Speckle Tracking Imaging in Normal Stress Echocardiography.

OBJECTIVES: Exercise stress echocardiography is a widely used modality for the diagnosis and follow-up of patients with coronary artery disease. During the last decade, speckle tracking imaging has been used increasingly for accurate evaluation of cardiac function. This work aimed to assess speckle-tracking imaging parameters during nonischemic exercise stress echocardiography. METHODS: During 2011 to 2014 we studied 46 patients without history of coronary artery disease, who completed exercise stress echocardiography protocol, had normal left ventricular function, a nonischemic response, and satisfactory image quality. These exams were analyzed with speckle-tracking imaging software at rest and at peak exercise. Peak strain and time-to-peak strain were measured at rest and after exercise. Clinical follow-up included a telephone contact 1 to 3 years after stress echo exam, confirming freedom from coronary events during this time. RESULTS: Global and regional peak strain increased following exercise. Time-to-peak global and regional strain and time-to-peak strain adjusted to the heart rate were significantly shorter in all segments after exercise. Rest-to-stress ratio of time-to-peak strain adjusted to the heart rate was 2.0 to 2.8. CONCLUSIONS: Global and regional peak strain rise during normal exercise echocardiography. Peak global and regional strain occur before or shortly after aortic valve closure at rest and after exercise, and the delay is more apparent at the basal segments. Time-to-peak strain normally shortens significantly during exercise; after adjustment to heart rate it shortens by a ratio of 2.0 to 2.8. These data may be useful for interpretation of future exercise stress speckle-tracking echocardiography studies.

Percutaneous coronary intervention of unprotected left main coronary artery in the emergent/urgent setting.

BACKGROUND: Treatment of unprotected left main coronary disease by percutaneous interventions, even in the urgent setting, is still not an approved indication. However, the evolution of transcatheter technology and supporting devices, along with greater skill in high-volume centers, led the interventional community to deal with these cases. This study aimed to investigate whether the percutaneous approach in this cohort could be a viable alternative to coronary artery bypass graft (CABG) surgery in the urgent setting. METHODS: We enrolled 51 acute myocardial infarction patients with left main disease as the culprit lesion and treated them by percutaneous coronary intervention. This cohort was followed for major adverse cardiac and cerebrovascular events (MACCE) in-hospital and at 30 days, 6 months and 1 year, and was compared with a population of 35 CABG patients matched for clinical and angiographic characteristics. RESULTS: The estimated MACCE-free survival at 6 months and 1 year was 90% and 88%, respectively. The overall MACCE was 6%. Analysis of the surgical cohort showed an overall MACCE of 17%. In the final Cox model, significant predictors of MACCE were Parsonnet score for surgical risk (HR 1.93, 95% CI 1.15-7.3; p = 0.04) and diabetes mellitus (HR 1.73, 95% CI 1.03-3.8; p = 0.038). CONCLUSIONS: Angioplasty for unprotected left main coronary disease in the urgent clinical setting is feasible, showing a relatively low short- and long-term rate of MACCE.

Optimization of myocardial perfusion after primary coronary angioplasty following an acute myocardial infarction. Beyond TIMI 3 flow.

UNLABELLED: Primary angioplasty has become the preferred therapeutic modality in patients with acute myocardial infarction (AMI). Despite restoration of antegrade epicardial flow by mechanical reperfusion therapy, angiographically assessed microvascular function and myocardial reperfusion (blush) allows for the stratification of patients with epicardial TIMI 3 flow into different strata of survival. Despite this fact, the best approach to achieving good myocardial blush has not yet been established. We sought to determine the efficacy of 3 different vasodilators. METHODS: A cohort of 40 patients were referred for primary angioplasty in the setting of STEMI; their TIMI 3 flow was achieved and myocardial blush (MB) was 0-1 (no myocardial opacification) according to the vant'Hof classification. The patients were assigned to 1 of 3 investigational groups: intracoronary (IC) injection of nitroprusside, adenosine and verapamil, and were compared with the control group: IC injection of nitroglycerin, their effect on MB, the sum ST-segment resolution and the left ventricular ejection fraction (LVEF) at 30 days. RESULTS: Nitroprusside proved to have the best effect on MB (p = 0.023). This correlated with an improvement in LVEF from the baseline (p = 0.048). Also, the sum ST-segment resolution showed a trend in favor of nitroprusside, but without statistical significance. CONCLUSION: IC injection of nitroprusside was more beneficial in reaching MB grade 3 in the setting of primary angioplasty for AMI, correlating with a significant improvement in LVEF at 30 days. Also, a trend toward the best ST-segment resolution was observed in the nitroprusside-treated group.