT success was defined as acquisition of good quality images enabling adequate quantification of vessel dimensions and lesion/percutaneous coronary intervention (PCI) assessment. Impact on management occurred when angiography-based planning was altered based on FD-OCT data. There were 297 FD-OCT acquisitions performed in 155 vessels from 150 patients. There were no FD-OCT procedural related cardiac adverse events and success was obtained in 85.7 % of all target vessels (pre-PCI = 76.8 % vs. post-PCI = 90.1 %, p = 0.004). Success on the first pullback occurred in 80.3 % overall (61.9 % in the initial operator experience and 85.5 % after the third procedure). FD-OCT impact on management was 81.8 % pre-PCI and 54.8 % post-PCI. Stent malapposition was detected in 39.2 % (89.4 % underwent further intervention) and edge dissection in 32.5 % (21.1 % treated with stent). FD-OCT success and management impact were similar in ACS and non-ACS patients (82.1 vs. 81.1 %, p = 1.000, and 62.5 vs. 65.1 %, p = 0.854, respectively). FD-OCT is safe, can successfully be incorporated into routine practice, and alters procedural strategy in a high proportion of patients undergoing PCI.

Incidence, predictors, morphological characteristics, and clinical outcomes of stent edge dissections detected by optical coherence tomography.

OBJECTIVES: This study sought to investigate the frequency, predictors, and detailed qualitative and quantitative assessment of optical coherence tomography (OCT)-detected stent edge dissections. Its impact on subsequent management and clinical outcomes were also investigated. BACKGROUND: OCT is a high-resolution imaging modality that can lead to more frequent recognition and accurate assessment of vascular injuries during percutaneous coronary intervention (PCI). METHODS: From September 2010 to June 2011, all patients with OCT post-PCI were enrolled. Edge dissections were defined as disruptions of the arterial lumen surface in both the 5-mm distal and proximal stent edges. Qualitative and quantitative analyses of all edges were performed at 0.2-mm intervals. RESULTS: In total, 395 edges (249 lesions in 230 patients) were analyzed. The overall incidence of OCT-detected edge dissection was 37.8%, and most (84%) were not apparent on angiography. Independent predictors for OCT-detected dissections were presence of atherosclerotic plaque at stent edges, calcification angle, minimum fibrous cap thickness, thin-cap fibroatheromas, stent/lumen eccentricity, and vessel overstretching. Mean dissection length measured 2.04 ± 1.60 mm, 96.2% appeared as flaps, and 52.8% extended beyond the intima/atheroma layer. Additional stenting was performed in 22.6% of all dissections, which were longer, had bigger dimensions, and promoted deeper vascular injury. The 12-month major adverse cardiac event rate was similar between patients with (7.95%) and without (5.69%, p = 0.581) dissections. CONCLUSIONS: High rates of stent edge dissections were detected by OCT, usually related to the presence of atherosclerosis at stent edges and to PCI technique. Detailed OCT assessment of dissection severity was possible and affected the subsequent management of this complication. Non-flow-limiting, small, and superficial dissections left untreated proved benign.

Utilization of frequency domain optical coherence tomography and fractional flow reserve to assess intermediate coronary artery stenoses: conciliating anatomic and physiologic information.

Fractional flow reserve (FFR) and intravascular imaging respectively provide hemodynamic and anatomical assessments of angiographic intermediate stenoses. Frequency domain optical coherence tomography (FD-OCT) is a promising high-resolution imaging modality, but its clinical use in determining severity of coronary disease has yet to be determined. There, we set out to determine the role of FD-OCT to complement FFR in the evaluation of intermediate coronary artery stenoses. FD-OCT was planned in 176 consecutive interventional procedures at our institution to delineate the proper use of FD-OCT in clinical practice. The decision to use other invasive assessments was at the discretion of the operator. This report describes an early series of the 14 patients who underwent FFR of 18 target stenoses in addition to FD-OCT. FD-OCT was successfully performed without complications in all cases. Fractional flow reserve was <0.80 in four patients, with minimal lumen areas and reference vessel diameters ranging from 1.03 to 3.47 mm(2) and 2.60 to 2.94 mm by FD-OCT, respectively. FD-OCT was important to rule out plaque rupture, erosion and thrombosis and to help guide decision to defer PCI in six patients with acute coronary syndrome and FFR > 0.80. FD-OCT was also valuable to guide PCI strategy in tandem lesions with an FFR < 0.80. This initial experience with FD-OCT suggests a potential complementary role of physiological and anatomical assessment to guide decision making in complex clinical scenarios. Future investigations are warranted to validate these findings and define the role of FD-OCT in assessing intermediate lesions.

Prevalence of unsuspected and significant mitral and aortic regurgitation.

OBJECTIVE: We sought to determine the prevalence of unsuspected, pre-existing valvular regurgitation in a large, heterogeneous population of patients referred for an echocardiogram. METHODS: The echocardiograms of 6851 consecutive individuals without suspected valve disease were reviewed. Regurgitant severity was graded using a clinical composite of published methods and multiple logistic analyses were used to model various clinical variables. RESULTS: The overall prevalence of moderate or greater mitral regurgitation (MR) was 11.7% in male patients and 12.5% in female patients. For mild or greater aortic insufficiency (AI), the prevalence was 18.9% in male patients and 19.7% in female patients. Both MR and AI increased exponentially as a function of age. Female sex predicted MR, but AI was sex neutral. Regurgitant severity increased with decreasing ejection fraction and body mass index, a history of hypertension, the presence of left ventricular hypertrophy, and valvular abnormalities. CONCLUSIONS: The prevalence of unsuspected MR and AI is substantial, increases exponentially with age, and is predicted by commonly used clinical variables.