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.

Septic pseudo-aneurysm of the left main trunk in a dialysis patient.

This case report relating the association between a septic pseudo-aneurysm of the left trunk and myocardial infarction underscores the importance of early non-invasive imaging when acute myocardial infarction is associated with frank clinical or biological signs of systemic sepsis.

Left ventricular remodeling is associated with the severity of mitral regurgitation after inaugural anterior myocardial infarction--optimal timing for echocardiographic imaging.

BACKGROUND: Although mitral regurgitation (MR) has been associated with an increased risk of death and heart failure after myocardial infarction (MI), the relationship between post-MI MR and left ventricular (LV) remodeling has not been entirely clarified. In addition, the optimal timing for assessing MR after MI remains unknown. METHODS: Post-MI MR was assessed by Doppler echocardiography at hospital discharge (baseline) and after 3 months in 261 patients with an inaugural anterior MI. We studied LV remodeling during a 1-year period and clinical follow-up after 3 years, according to MR severity at baseline and at 3 months. RESULTS: Left ventricular remodeling was demonstrated as an increase in LV end-diastolic volume from 56 +/- 15 mL/m(2) at baseline to 63 +/- 19 mL/m(2) at 1 year (P < .0001). MR severity at baseline was not significantly associated with LV remodeling. By contrast, MR severity at 3 months was a strong indicator of LV remodeling. There was a graded increase in the proportion of patients with a >20% increase in LV end-diastolic volume between baseline and 1 year according to MR severity at 3 months (no MR: 21%, mild MR: 32%, moderate/severe MR: 60%) (P = .008). Both MR at baseline and at 3 months were associated with death or rehospitalization for heart failure by univariate analysis (P = .014 and P < .0001, respectively). By multivariable analysis, MR at baseline was not an independent predictor of adverse outcome (P = .66). By contrast, MR at 3 months was independently associated with adverse outcome with a hazard ratio of 2.23 (1.02-4.91 [P = .04]). CONCLUSIONS: After an inaugural anterior MI, MR is associated with LV remodeling and adverse clinical outcome. For prognostic purpose, the optimal timing for assessing MR is the chronic post-MI stage rather than the early post-MI period.

Prognostic importance of tissue Doppler-derived diastolic function in patients presenting with acute coronary syndrome: a bedside echocardiographic study.

AIMS: We sought to evaluate the prognostic value of bedside tissue Doppler derived diastolic function in patients presenting with acute coronary syndrome (ACS) on top of major clinical predictors of mortality and routine laboratory testings. METHODS AND RESULTS: Bedside Doppler echocardiography and laboratory tests were prospectively performed in 239 consecutive patients (mean age 62 +/- 14, 69% men) admitted for ACS. Ratio of early transmitral flow (E) to early mitral annulus velocities (e') was calculated. The study endpoint was cardiac death. The median follow-up period was 2 years. E/e' was >15 in 39 patients. Multivariate predictors of E/e' > 15 were older age, diabetes, non-ST-segment elevation ACS, and decreased LV ejection fraction (LVEF). Survival free from cardiac death was lower in patients with E/e' ratio >15 (P = 0.01). History of coronary artery disease, lower creatinine clearance, higher glycemia on admission, decreased LVEF, and E/e' >15 were independent predictors of cardiac death. CONCLUSION: Bedside Doppler echocardiography provides prognostic information on top of major clinical predictors of mortality and routine laboratory testings in patients presenting with ACS.

Mid-ventricular ballooning heart syndrome.

Stress cardiomyopathies have been increasingly reported these last years, especially in women as a transient left ventricular apical ballooning syndrome. We report six cases in whom, in the context of anxious situations, echocardiograms and ventriculographies revealed mid-ventricular akinesis with preservation of apical and basal contractilities with normal coronary arteriography. This "mid-ventricular ballooning heart syndrome " should probably be classified as a new type of heart stress related syndrome.

Momentarily stuck in the foramen ovale.

An 80-year-old woman was admitted for a diagnosis of severe pulmonary embolism. A large serpentine thrombus stuck in a patent foramen ovale (PFO) completely resolved without the patient experiencing any manifestation. The right renal artery was the final destination. Thromboaspiration was unsuccessful. Three months later, the patient was diagnosed with a malignant melanoma and metastatic dissemination.

Hemidiaphragmatic paralysis: an underestimated etiology of right-to-left shunt through patent foramen ovale?

OBJECTIVE: To report a specific pathophysiology of hemidiaphragmatic paralysis that may result in severe hypoxemia. DESIGN: Case series. SETTING: Intensive care unit in a cardiology hospital. PATIENTS: The series included three patients with refractory hypoxemia in whom a diagnosis of right-to-left-shunt through a patent foramen ovale was made by contrast echocardiography. The three patients had a complete right hemidiaphragmatic paralysis. INTERVENTION: Permanent percutaneous closure of the patent foramen ovale was successfully proceeded in all cases. MAIN RESULT: These procedures resulted in complete normalization of arterial oxygen saturation. CONCLUSION: To our knowledge, only three previous reports have described the association of right-to-left shunt through a patent foramen ovale and hemidiaphragmatic paralysis. Such association may be underestimated.

[What is the place of beta-adrenergic blockade therapy in coronary syndromes in the modern management era?]. / Bêta-bloquants et syndromes coronariens: les réponses d'hier s'appliquent-elles aux stratégies d'aujourd'hui?

This paper shows the eventual benefits of treatment with beta-blockers in post-myocardial infarction. An overview of main clinical trials that have been conducted to test this therapeutic in acute coronary syndrome. In patients presenting with acute myocardial infarction, the early use of intravenous beta-blockers had shown a modest and non significant reduction in mortality. Substantial reductions in mortality and reinfarction have been demonstrated when beta-blockers have been used soon after an acute myocardial infarction and continued long-term. However, these benefits were observed in randomised clinical trials conducted in the 1970s and 1980s, prior to the widespread use of reperfusion therapies and antiplatelet agents. It appears obvious that the long-term use of beta-blockers may be questionable after any acute coronary syndrome especially if complete reperfusion has been achieved and left ventricular function is preserved.

[Is there a role for calcium antagonists when beta-adrenergic blockade therapy is contraindicated in post-myocardial infarction?]. / Quelle est la place des inhibiteurs calciques lorsque les bêta-bloquants sont contre-indiqués dans le traitement du post-infarctus du myocarde?

The purpose of this paper is to examine the eventual benefits of treatment with calcium channel blockers in post-myocardial infarction, through an overview of main placebo-controlled trials that have been conducted to test this therapeutic in acute coronary syndromes. It appears obvious that the vast majority of these trials was conducted in the pre-reperfusion era and failed to demonstrate a reduction in mortality. To conclude, the superiority of a therapy with calcium antagonists over a placebo in the management of post-myocardial infarction remains unknown. In contrast, adverse effects associated with the prescription of calcium antagonists are well known.

[Not Available]. / Quelle est la place des inhibiteurs calciques lorsque les bêta-bloquants sont contre-indiqués dans le traitement du post-infarctus du myocarde ?

The purpose of this paper is to examine the eventual benefits of treatment with calcium channel blockers in post-myocardial infarction, through an overview of main placebo-controlled trials that have been conducted to test this therapeutic in acute coronary syndromes. It appears obvious that the vast majority of these trials was conducted in the pre-reperfusion era and failed to demonstrate a reduction in mortality. To conclude, the superiority of a therapy with calcium antagonists over a placebo in the management of post-myocardial infarction remains unknown. In contrast, adverse effects associated with the prescription of calcium antagonists are well known.