Effects of Nicorandil Administration on Infarct Size in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: The CHANGE Trial.

Background Nicorandil was reported to improve microvascular dysfunction and reduce reperfusion injury when administered before primary percutaneous coronary intervention. In this multicenter, prospective, randomized, double-blind clinical trial (CHANGE [Effects of Nicorandil Administration on Infarct Size in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention]), we investigated the effects of nicorandil administration on infarct size in patients with ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention. Methods and Results A total of 238 patients with ST-segment-elevation myocardial infarction were randomized to receive intravenous nicorandil (n=120) or placebo (n=118) before reperfusion. Patients in the nicorandil group received a 6-mg intravenous bolus of nicorandil followed by continuous infusion at a rate of 6 mg/h. Patients in the placebo group received the same dose of placebo. The predefined primary end point was infarct size on cardiac magnetic resonance (CMR) imaging performed at 5 to 7 days and 6 months after reperfusion. CMR imaging was performed in 201 patients (84%). Infarct size on CMR imaging at 5 to 7 days after reperfusion was significantly smaller in the nicorandil group compared with the placebo (control) group (26.5±17.1 g versus 32.4±19.3 g; P=0.022), and the effect remained significant on long-term CMR imaging at 6 months after reperfusion (19.5±14.4 g versus 25.7±15.4 g; P=0.008). The incidence of no-reflow/slow-flow phenomenon during primary percutaneous coronary intervention was much lower in the nicorandil group (9.2% [11/120] versus 26.3% [31/118]; P=0.001), and thus, complete ST-segment resolution was more frequently observed in the nicorandil group (90.8% [109/120] versus 78.0% [92/118]; P=0.006). Left ventricular ejection fraction on CMR imaging was significantly higher in the nicorandil group than in the placebo group at both 5 to 7 days (47.0±10.2% versus 43.3±10.0%; P=0.011) and 6 months (50.1±9.7% versus 46.4±8.5%; P=0.009) after reperfusion. Conclusions In the present trial, administration of nicorandil before primary percutaneous coronary intervention led to improved myocardial perfusion grade, increased left ventricular ejection fraction, and reduced myocardial infarct size in patients with ST-segment-elevation myocardial infarction. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03445728.

Effects of Liraglutide on Reperfusion Injury in Patients With ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: Liraglutide, a glucagon-like peptide-1 analog, was reported to reduce reperfusion injury in mice. We planned to evaluate the effects of liraglutide on reperfusion injury in patients with acute ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention. METHODS AND RESULTS: A total of 96 patients with ST-segment-elevation myocardial infarction undergoing emergency primary percutaneous coronary intervention were randomized to receive either subcutaneous liraglutide or placebo. Study treatment was commenced 30 minutes before intervention (1.8 mg) and maintained for 7 days after the procedure (0.6 mg for 2 days, 1.2 mg for 2 days, followed by 1.8 mg for 3 days). The salvage index was calculated from myocardial area at risk, measured during the index admission (35±12 hours), and final infarct size measured at 91±5 days after primary percutaneous coronary intervention by cardiac magnetic resonance. At 3 months, the primary end point, a higher salvage index was found in the liraglutide group than in the placebo group in 77 patients evaluated with cardiac magnetic resonance (0.66±0.14 versus 0.55±0.15; P=0.001). The final infarct size was lower in the liraglutide group than that in the placebo group (15±12 versus 21±15 g; P=0.05). Serum high-sensitivity C-reactive protein level was lower in the liraglutide group (P<0.001). During a 6-month follow-up period, no difference was observed in the incidence of major adverse cardiovascular event. Safety and tolerability were similar among the 2 groups. CONCLUSIONS: Our study provides evidence that liraglutide improves myocardial salvage and infarct size after ST-segment-elevation myocardial infarction, possibly by reducing reperfusion injury, making it a promising treatment for evaluation in larger trials. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02001363.

Neovascularization in the carotid atherosclerotic plaque is not associated with inflammatory cell aggregation.

BACKGROUND: Monocytes and macrophages in atherosclerotic plaque lead to plaque instability. The aim of the study was to determine if plaque neovascularization led to inflammation. METHODS: Patients were consecutively enrolled if their carotid intimal media thickness was > 2 mm, as revealed by duplex ultrasound. The patients then underwent dynamic contrast enhanced magnetic resonance imaging (DCE MRI) and fluorine-18 fluorodeoxyglucose ((18)F-FDG) positron emission tomography combined with computed tomography (PET CT). A target to background ratio (TBR) of ≥ 1.25 or < 1.25 served as the cutoff point for the presence and absence of inflammation, respectively. RESULTS: Twenty-six patients underwent bilateral carotid DCE MRI and 24 patients also underwent PET CT. One hundred and fifty-five plaques were evaluated by both DCE MRI and PET CT. There was no significant difference in plaque morphology between the TBR ≥ 1.25 (n = 61) and TBR < 1.25 (n = 94) groups. No significant differences were found in plasma volume and transfer constant between the TBR ≥ 1.25 and TBR < 1.25 groups. CONCLUSION: Our study did not find a significant correlation between plaque neovascularization and the aggregation of inflammatory cells.

[Clinical value of double respiratory navigator-gated high-resolution black-blood coronary artery wall magnetic resonance imaging].

OBJECTIVE: To explore the value of phase ordering with automatic window selection(PAWS)and simultaneous multiple volume(SMV)algorithm double respiratory navigator-gated two-dimensional(2DNAV)dual inversion recovery(DIR)fast spin echo(FSE)high-resolution black-blood coronary artery wall magnetic resonance imaging(MRI)and evaluate its advantages and limitations. METHODS: PAWS and SMV 2DNAV DIR FSE high-resolution black-blood MRI was performed in 21 healthy volunteers. The images were evaluated qualitatively by using four grades(grade 0can not evaluate;grade 1bad;grade 2good;grade 3perfect). Images defined as grade 0 and grade 1 were excluded and those defined as grade 2 and 3 were evaluated further. Thickness of proximal(or middle)segment of right coronary artery(RCA)and left anterior descending branch(LAD)were measured. The difference of wall thickness was analyzed by using two-tailed independent sample t-test. P values of less than 0.05 were considered statistically significant. RESULTS: Among the 38 slice images,31 slices(RCA13 slices,LAD18 slices;grade 214 slices,grade 317 slices)were obtained for further evaluation. The mean thickness of RCA and LAD was(0.94±0.16)and(0.89±0.15)mm,respectively,and the difference was not significant(t=-0.790,P>0.05). CONCLUSION: PAWS and SMV algorithm 2DNAV DIR FSE high-resolution black-blood MRI has certain clinical value for coronary artery wall imaging.

Application of immediate breast reconstruction with silicon prosthetic implantation following bilateral mammary gland excision in treatment of young patients with early breast cancer.

OBJECTIVE: To evaluate the application of immediate breast reconstruction (IBR) with silicon prosthetic implantation following bilateral nipple-preserving subcutaneous mammary gland excision in the treatment of young patients with early breast cancer. METHODS: We retrospectively analyzed the clinical data of 21 patients with breast cancer who were performed on IBR following bilateral nipple-preserving subcutaneous mammary gland excision in our hospital from January 2006 to March 2011. RESULTS: The operations were successful in all the 21 patients. Also, the treatment provided a good cosmetic effect. No local recurrence or distant metastasis was found in these 21 patients during the 6-66-month follow-up. CONCLUSIONS: For the young patients with early breast cancer, mammary gland excision on the affected side along with prophylactic excision of the contralateral side, namely IBR following bilateral nipple-preserving subcutaneous mammary gland excision, provides good clinical effectiveness and cosmetological effects.

[Diagnostic value of MRI and MR arthrography in the detection of injuries of anterior labrum in shoulder].

OBJECTIVE: To investigate the diagnostic value of MRI and MR arthrography in the detection of injuries of anterior labrum in shoulder and to evaluate the accuracy of MR arthrography in the classification of anterior labrum lesion. METHODS: Seventy-eight patients with arthroscopically proved anterior labrum lesions(study group) and 75 patients with arthroscopically proved intact anterior labrum (control group) from January 2007 to December 2010 were included to the study. All patients underwent MRI and MR arthrography at our institution prior to shoulder arthroscopy. All MRI and MR arthrography were analyzed by one musculoskeletal radiologists and one sports medicine surgeon who had no knowledge of the clinical histories and arthroscopic results. The same classification system of labrum lesions based on arthroscopy was used in image analysis. Imaging findings and arthroscopic findings were compared in all patients. With arthroscopy used as the standard of reference, the sensitivities, specificities and accuracies of MRI and MR arthrography in the detection of anterior labrum lesions were compared, and the sensitivities, specificities and accuracies of MR arthrography in the correct classification of anterior labrum lesions were calculated. RESULTS: In arthroscopy, 78 anterior labrum lesions, 67 rotator cuff lesions and 8 SLAP lesions were diagnosed, for the detection of anterior labrum lesions, the sensitivity of MRI and MR arthrography was 80.8% and 92.3%,the specificity was 89.3% and 97.3%,the accuracy was 85.0% and 94.8% respectively. Seventy-eight patients with arthroscopically proved anterior labrum lesions included 39 Bankart lesions, 32 ALPSA lesions and 7 Perthes lesions, with MR arthrography, Bankart, ALPSA, and Perthes lesions were correctly classified in 84.6%, 84.4%, and 57.1% of cases, respectively. CONCLUSION: MR arthrography has a higher sensitivity, specificity and accuracy than MRI in the detection of anterior labrum injuries. MR arthrography was useful in the classification of different variants of anterior labrum injuries before operations. It may directly influence the surgeon's strategy and is useful in preoperative planning of arthroscopic reconstructions.

Progressive deterioration of left ventricular function in a patient with a normal coronary angiogram.

Cardiac ischemia with a normal coronary angiogram can be caused by coronary microvascular dysfunction. A favorable prognosis, with excellent long-term clinical outcome, without major acute coronary events, has been consistently reported in these patients. We report a patient with a normal coronary angiogram and 3 episodes of myocardial infarctions, where the formation of a ventricular aneurysm and progressive deterioration of left ventricular function was documented, and hypoperfusion of the myocardium was confirmed by cardiovascular magnetic resonance imaging. This case suggests that myocardial ischemia caused by coronary microvascular dysfunction could have a poor prognosis. Whether this case represents a special clinical condition which is between the cardiac syndrome X and coronary artery disease remains to be investigated.

DW-MRI ADC values can predict treatment response in patients with locally advanced breast cancer undergoing neoadjuvant chemotherapy.

The purpose of this study was to evaluate the importance of diffusion-weighted magnetic resonance imaging (DW-MRI) apparent diffusion coefficient (ADC) values to predict treatment response to neoadjuvant chemotherapy (NCT) in patients with locally advanced breast cancer (LABC). Thirty-two patients with LABC underwent 2-4 cylces of NCT (docetaxel and epirubicin). The DW-MRI scans were performed within one week prior to chemotherapy and after the first course of treatment, respectively. Accordingly, tumor volumes, changes in tumor ADC values, and their degree of correlation were analyzed. The overall response (OR) was observed in 62.5% (95% CI, 45.7-79.3%) of patients after 2 cycles of NCT. The clinical complete response (CR) rate and pathological CR (pCR) rate were 15.6 and 9.4%, respectively. The stable disease (SD) rate was 34.4% (11 patients), and progressive disease (PD) was observed in only one patient (3.1%). After the first cycle of NCT, the ADC values in the CR + PR group significantly increased (P < 0.001). The initial ADC values before chemotherapy in the OR group were significantly lower than those in the SD + PD group (P < 0.001). The initial ADC values and the changes in tumor volume after chemotherapy were negatively correlated (r = -0.58, P = 0.02). The lower the initial tumor ADC value was the more obvious the decrease in tumor volume after chemotherapy. The changes in ADC values of tumors after chemotherapy and the changes in tumor volume were positively correlated (r = 0.96, P < 0.001). After chemotherapy, the greater the change in ADC value, the more the tumor volume was reduced. Using the initial ADC values of breast cancer tumors and the early changes in ADC values after NCT, we may be able to predict tumor response to chemotherapy. Tumors with low initial ADC values may be sensitive to chemotherapy; tumors with significantly increasing ADC values early after chemotherapy may be sensitive to chemotherapy.

Intraoperative radiotherapy in patients with breast cancer treated by breast-conserving therapy.

OBJECTIVE: To assess the safety, cosmetic effects, and clinical efficacy of breast-conserving surgery combined with intraoperative radiation therapy for the treatment of Chinese patients with breast cancer. METHODS: Breast-conserving surgery combined with intraoperative radiation therapy was performed in 64 breast cancer patients. The postoperative short-term efficacy, safety, and cosmetic effects were assessed. RESULTS: Of the 64 patients, 1 case (1.6%) had local recurrence one year later, 7 cases (10.9%) had grade I postoperative radiation-induced lung injury, 10 cases (15.6%) had local hardening at the surgical sites, 8 cases (12.5 %) had changes in skin color, and 8 cases (12.5%) had pain at the surgical sites. Excellent or good levels of cosmetic effects were achieved in 95.3% of the patients. CONCLUSIONS: The application of intraoperative radiation therapy with breast-conserving surgery can yield satisfactory short-term curative efficacy, a high level of clinical safety, and good cosmetic effects.

Effects of omega-3 fatty acid for sudden cardiac death prevention in patients with cardiovascular disease: a contemporary meta-analysis of randomized, controlled trials.

PURPOSE: Experimental and epidemiological studies suggest that omega-3 fatty acids have an antiarrhythmic effect. However, evidence from randomized controlled trials (RCTs) for prevention of sudden cardiac death (SCD) remains controversial. This study sought to evaluate the efficacy of omega-3 fatty acids for secondary prevention of SCD in patients with cardiovascular disease (CVD) in the era of guidelines-based therapy. METHODS: We conducted a PubMed/EMBASE/CENTRAL search for RCTs evaluating omega-3 fatty acids for CVD secondary prevention with at least 6 months follow-up and with data on SCD. Primary outcome was SCD. Secondary outcomes were cardiovascular mortality and all-cause mortality. RESULTS: Ten randomized controlled trials were identified evaluating a total of 33,429 patients with CVD. In patients with guidelines-adjusted therapy, omega-3 fatty acids did not reduce the risk ratio (RR) of SCD (RR:0.96; 95% CI: 0.84-1.10). In patients with non- guidelines-adjusted therapy, omega-3 fatty acids reduced the RR of SCD (RR: 0.64; 95% CI: 0.51-0.80). Overall, RR for cardiac death and all-cause mortality were 0.81 (95% CI: 0.69-0.95) and 0.89 (95% CI: 0.79-1.01), respectively. CONCLUSIONS: In the era of guidelines-adjusted treatment for CVD secondary prevention, omega-3 fatty acids do not appear to reduce SCD.

[MR image-guided anterior direct arthrography of the shoulder].

OBJECTIVE: To investigate the method of MR guided anterior direct arthrogaphy of shoulder and its clinical applications. METHODS: From 2008.4 to 2008.10, 40 patients with rotator-cuff tear (29 males and 11 females, ranging in age from 22 to 70 years, with an average of 35 years) underwent MR guided anterior direct arthrogaphy of shoulder, so as to diagnosis shoulder wound. The results were compared to that of arthroscopy. RESULTS: Shoulder arthrography showed lesons in 36 patients, and failure in 2 patients, including contrast media extravasation in 1 patient, and gas entry to joint cavity in 1 patient. Two patients showed no rotator cuff injuries. Twenty-eight patients were confirmed by arthroscopy as rotator-cuff injured in different degree. Twenty-six patients were confirmed injuries by both arthroscopy and MR guided anterior direct arthrogaphy. CONCLUSION: MR guided anterior direct arthrogaphy of shoulder as a minimally invasive method in displaying the rotator-cuff tear has higher accuracy and wide clinical application prospect.

Feasibility of integrating high-spatial-resolution 3D breath-hold coronary MR angiography with myocardial perfusion and viability examinations.

The study was institutional review board approved and Health Insurance Portability and Accountability Act compliant. All subjects provided informed consent. Three-dimensional breath-hold coronary magnetic resonance (MR) angiography with use of steady-state free precession was performed in 12 patients up to 20 minutes after 0.2 mmol gadolinium-based contrast material per kilogram of body weight was administered. Within 24 heartbeats, a spatial resolution of up to 1.0 x 1.2 x 2.0 mm was achieved. Sixty-five (82%) of the 79 visualized coronary artery segments had a grade of 3 or 4 on a four-point scale of depiction in which grade 4 indicated excellent depiction. Twenty-seven percent (n = 21) of the 79 segments were assigned a grade of 4; 56% (n = 44), a grade of 3; 16% (n = 13), a grade of 2; and 1% (n = 1), a grade of 1. Coronary MR angiography performed as part of a first-pass myocardial perfusion and viability assessment MR imaging examination is feasible and does not involve additional imaging time.