Echocardiography Core Laboratory Methodology for TAVR: A Transatlantic Consensus.

Inter-echocardiography core laboratory (ECL) harmonization is pivotal to consider data from different ECLs interchangeable. On the basis of the experience of the first trans-Atlantic harmonization of 2 established ECLs in the field of transcatheter aortic valve replacement (TAVR) trials, this review describes the harmonized ECL methodology in analyzing and adjudicating the post-TAVR echocardiographic endpoints according to Valve Academic Research Consortium 3 definitions. This review presents the feasibility and intra- and inter-ECL reproducibility, explains the root cause of potential important inter-ECL variability, and formulates ECL recommendations for optimal post-TAVR echocardiographic image acquisition. The implementation of inter-ECL harmonization may further define the best practice of ECLs and have logistic and regulatory implications for the realization of future TAVR trials.

Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention in unprotected left main coronary artery disease: A systematic review.

BACKGROUND: Significant unprotected left main coronary artery (ULMCA) disease is encountered in approximately 5 % of patients undergoing diagnostic coronary angiography. Intravascular ultrasound (IVUS) overcomes many of the known limitations of angiography and improves outcomes of patients undergoing percutaneous coronary interventions (PCI) in stable or complex coronary artery disease. The aim of this systematic review is to evaluate the evidence on IVUS-guidance versus angiography-guidance in ULMCA PCI, highlighting the chronological frequencies of event rates in line with the maturation of PCI technique and devices over time. METHODS: A comprehensive systematic search in Medline was performed to identify all studies that had assessed the effect of IVUS-guided versus angiography-guided ULMCA PCI on various primary and secondary endpoints. RESULTS: Seventeen studies (2 randomized, 10 non-randomized and 5 meta-analyses) were included in this systematic review. CONCLUSIONS: This systematic review on IVUS-guided versus angiography-guided PCI in patients with significant ULMCA disease strongly supports the hypothesis that IVUS-guided PCI is associated with a significant reduction in major adverse cardiac events composites, all-cause death, cardiac death, myocardial infarction and stent thrombosis. Ongoing, adequately powered trials will contribute significantly to the level of evidence.

Echocardiography Core Laboratory Validation of a Novel Vendor-Independent Web-Based Software for the Assessment of Left Ventricular Global Longitudinal Strain.

BACKGROUND: Global longitudinal strain (GLS) is an accurate and reproducible parameter of left ventricular (LV) systolic function which has shown meaningful prognostic value. Fast, user-friendly, and accurate tools are required for its widespread implementation. We aim to compare a novel web-based tool with two established algorithms for strain analysis and test its reproducibility. METHODS: Thirty echocardiographic datasets with focused LV acquisitions were analyzed using three different semi-automated endocardial GLS algorithms by two readers. Analyses were repeated by one reader for the purpose of intra-observer variability. CAAS Qardia (Pie Medical Imaging) was compared with 2DCPA and AutoLV (TomTec). RESULTS: Mean GLS values were -15.0 ± 3.5% from Qardia, -15.3 ± 4.0% from 2DCPA, and -15.2 ± 3.8% from AutoLV. Mean GLS between Qardia and 2DCPA were not statistically different (p = 0.359), with a bias of -0.3%, limits of agreement (LOA) of 3.7%, and an intra-class correlation coefficient (ICC) of 0.88. Mean GLS between Qardia and AutoLV were not statistically different (p = 0.637), with a bias of -0.2%, LOA of 3.4%, and an ICC of 0.89. The coefficient of variation (CV) for intra-observer variability was 4.4% for Qardia, 8.4% 2DCPA, and 7.7% AutoLV. The CV for inter-observer variability was 4.5%, 8.1%, and 8.0%, respectively. CONCLUSIONS: In echocardiographic datasets of good image quality analyzed at an independent core laboratory using a standardized annotation method, a novel web-based tool for GLS analysis showed consistent results when compared with two algorithms of an established platform. Moreover, inter- and intra-observer reproducibility results were excellent.

Optical coherence tomography versus intravascular ultrasound for culprit lesion assessment in patients with acute myocardial infarction.

INTRODUCTION: In patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) the implanted stent may not fully cover the whole intravascular ultrasound (IVUS)-derived thin-cap fibroatheroma (TCFA) related to the culprit lesion (CL). AIM: Whether this phenomenon is more pronounced when optical coherence tomography (OCT) assessment of the CL is performed is not known. MATERIAL AND METHODS: Thus, we aimed to assess CLs in 40 patients with AMI treated with PCI, using VH (virtual histology)-IVUS and OCT before and after intervention. The results were blinded to the operator and PCI was done under angiography guidance. RESULTS: Uncovered lipid-rich plaques were identified in the stent reference segments of 23 (57.5%) patients: in 13 (32.5%) of them in the distal reference segment and in 19 (47.5%) of them in the proximal reference segment. In 9 of them (22.5%) lipid plaques were found in both reference segments. In 36 (90%) patients OCT confirmed lipid plaques identified as VH-derived TCFA by VH-IVUS in the reference segments of the stented segment. However, OCT confirmed that only in 2 (5%) patients were uncovered lipid plaques true TCFA as defined by histology. Comparing IVUS and OCT qualitative characteristics of the stented segments OCT detected more thrombus protrusions and proximal and distal stent edge dissections compared to IVUS (92.5 vs. 55%, p = 0.001; 20% vs. 7.5%, p = 0.03 and 25% vs. 5%, p < 0.001, respectively). CONCLUSIONS: Due to its superior resolution, OCT identifies TCFA more precisely. OCT more often shows remaining problems related to stent implantation than IVUS after angiographically guided PCI.

Percutaneous Dual-valve Intervention in a High-risk Patient with Severe Aortic and Mitral Stenosis.

Aortic stenosis is the most frequent and mitral stenosis is the least frequent native single-sided valve disease in Europe. Patients with the combination of severe symptomatic degenerative aortic and mitral stenosis are very rare. Guidelines for the treatment of heart valve diseases are clear for single-valve situations. However, there is no common agreement or recommendation for the best treatment strategy in patients with multiple valve disease and severe concomitant comorbidities. A 76-year-old female patient with the combination of severe degenerative symptomatic aortic and mitral stenosis and several comorbidities including severe obesity, who was found unsuitable surgical candidate by the heart team and unsuitable for two-time general anesthesia in the case of two-step single-valve percutaneous approach by anesthesiologists, underwent successful percutaneous dual-valve single-intervention (transcatheter aortic valve implantation and percutaneous mitral balloon commissurotomy). Percutaneous dual-valve single-intervention is feasible in selected symptomatic high-risk patients.

Complete infarct-related artery revascularization in acute myocardial infarction patients. CORAMI Registry.

INTRODUCTION: There are still limited data on the occurrence of multiple stenotic lesions within the infarct-related artery (IRA) in acute myocardial infarction (MI), and there is no consensus on the optimal treatment of this patient subgroup, which varies between centers and operators. AIM: To analyse the clinical efficacy of percutaneous coronary intervention (PCI) strategy of culprit lesion only in patients with myocardial infarction. MATERIAL AND METHODS: Patients with acute MI with the presence of at least two significant lesions in the IRA - (1) the target culprit lesion which required immediate stenting (> 50-100% stenosis) and (2) a second distal critical lesion (70-90%) - were included in the registry. Both lesions in the IRA were considered to be independent lesions requiring two separate stent platforms to be covered (no overlap). The decision on the treatment strategy of either complete (CR) or culprit-lesion-only (CLO) revascularization was at the discretion of the operator. RESULTS: There were altogether 95 patients enrolled in the registry, 63 (66%) in the group with CR of the IRA and 32 (34%) with CLO revascularization, which did not differ in terms of baseline demographics. In-hospital and long-term outcomes were similar between the groups. Stent thrombosis at 1 year occurred in 1.6% in CR and in 6.2% in CLO groups respectively (statistically not significant). There were no patients from the CLO group who had a planned percutaneous coronary intervention (PCI) of the 2(nd) lesion in the IRA during 1-year observation. CONCLUSIONS: At 1 year the clinical outcome was similar between those with complete and CLO PCI. Complete coverage of significant lesions did not increase the risk of stent thrombosis or need for repeated revascularization in long-term observation.

Radiofrequency-intravascular ultrasound assessment of lesion coverage after angiography-guided emergent percutaneous coronary intervention in patients with non-ST elevation myocardial infarction.

Using radiofrequency-intravascular ultrasound (VH-IVUS), we have previously demonstrated that in 50% of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention with optimal angiographic result, the stent does not fully cover the whole VH-IVUS-derived thin-cap fibroatheroma (VH-TCFA) related to the culprit lesion. Presently, we set out to extend these findings to 20 patients with non-STEMI with Thrombolysis In Myocardial Infarction flow 3 in the infarct-related artery before intervention who were then treated with angiography-guided direct stent implantation. The lesion was imaged with VH-IVUS before and after intervention, but the results were blinded to the operator. Plaque rupture site was identified in 8 lesions (40%), all proximal to the minimum lumen area (MLA) site. The maximum necrotic core site was found proximal to MLA in 18 lesions and at the MLA in 2 lesions. Although the plaque rupture site was fully covered with the stent in all lesions, an uncovered VH-TCFA was found in 7 lesions (35%), 4 in the proximal reference segment, 1 in the distal reference segment, and 2 in both the proximal and distal reference segments. In conclusion, in 35% of patients with non-STEMI undergoing angiography-guided emergent percutaneous coronary intervention, the stent does not fully cover a VH-TCFA related to the culprit lesion.

Virtual histology-intravascular ultrasound assessment of lesion coverage after angiographically-guided stent implantation in patients with ST Elevation myocardial infarction undergoing primary percutaneous coronary intervention.

An occlusion or severe stenosis (angiographic culprit lesion) of the infarct-related artery is frequently located at the site of the maximum thrombus burden, whereas the origin of the plaque rupture (the true culprit) can be situated proximal or distal to it. The aim of this study was to examine stent coverage of true culprit lesions in 20 patients who underwent primary percutaneous coronary intervention and had Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow restored in the infarct-related artery by angiographically guided direct stenting. Images of lesions were obtained using virtual histology-intravascular ultrasound before and after intervention (blinded to the operator). Plaque rupture sites were identified by intravascular ultrasound in 12 lesions (60%), 11 proximal and 1 distal to the minimum luminal area (MLA). Maximum necrotic core sites were found proximal to the MLA in 16 lesions, at the MLA in 3 lesions, and distal to the MLA in 1 lesion. Plaque rupture sites were fully covered by stents in 11 lesions. Virtual histology-intravascular ultrasound-derived thin-cap fibroatheroma longitudinal geographic misses were found in 10 lesions, 7 in the proximal reference segment and in 3 patients in the proximal and distal reference segments. In conclusion, in about 50% of patients who undergo primary percutaneous coronary intervention for ST-segment elevation myocardial infarction with optimal angiographic results, the stent does not fully cover the maximum necrotic core site related to the culprit lesion.

Cardiac granulocytic sarcoma diagnosed by intracardiac echocardiography-guided biopsy.

A 52-year-old man presented with clinical and echocardiographic signs of cardiac tamponade. A transthoracic echocardiogram revealed a large right atrial mass that obstructed the superior vena cava flow. Cardiac magnetic resonance imaging and computed tomography demonstrated extracardiac tumour invasion of the free atrial wall extending to the right pulmonary hilus. Intracardiac echocardiography-guided biopsy of the tumour revealed the tissue diagnosis-granulocytic sarcoma of the heart. The patient was effectively treated with radiotherapy, chemotherapy and allogeneic haematopoietic stem cell transplantation. He has remained free of the disease for 12 months after treatment.