Normalization of FFRCT after surgical unroofing of a myocardial bridge: a case report.

Background: Cardiac computed tomography angiography derived fractional flow reserve (FFRCT) is a diastolic measurement and has emerged as a valuable non-invasive alternative to FFR in patients with stable coronary artery disease. It has, unlike FFR during coronary angiography, not been validated for the physiological evaluation of an isolated myocardial bridge (MB) so far. Case summary: Our patient, previously known with a long myocardial bridge of the mid-segment of the left anterior descending artery, presented with a non-ST-segment elevation myocardial infarction that was treated by surgical unroofing of the MB. FFRCT after surgery confirms a major amelioration of coronary blood flow. Discussion: Myocardial bridge may rarely present as a non-ST-segment elevation myocardial infarction. FFRCT has thus far been accepted as a useful diagnostic tool in stable coronary artery disease. Our case report suggests that cardiac computed tomography angiography may be considered a useful technique for anatomical and physiological evaluation of MBs.

Clinical and prognostic incremental value of FFRCT in screening of patients with obstructive coronary artery disease.

BACKGROUND: Coronary computed tomography angiography (CCTA) -derived fractional flow reserve (FFRCT) is recommended to evaluate the functional consequences of obstructive coronary artery disease (OCAD). Real-world incremental impacts of FFRCT use still remains under debate. METHODS: 1601 patients with suspected OCAD on CCTA (>50 â€‹% stenosis), including 808 (50.5 â€‹%) patients evaluated by FFRCT, were included from a 2013-2021 registry. Propensity adjusted impacts of FFRCT use on rates of invasive coronary angiography (ICA), myocardial revascularization (MR) and post MR major adverse cardiac events (MACE) were reported, including a sensitivity analysis in severe OCAD (>70 â€‹% stenosis) (n â€‹= â€‹450). Accuracy of numerical and comprehensive FFRCT interpretations in selection of patients requiring a MR were also compared. RESULTS: 1160 (72,5 â€‹%) ICA, 559 (34.9 â€‹%) MR and 137 (24.5 â€‹%) post MR MACE occurred at 4.7 â€‹± â€‹1.9 years. FFRCT use was independently associated with decreased rate of ICA and MR (OR: 0.66; 95 â€‹% CI 0.53-0.83, p â€‹< â€‹0.001 and OR: 0.71; 95 â€‹% CI 0.58-0.88, p â€‹< â€‹0.01, respectively). Compared to the numerical interpretation, the FFRCT comprehensive assessment increased the ratio of MR per ICA (61.7 â€‹% vs 50.1 â€‹%, p â€‹< â€‹0.01) and was more accurate in selection of patients requiring MR. FFRCT reduced post MR MACE (OR: 0.64; 95 â€‹% CI 0.43-0.96, p â€‹< â€‹0.05). All these associations were no longer observed in severe OCAD. CONCLUSION: Implementing FFRCT in OCAD patients reduces ICA use, improves selection of patients requiring MR and reduces post MR MACE. However, these incremental values of FFRCT were no longer observed in severe OCAD.

Depression and Malnutrition for Prediction of Mortality after Transcatheter Aortic Valve Replacement: A Registry Study of a Tertiary Referral Hospital.

Moderate to severe frailty is a predictor of a poor outcome after transcatheter aortic valve replacement (TAVR), but little is known about the prognostic importance of different geriatric frailty markers in an overall fit or pre-frail geriatric population undergoing TAVR. This retrospective study aimed to examine the incremental value of adding patient frailty markers to conventional surgical risk score to predict all-cause mortality in relatively fit elderly patients undergoing TAVR. Overall patient frailty was assessed using the comprehensive geriatric assessment frailty index (CGA-FI). Multivariable Cox regression models were used to evaluate relationships of different geriatric frailty markers with all-cause mortality and single and combined frailty models were compared to a baseline model that included EuroSCORE II factors. One hundred relatively fit geriatric patients (84 ± 4 years old, mean CGA-FI 0.14 ± 0.05) were included, and 28% died during a median follow-up of 24 months. After adjustment, risk of depression (geriatric depression scale 15 (GDS-15)) and malnutrition remained significantly associated with all-cause mortality (HR 4.381, 95% CI 1.787-10.743; p = 0.001 and HR 3.076, 95% CI 1.151-8.217; p = 0.025, respectively). A combined frailty marker model including both GDS-15 and malnutrition on top of EuroSCORE II improved the discriminative ability to predict all-cause mortality (change in c-index: + 0.044). Screening for those frailty markers on top of the traditionally used EuroSCORE II may improve risk stratification and prognosis in relatively fit geriatric patients undergoing TAVR.

Effects of left ventricular mass on computed tomography derived fractional flow reserve in significant obstructive coronary artery disease.

BACKGROUND: In significant obstructive coronary artery disease (SOCAD), a mismatch in assessment of severity of coronary artery stenosis may occur between invasive coronary angiography (ICA) and computed tomography (CT) derived fractional flow reserve (FFRCT). The present study aimed to identify the factors giving an FFRCT > 0.80 and leading to an underestimation of coronary artery severity in SOCAD vessels. METHODS: A total of 141 consecutive patients who underwent both CT angiography including FFRCT and ICA, the latter showing >75% coronary artery stenosis were evaluated. Vessels were divided into two groups according to FFRCT at the distal aspect of the vessel: FFRCT > 0.80 (n = 12) and FFRCT ≤ 0.80 (n = 153). Vessel morphology, plaque characteristics, left-ventricular (LV) wall thickness at each site of the myocardium, and LV mass were also assessed. RESULTS: LV myocardium-related parameters including LV wall thickness (base, middle, apex, average, and maximal), LV mass, and LV mass index were higher in FFRCT > 0.80, whereas vessel-related parameters including, vessel morphology and plaque characteristics were not significantly different between >0.80 and < 0.80. Vessel morphology and plaque characteristics had no effect on FFRCT, whereas maximum LV wall thickness, LV mass, and LV mass index influenced FFRCT. LV mass index was the strongest predictor of distal FFRCT > 0.80 with an area under the curve of 0.81, and an optimal cut-off value of 66.5 g/m2 (sensitivity 77.8%, specificity 89.6%). CONCLUSIONS: The presence of a high LV mass is a major cause for underestimation of coronary artery severity on FFRCT in SOCAD vessels. LV myocardium-related parameters should be considered when interpreting numerical values of FFRCT.

Long term effects of surgical and transcatheter aortic valve replacement on FFRCT in patients with severe aortic valve stenosis.

The long-term variations of fractional flow reserve derived from coronary computed tomography (FFRCT) after surgical (SAVR) or transcatheter (TAVR) aortic valve replacement in patients with severe aortic valve stenosis (AS) have not been investigated. A total of 25 patients with isolated, severe AS underwent coronary computed tomography with 3-vessel FFRCT analysis (Heartflow Inc.-Redwood City, California, USA) and measurement of total coronary volume (V), left ventricular mass (M) and their ratio (V/M) before and 6 months after SAVR or TAVR. A significant increase in V/M due to a decrease in left ventricular mass 6 months after intervention was observed, whereas total coronary volume did not change (coronary volume pre: 2924.5 ± 867.9 mm3, coronary volume post: 2844.2 ± 792.8 mm3, P = 0.158; LV mass pre: 151.7 ± 40.7 g, LV mass post: 127.3 ± 34.7 g, P < 0.001; V/M pre: 19.5 ± 4.1 mm3/g, V/M post: 22.7 ± 4.28 mm3/g, P = 0.002). FFRCT (expressed as area under the virtual pullback curve) remained constant. This proof-of-concept study showed that FFRCT was not subject to the confounding effect of left ventricular mass regression after SAVR or TAVR. Despite significant left ventricular remodeling at 6 months after AS treatment, FFRCT values remained constant. Further studies are needed comparing the performance of the different invasive and non-invasive coronary physiological indices in this patient cohort.

Impact of vascular morphology and plaque characteristics on computed tomography derived fractional flow reserve in early stage coronary artery disease.

BACKGROUND: Computed-tomography (CT) derived fractional-flow-reserve (FFRCT) gradually may decrease from proximal to distal vessels even without apparent coronary artery disease (CAD). It may be unclear whether the decrease in FFRCT at the distal coronal artery is physiological or due to stenosis. We decided to study predictive factors of an FFRCT decline below the pathological value of 0.80 in no-apparent CAD. METHODS: A total of 150 consecutive patients who had both CT angiography coupled to FFRCT analysis and invasive angiogram showing < 20% coronary stenosis were included. Vessels were divided into two groups according to FFRCT at the distal vessel: FFRCT > 0.80 (n = 317) and FFRCT ≤ 0.80 (n = 114). ΔFFRCT was defined as the change in FFRCT from proximal to distal vessel. Vessel morphology (vessel length and lumen volume) and plaque characteristics [low-attenuation plaque volume, intermediate-attenuation (IAP) plaque volume, and calcified plaque volume] were evaluated. RESULTS: FFRCT decreased from proximal to distal for the three major vessels in both FFRCT > 0.80 and FFRCT ≤ 0.80. Compared to FFRCT > 0.80, IAP volume was significantly higher in all three major vessels in FFRCT ≤ 0.80. ΔFFRCT was correlated with vessel length and lumen volume in FFRCT > 0.80, whereas ΔFFRCT was correlated with IAP volume in FFRCT ≤ 0.80. IAP volume above 44.8 mm3 was the strongest predictor of distal FFRCT of ≤ 0.80. CONCLUSIONS: The presence of IAP is a major predictor of gradual decrease of FFRCT below 0.80 in no-apparent CAD vessels. Vessel morphology and plaque characteristics should be considered when interpreting FFRCT.

Streptococcal pharyngitis associated myocarditis (SPAM): the perfect ST-segment elevation myocardial infarction (STEMI) mimic in young individuals. A case series.

BACKGROUND: The mean prevalence of ST-segment elevation myocardial infarction (STEMI) in the absence of obstructive coronary artery disease is 5-6%, while one third of these cases is attributed to myocarditis. Streptococcal pharyngitis associated myocarditis (SPAM) is a rare form of myocarditis which appears shortly after a streptococcal pharyngitis and presents as a STEMI on the surface electrocardiogram. METHODS: We present the clinical course and outcome of two young and previously healthy individuals, diagnosed with SPAM. Both of them had a positive throat culture for streptococcus with a typical ST-segment elevation myocardial infarction (STEMI) on surface electrocardiogram. The coronary angiogram was normal, while cardiac imaging tests revealed myocarditis. The patients were treated with intravenous antibiotics and made a full clinical recovery within a couple of days. Echocardiography after discharge showed no residual ventricle wall hypokinesia. RESULTS: Streptococcal pharyngitis associated myocarditis (SPAM) presents as STEMI on surface ECG, with recent history of streptococcal pharyngitis, evidence of myocardial injury and normal epicardial coronary arteries. CONCLUSION: SPAM is an infrequent cause of myocarditis presenting as a STEMI and most commonly affects young individuals. Clinical examination and anamnesis can hint towards ongoing or recent pharyngitis whereas coronary angiography remains obligatory to exclude obstructive coronary artery disease. Positive throat culture and cardiac imaging compatible with myocarditis can confirm the diagnosis. Group A streptococcus is potentially the most frequent cause and Group B Streptococcus could be considered as a rare cause. Short-term prognosis appears to be favourable.

An irregular, extremely broad QRS complex rhythm.

We report a case of a 74-year-old lady admitted to the emergency department with a very broad QRS complex caused by flecainide intoxication due to acute renal failure. Appropriate recognition of the ECG changes and symptoms provoked by flecainide intoxication permitted quick directed treatment with intravenous administration of high dose sodium bicarbonate, which resolved the QRS elongation.

A shocking bike accident.

CLINICAL INTRODUCTION: A man in his late 40s presented with severe chest pain and progressive dyspnoea after hitting a tree at high speed during a bike ride in the woods. On admission, the patient appeared agitated, pale and sweaty. Core temperature was 35.5°C, respiratory rate 35/min and blood pressure 90/50 mm Hg with a regular pulse at 110 beats/min. Physical examination revealed multiple sternal bruises, distended jugular veins and muffled heart sounds (figure 1A). Lactate level was 4.4 mmol/L (normal <2.0 mmol/L) and high-sensitivity cardiac troponin T 0.142 mcg/L (normal <0.005 mcg/L). An ECG and a total body CT scan were performed (figure 1B,C).heartjnl;104/20/1706/F1F1F1Figure 1(A) Multiple sternal bruises. (B) ECG on admission. (C) Thoracic CT. QUESTION  WHAT IS THE MOST LIKELY DIAGNOSIS?: Inferior myocardial infarction with right ventricular involvement.Cardiac contusion with tamponade.Commotio cordis.Aortic laceration.

Transcatheter mitral paravalvular leakage closure: A beautiful last resort.

We describe a case of a 54-year-old patient with rheumatic heart valve disease who was treated with double valve replacement (both aortic and mitral) twice. Two months after the second operation she developed a severe mitral paravalvular leakage (PVL) leading to cardiogenic shock for which she was hospitalized in the intensive care unit. Multiple weaning efforts proved to be unsuccessful because of persistent hemodynamic instability caused by the severe PVL. Since re-redo cardiac surgery would have meant an unacceptable high peri-operative risk it was decided in the heart team to close the PVL by a transcatheter technique. This was done successfully and led to a spectacular hemodynamic improvement. Just 24 h after closure of the PVL she could be discharged from the intensive care unit and the day after the procedure she came walking into the echocardiography laboratory for an echocardiographic evaluation. This case demonstrates not only the feasibility of transcatheter closure of a PVL but also that this can be a true life-saving act. .

Relationship between time of day and periprocedural myocardial infarction after elective angioplasty.

OBJECTIVES: To test if the time of day significantly influences the occurrence of type 4A myocardial infarction in elective patients undergoing percutaneous coronary intervention (PCI). BACKGROUND: Recent studies have suggested an influence of circadian rhythms on myocardial infarction size and mortality among patients with ST-elevation myocardial infarction. The aim of the study is to investigate whether periprocedural myocardial infarction (PMI) is influenced by the time of day in elective patients undergoing PCI. METHODS: All consecutive patients undergoing elective PCI between 2007 and 2011 at our institutions with known post-interventional troponin were retrospectively included. Patients (n = 1021) were divided into two groups according to the starting time of the PCI: the morning group (n = 651) between 07:00 and 11:59, and the afternoon group (n = 370) between 12:00 and 18:59. Baseline and procedural characteristics as well as clinical outcome defined as the occurrence of PMI were compared between groups. In order to limit selection bias, all analyses were equally performed in 308 pairs using propensity score (PS) matching. RESULTS: In the overall population, the rate of PMI was statistically lower in the morning group compared to the afternoon group (20% vs. 30%, p < 0.001). This difference remained statistically significant after PS-matching (21% vs. 29%, p = 0.03). Multivariate analysis shows that being treated in the afternoon independently increases the risk for PMI with an odds ratio of 2.0 (95%CI: 1.1-3.4; p = 0.02). CONCLUSIONS: This observational PS-matched study suggests that the timing of an elective PCI influences the rate of PMI.

Ischemic stroke after administration of fibrinolytics in a patient with a ventricular pseudoaneurysm.

We present a case of a 66-year-old man with a preexisting left ventricular pseudoaneurysm as a sequel of an old inferoposterior myocardial infarction. The patient currently presented with respiratory insufficiency and chest pain. Based on his admittance electrocardiogram, he was treated with fibrinolytics for a presumed acute inferior ST-elevation myocardial infarction (in fact, the ST-elevations were the hallmark of the pseudoaneurysm). This treatment caused extensive ischemic stroke, as a consequence of dissolution and embolization of thrombi that were abundantly present in the pseudoaneurysm. The admittance electrocardiogram pointed out to be misleading to the treating physician and led to the unnecessary administration of fibrinolytics with serious complications.