Balloon aortic valvuloplasty for severe aortic stenosis before urgent non-cardiac surgery.

BACKGROUND: Balloon aortic valvuloplasty (BAV) has been proposed as a therapeutic option in patients suffering from severe aortic stenosis (SAS) who need urgent non-cardiac surgery (NCS). Whether this strategy is better than medical therapy in this very specific population is unknown. AIMS: We aimed to evaluate the clinical benefit of an invasive strategy (IS) with preoperative BAV in patients with SAS requiring urgent NCS. METHODS: From 2011 to 2019, a registry conducted in two centres included 133 patients with SAS undergoing urgent NCS, of whom 93 underwent preoperative BAV (IS) and 40 a conservative strategy (CS) without BAV. All analyses were adjusted for confounding using inverse probability of treatment weighting (IPTW) (10 clinical and anatomical variables). RESULTS: The primary outcome was MACE at one-month follow-up after NCS including mortality, heart failure, and other cardiovascular outcomes. In patients managed conservatively, occurrence of MACE was 20.0% (n=8) and death was 10.0% (n=4) at 1 month. In patients undergoing BAV, the occurrence of MACE was 20.4% (n=19) and death was 5.4% (n=5) at 1 month. Among patients undergoing conservative management, all events were observed after NCS while, in patients undergoing BAV, 12.9% (n=12) had events between BAV and NCS including 3 deaths, and 7.5% (n=7) had events after NCS including 2 deaths. In IPTW propensity analyses, the incidence of the primary outcome (20.4% vs 20.0%; OR 0.93, 95% CI: 0.38-2.29) and three-month survival (89.2% vs 90.0%; IPTW-adjusted HR 0.90, 95% CI: 0.31-2.60) were similar in both groups. CONCLUSIONS: Patients with SAS managed conservatively before urgent NCS are at high risk of events. A systematic invasive strategy using BAV does not provide a significant improvement in clinical outcome.

Characterization of acute and chronic myocardial infarcts by multidetector computed tomography: comparison with contrast-enhanced magnetic resonance.

BACKGROUND: We evaluated whether contrast-enhanced multidetector computed tomography (CE-MDCT) might characterize myocardial infarct (MI) with patterns similar to those obtained by contrast-enhanced magnetic resonance (CE-MR) and studied the underlying mechanisms. METHODS AND RESULTS: In vivo infarct characterization by CE-MDCT was shown to be feasible between 4 and 20 minutes after contrast injection in 7 pigs with MI. Subsequently, in 16 patients with acute MI and 21 patients with chronic MI, contrast patterns by CE-MDCT were related to CE-MR. Eighteen patients had hypoenhanced regions on early CE-MDCT images at the time of coronary imaging, and 34 patients had hyperenhanced regions on images acquired 10 minutes later. On a segmental basis, there was moderately good concordance of early hypoenhanced regions (92%, kappa=0.54, P<0.001) and late hyperenhanced regions (82%, kappa=0.61, P<0.001) between CE-MDCT and CE-MR. Absolute sizes of early hypoenhanced (6+/-16 versus 7+/-16 g, P=0.25) and late hyperenhanced (36+/-34 versus 31+/-40 g, P=0.14) regions were similar on CE-MDCT and CE-MR and were highly correlated (r=0.93, P<0.001 and r=0.89, P<0.001 respectively). In 8 retrogradely perfused infarcted rabbit hearts, contrast kinetics of iomeprol were similar to gadodiamide, ie, slow wash in (8.7+/-6.7 versus 1.2+/-0.3 minutes, P<0.001) in infarct core and slow washout (20+/-12 versus 2.5+/-0.5 minutes, P<0.001) in both infarct core and rim compared with the remote region. CONCLUSIONS: Because iodated contrast agents have similar kinetics in infarcted and noninfarcted myocardium as gadolinium DPTA, CE-MDCT can characterize acute and chronic MI with contrast patterns similar to CE-MR. CE-MDCT may thus provide important information on infarct size and viability at the time of noninvasive coronary imaging.

Head-to-head comparison of three-dimensional navigator-gated magnetic resonance imaging and 16-slice computed tomography to detect coronary artery stenosis in patients.

OBJECTIVES: The purpose of this research was to compare the diagnostic accuracy of three-dimensional navigator-gated magnetic resonance (MR) imaging and 16-slice multidetector row computed tomography (MDCT) versus quantitative coronary angiography (QCA) for the detection of coronary artery stenosis in patients. BACKGROUND: Both MR and MDCT are novel non-invasive tests, which have been proposed for noninvasive detection of coronary artery disease. Yet their diagnostic accuracy has not been directly compared in the same population. METHODS: Fifty-two patients underwent coronary MR and 16-slice MDCT before invasive coronary angiography. Diameter stenosis (DS) severity in vessels >1.5-mm reference diameter were graded visually and measured quantitatively on both MR and MDCT images. Diagnostic accuracy of both methods was compared using QCA as the reference test. RESULTS: According to QCA, 81 of 452 (18%) coronary segments with >1.5 mm diameter had >50% DS. By visual analysis, MR and MDCT had similar sensitivity (75% vs. 82%, p = NS), specificity (77% vs. 79%, p = NS), and diagnostic accuracy (77%, vs. 80%, p = NS) for detection of >50 % DS. Quantitative measures of DS by MR (r = 0.60, p < 0.001) and MDCT (r = 0.75, both p < 0.001) correlated well with QCA. Receiver-operating characteristic analysis demonstrated that quantification of DS severity improved the diagnostic accuracy of MDCT (area under curve [AUC] 0.81 vs. 0.92, p < 0.001) but not that of MR (AUC 0.78 vs. 0.83, p = NS). CONCLUSIONS: Visual assessment of coronary diameter stenosis severity by MR or MDCT allows identification of significant coronary artery disease with a similar high diagnostic accuracy. Quantitative analysis significantly further improves the diagnostic accuracy of MDCT but not that of MR.

Relationship between transmural extent of necrosis and quantitative recovery of regional strains after revascularization.

OBJECTIVES: To better understand the quantitative relationship of recovery of regional and global dysfunction after revascularization in chronic infarcts with variable transmural extent of necrosis by delayed enhanced cardiac magnetic resonance. BACKGROUND: Studies relating transmurality of delayed enhanced magnetic resonance to functional recovery in dysfunctional myocardium using semiquantitative Likert scales have demonstrated the intermediate likelihood (50% probability) of recovery of dysfunction in subendocardial scars. METHODS: Forty-two patients with chronic left ventricular dysfunction due to coronary artery disease underwent tagged and delayed enhanced magnetic resonance before and 10 +/- 7 months after revascularization (coronary artery bypass graft: 35, percutaneous transluminal coronary angioplasty: 7). Left ventricular ejection fraction and regional mid-myocardial Eulerian radial thickening strain (Err) and mid-myocardial, subendocardial, and subepicardial Eulerian circumferential shortening strain (Ecc) strains were quantified in 16 segments per patient before and after revascularization and related to pre-operatively measured transmurality of necrosis. RESULTS: At baseline, 256 of 672 segments were dysfunctional, having <2 SD (i.e., >-10%) mid-myocardial Ecc. The magnitude of recovery of mid-myocardial Ecc (r = -0.33, p < 0.01) was inversely correlated with transmurality of necrosis before revascularization. Segments with <25% necrosis improved mid-myocardial Ecc and Err. No significant improvement of mid-myocardial Ecc or Err occurred when transmurality was > or =25%. However, subendocardial Ecc improved up to 75% transmural necrosis. Receiver-operator characteristic analysis determined optimal sensitivity (54%) and specificity (82%) for normalization of mid-myocardial Ecc (to <-10% Ecc) at a cutoff value of > or =18% transmural necrosis. Improvement of left ventricular ejection fraction (from 35 +/- 15% to 40 +/- 7%, p < 0.001) was best predicted (67% sensitivity, 58% specificity) by the presence of <4.5 dysfunctional segments with <75% transmural necrosis. CONCLUSIONS: The quantitative relationship between necrosis transmurality and improvement of regional and global dysfunction after revascularization is complex. Although improvement of recovery of regional mid-myocardial dysfunction after revascularization was observed only for scarring not exceeding 25% transmurality, global dysfunction significantly improved even when more extensive subendocardial scarring was revascularized.