Global longitudinal strain and long-term outcomes in asymptomatic extracardiac sarcoid patients with no apparent cardiovascular disease.

PURPOSE: Global longitudinal strain (GLS) is increasingly accepted as a predictor of mortality in various clinical settings. This study tested the hypothesis that GLS is associated with increased event rate in patients with extracardiac sarcoidosis, who have no overt symptoms of cardiovascular disease and preserved ejection fraction (EF). METHODS: We retrospectively studied 117 patients with extracardiac sarcoidosis and 45 age- and sex-matched controls, who underwent comprehensive echocardiographic study, while GLS was measured by an offline speckle tracking algorithm. Patients who had signs and symptoms of cardiovascular disease at the time of the examination were excluded from the study. Patients were followed for an average of 57.1 months. Primary endpoint was defined as a composite endpoint of heart failure-related hospitalizations, need for device therapy, arrhythmias, and all-cause mortality. RESULTS: The age of patients was 42 ± 6 years old (43 men). Events were recorded in 10 patients (8.5%). Tissue Doppler revealed E/Em 7.9 ± 3.5, while EF was 54.2 ± 3.5%. Global longitudinal strain was 14.4 ± 3%, and a cutoff value ≤-13.6% for GLS was considered more associated with adverse outcomes (AUC 0.84). After adjustment for multiple potential confounders (age, gender, hypertension, diabetes, E/Em, and EF), GLS remained strongly associated with adverse outcomes (HR 0.8, 0.63 to 0.98 95% C.I, P = .04). CONCLUSIONS: In conclusion, among patients with extracardiac sarcoidosis and no symptoms of cardiovascular disease, even when EF is preserved, GLS seems to be strongly associated with adverse future events.

Two-dimensional speckle tracking for the assessment of coronary artery disease during dobutamine stress echo: clinical tool or merely research method.

BACKGROUND: Two-dimensional speckle tracking provides valuable information for regional wall motion abnormalities. The purpose of this study was to determine the diagnostic value of left ventricular longitudinal strain and torsion to diagnose coronary artery disease during dobutamine stress echocardiography. METHODS: We studied 100 patients (mean age 60.8 ± 10.7 years, 72 male) with known or suspected coronary artery disease, excluding those with prior history of transmural infraction. All of them underwent dobutamine stress echo and coronary angiography within one month. Wall-motion score index, left ventricular global longitudinal strain and torsion were measured at rest and peak stress. Additionally, the respective differences between rest and stress were also calculated. Optimal cut-offs were derived from receiver operating characteristic curves for strain and torsion values. RESULTS: Mean left ventricular ejection fraction was 55 ± 5.4 %. Coronary angiography revealed significant lesions in 67 patients. Values regarding sensitivity, and specificity for wall motion score index difference were 78 % and 88 % respectively (area under curve 0.84). Global longitudinal strain difference (median 0.5 %) illustrated 81 % sensitivity and 72 % specificity for disease detection (area under curve 0.80, cut-off value ≤0 %). The respective values for torsion difference (median 4.7°) were 81 % and 82 % (area under curve 0.76, cut-off value ≤6.5°). Combination of wall motion score index difference and torsion difference for disease detection showed 91 % sensitivity and 79 % specificity (area under curve 0.85). CONCLUSIONS: The implementation of speckle tracking during dobutamine stress echo could serve as an adjunct method for coronary artery disease assessment, providing quantitative diagnostic information.

Myocardial ischaemia without obstructive coronary artery disease in rheumatoid arthritis: hypothesis-generating insights from a cross-sectional study.

OBJECTIVE: RA is associated with increased cardiovascular events, reportedly to equal diabetes mellitus (DM). The presence of myocardial ischaemia was assessed in asymptomatic high-risk RA patients and compared with patients with DM and a healthy control group. METHODS: Eighteen consecutive non-diabetic RA patients without known cardiovascular disease who developed a new carotid atheromatic plaque during the last 3 years were matched 1:1 for traditional cardiovascular risk factors with asymptomatic type 2 DM patients and 1:2 with asymptomatic non-RA, non-DM control subjects. After dobutamine stress contrast echocardiography with wall-motion and perfusion evaluation, coronary angiography was performed in those with positive stress tests. RESULTS: Ischaemia by echocardiography was found in 67% of RA patients; this was significantly higher than controls (31%, P = 0.019) but comparable to those with DM (78%, P = 0.71). Angiography performed in eight consenting RA patients was normal in four, revealed non-flow-limiting coronary atheromatic lesions in two and significant lesions in two patients. RA patients with ischaemia had CRP serum levels significantly higher by six-fold compared with those with normal stress echocardiography. CONCLUSION: Asymptomatic RA patients may display myocardial ischaemia at similar levels to DM patients but with low prevalence of obstructive coronary artery disease. Microvascular abnormalities associated with increased inflammatory response may account for these findings. Their exact nature and significance require further evaluation.

Assessment of left atrial function after percutaneous closure of patent foramen ovale.

BACKGROUND: The influence of atrial septal occluders in left atrial (LA) function after percutaneous closure of patent foramen ovale (PFO) has not been thoroughly studied. METHODS: Twenty-five patients (mean age 40.7 ± 12 years) undergoing percutaneous PFO closure were enrolled in this study. Transthoracic echocardiogram (TTE) was performed 3 and 6 months before the procedure. Volumetric indices (active emptying fraction: LA AEF, expansion index: LA EI, and passive emptying fraction: LA PEF), strain and strain rate (SR), were calculated during the contractile, reservoir, and conduit LA phases for the lateral, anterior, and inferior LA walls with TTE. RESULTS: After 3 months, a decrease in the SR of the LA anterior wall was observed (from 2.12 ± 0.22 to 1.66 ± 0.26, P < 0.045), while the LA lateral wall strain was found to be increased (from 0.708 ± 0.15 to 0.783 ± 0.159, P < 0.001). Moreover, simultaneously LA AEF was greater compared with baseline (from 31.0 ± 1.6 to 34.0 ± 1.6, P < 0.004). However, all these alterations reversed at 6 months. CONCLUSIONS: Segmental LA function is altered transiently after percutaneous PFO closure with a septal occlude. The LA anterior wall SR decreases, while the lateral wall strain increases. The impact of these alterations needs further clarification.

In-stent Thrombosis and COVID-19 Infection: Current Insights on the Mechanistic Relationship.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been demonstrated as a major risk factor in inducing coronary stent thrombosis due to its propensity to create a pro-thrombotic state. This review explores the mechanisms that may contribute to the increased thrombosis risk seen in COVID-19. Furthermore, we discuss the patient and haematological factors that predispose to an increased risk of stent thrombosis, as well as the role of certain antiplatelet and anticoagulation therapies, including ticagrelor and enoxaparin, that may reduce the likelihood and severity of in-stent thrombosis, in SARS-CoV-2 infection. To counter the proinflammatory and pro-thrombotic state shown in COVID-19, anti-thrombotic therapy in the future may be optimised using point-of-care platelet inhibition testing and inflammation-modifying therapies. Large-scale randomised trials with long-term follow-up are increasingly necessary to assess the intersection of COVID-19 and stent optimisation as well as the reduction of stent thrombosis after drug-eluting stent (DES) implantation.

Validation of the MIRACLE2 Score for Prognostication After Out-of-hospital Cardiac Arrest.

Background: Out-of-hospital cardiac arrest (OHCA) is associated with very poor clinical outcomes. An optimal pathway of care is yet to be defined, but prognostication is likely to assist in the challenging decision-making required for treatment of this high-risk patient cohort. The MIRACLE2 score provides a simple method of neuro-prognostication but as yet it has not been externally validated. The aim of this study was therefore to retrospectively apply the score to a cohort of OHCA patients to assess the predictive ability and accuracy in the identification of neurological outcome. Methods: Retrospective data of patients identified by hospital coding, over a period of 18 months, were collected from a large tertiary-level cardiac centre with a mature, multidisciplinary OHCA service. MIRACLE2 score performance was assessed against three existing OHCA prognostication scores. Results: Patients with all-comer OHCA, of presumed cardiac origin, with and without evidence of ST-elevation MI (43.4% versus 56.6%, respectively) were included. Regardless of presentation, the MIRACLE2 score performed well in neuro-prognostication, with a low MIRACLE2 score (≤2) providing a negative predictive value of 94% for poor neurological outcome at discharge, while a high score (≥5) had a positive predictive value of 95%. A high MIRACLE2 score performed well regardless of presenting ECG, with 91% of patients receiving early coronary angiography having a poor outcome. Conclusion: The MIRACLE2 score has good prognostic performance and is easily applicable to cardiac-origin OHCA presentation at the hospital front door. Prognostic scoring may assist decision-making regarding early angiographic assessment.

Acute Coronary Syndromes Due to Atherosclerotic Coronary Artery Disease in Young Patients.

Young patients represent about 4-10% of the population presenting with acute coronary syndrome. In this focused mini-review, we highlight the data regarding acute coronary syndromes in young patients with atherosclerotic coronary artery disease. Differences in the underlying pathologies and pathophysiological mechanisms should yield to different clinical management and treatment strategies.

Challenges in Primary PCI: How to Treat a Large Intracoronary Thrombus With TIMI 3 Flow?

This case highlights 2 important issues: the immediate management of large intracoronary thrombus in the ST-segment elevation myocardial infarction setting with TIMI 3 flow, and the risks/benefits associated with sealing a plaque in an unobstructed artery by stenting. Potent antithrombotic therapy with a view to subsequent intracoronary imaging to define etiology and plaque morphology appears to be a reasonable initial strategy in this specific population. Furthermore, for patients with acute coronary syndromes diagnosed with plaque erosion by optical coherence tomography and residual diameter stenosis <70%, deferred stenting appears a viable option.

Value of real-time three-dimensional adenosine stress contrast echocardiography in patients with known or suspected coronary artery disease.

AIM: The aim of this study was to evaluate the feasibility of myocardial wall-motion and perfusion assessment using contrast echocardiography during real-time three-dimensional (RT3D) adenosine stress test, and compare its diagnostic accuracy with the two-dimensional (2D) method using coronary angiography as reference. METHODS AND RESULTS: Patients with known or suspected coronary artery disease (CAD) have been submitted to adenosine stress contrast echocardiography and coronary angiography, within a 1-month period. Two-dimensional apical four, two, and three chamber, as well as three-dimensional (3D) pyramidal full-volume data sets were acquired at rest and at peak stress. The 17-segment division of the left ventricle was used and each segment was evaluated based on wall motion and perfusion. Sixty patients (age: 60.1 ± 8.5 years, 38 men) were enrolled, i.e. 1020 segments were evaluated at rest and at peak stress. Wall-motion analysis per patient revealed that the sensitivity and specificity of 2D to detect CAD were 80 and 82% and of RT3D echocardiography were 82 and 64%, respectively, whereas in the per patient perfusion analysis the respective percentages were 88, 64% for 2D and 90, 73% for RT3D. Regarding left anterior descending artery and right coronary system, there seems to be no statistical significant difference in terms of wall-motion and perfusion evaluation between the two modalities. CONCLUSIONS: Real-time 3D adenosine stress echocardiography is a feasible and valuable technique to evaluate myocardial wall motion and perfusion in patients with suspected CAD, despite existing problems concerning lower spatial and temporal resolution when compared with 2D echocardiography.

Quantitative analysis of left atrial function in asymptomatic patients with b-thalassemia major using real-time three-dimensional echocardiography.

BACKGROUND: There is strong evidence that left atrial (LA) size is a prognostic marker in a variety of heart diseases. Recently, real-time three-dimensional echocardiography (RT3DE) has been reported as a useful tool for studying the phasic changes of the left atrial volumes. The aim of this study was to investigate the performance of the left atrium in beta-thalassemic patients with preserved left ventricular ejection fraction (EF) and no iron overload, using RT3DE. METHODS: Twenty-eight asymptomatic b-thalassemic patients (32.2 ± 4.3 years old, 17 men) who were on iron chelating therapy, as well as 20 age- and sex-matched healthy controls underwent transthoracic RT3DE. The patient group had normal echocardiographic systolic and diastolic indices, while there was no myocardial iron disposition according to MRI. Apical full volume data sets were obtained and LA volumes were measured at 3 time points of the cardiac cycle: (1) maximum volume (LAmax) at end-systole, just before mitral valve opening; (2) minimum volume (LAmin) at end-diastole, just before mitral valve closure; and (3) volume before atrial active contraction (LApreA) obtained from the last frame before mitral valve reopening or at time of the P wave on the surface electrocardiogram. From the derived values, left atrial active and passive emptying volumes, as well as the respective emptying fractions were calculated. RESULTS: Left ventricular EF (59.2 ± 2.5% patients vs. 60.1 ± 2.1% controls), E/A, E/E' were similar between the two groups. Differences in the LAmax, LAmin and LApreA between b-thalassemic patients and controls were non-significant, LAmax:(35.5 ± 13.4 vs 31.8 ± 9.8)cm3, LAmin:(16.0 ± 6.0 vs. 13.5 ± 4.2)cm3, and LApreA:(25.4 ± 9.8 vs. 24.3 ± 7.2)cm3. However, left atrial active emptying fraction was reduced in the patient group as compared to the healthy population (34.3 ± 16.4% vs. 43.2 ± 11.4%, p < 0.05). CONCLUSION: RT3DE may be a novel technique for the evaluation of LA function in asymptomatic patients with b-Thalassemia Major. Among three-dimensional volumes and indices, left atrial active emptying fraction may be an early index of LA dysfunction in the specific patient population.

PCSK9 Inhibitors for the Management of Dyslipidemia in People with Type 2 Diabetes: How Low is Too Low?

Diabetic patients are considered to be at high risk for the development of atherosclerotic disease. Management of hypercholesterolemia is of paramount importance to optimize cardiovascular outcomes in this subset of patients and statins are regarded as the mainstay of treatment. However, the recent advent of PCSK-9 inhibitors has provided a useful alternative in the management of dyslipidemia, especially when statins cannot be tolerated or when hypolipidemic targets cannot be achieved. In this review, we discuss current trends in their use, and we focus on their role in the management of diabetic dyslipidemia.

Echocardiographic imaging of tricuspid and pulmonary valve abnormalities in primary ovarian carcinoid tumor.

Carcinoid is a rare malignancy originating from enterochromaffin cells and is clinically characterized by flushing, diarrhea and bronchospasm, due to secretion of vasoactive substances. A dreaded complication is carcinoid heart disease, which mainly affects right cardiac chambers, resulting in thickened, immobile and retracted tricuspid and pulmonary valves. In the current report, a case of a 60-year old female presenting with symptoms of right heart failure is described. Transthoracic two-dimensional and real-time three-dimensional echocardiography findings, as well as biochemical markers, including pro-BNP and NT-pro-BNP, were consistent with carcinoid syndrome. The histological diagnosis of carcinoid was confirmed after surgical resection of an ovarian mass.

Acute Circumflex Occlusion After a Successful Mitral Valve Repair.

We herein present an interesting case of acute iatrogenic coronary artery occlusion after a successful mini mitral valve repair in a young patient with Barlow's disease. It was successfully managed with percutaneous coronary intervention. This is a well-recognized complication of mitral valve surgery and is often misdiagnosed or late recognized. Implementation of non-invasive and intracoronary imaging is pivotal in-patient management.

Spinal Hematoma Following Coronary Angioplasty: An Uncommon Complication.

We report an unusual case of post-procedural spontaneous spinal epidural hematoma in a 65 year old man who presented with an acute coronary syndrome and underwent complex coronary intervention with adjunct use of a GPIIb/IIIa inhibitor. Although spontaneous spinal epidural hematoma (SSEH) following coronary intervention is extremely rare, clinicians should be aware of this unusual diagnosis. Prompt investigation with MRI and early referral for neurosurgical input are recommended to prevent potentially significant sequelae.

When everything else fails: High-pressure balloon for undilatable lesions.

Heavily calcified lesions are encountered with increasing frequency during percutaneous coronary interventions (PCI). This poses a significant problem as it often leads to suboptimal stent expansion, which in turn is a major cause for stent restenosis and thrombosis. Various technologies have been developed to tackle this. The high-pressure balloon (OPN) seems to be a promising adjunct in treating undilatable lesions. In this concise mini review we highlight the use of HPB and we present the current status of technology implemented in complex PCI cases.

Balloon-assisted tracking: A practical solution to avoid radial access failure due to difficult anatomical challenges.

AIM: The balloon assisted tracking (BAT) technique is utilised to overcome various anatomical difficulties during radial procedures when standard measures such as adequate sedation, pain relief, vasodilators and use of hydrophilic guidewires, fail. The aim of this study was to evaluate the success rates of the BAT technique in overcoming anatomical difficulties during radial coronary interventional procedures. METHODS: We retrospectively reviewed 1100 consecutive patients undergoing coronary procedures from the transradial approach (TRA) between May 2015 and May 2017. Anatomic variations and equipment used were recorded from procedure logs. RESULTS: Overall 30 patients (2.72%) required the use of BAT. Mean age was 66.7years, with a range from 48 to 90years (53.3% female). Out of these 30 cases, 86.7% patients underwent percutaneous coronary intervention (PCI) while the remaining patients underwent coronary angiography alone. Acute coronary syndrome cases represented 63.3% of the cases while the remaining patients were elective procedures. Anatomical difficulties included severe, non-resolving radial spasm (66.6%), catheter induced radial or brachial perforation (16.6%), small calibre and/or diseased radial artery (10.0%), severe radial, branchial and/or subclavian tortuosity (3.0%) and radial loops (3.0%). Anatomical difficulties were overcome in all cases (100%). Coronary angiography and/or PCI were successfully completed in all 30 cases without the need for obtaining alternative arterial access. Mean added procedural time was 131s. There were no procedure related complications. CONCLUSION: Balloon assisted tracking is a highly successful and safe technique for overcoming various anatomical difficulties at the level of the radial, brachial or subclavian arteries, which minimises the need for alternative arterial access.

Effect of gender on the prognostic value of dobutamine stress myocardial contrast echocardiography.

BACKGROUND: Dobutamine stress contrast echo (DSCE) has a well-established prognostic value in the context of coronary artery disease (CAD). However, data regarding its prognostic capability separately in men and women are scarce. The aim of the current study was to assess gender-related differences in the prognostic performance of DSCE. METHODS: DSCE was performed in 2645 consecutive patients, who were classified into two groups depending on gender. Follow-up lasted 57.1±10.1 months. End points included all-cause mortality, cardiac death, late revascularization, and hospitalizations. Survival analysis was performed comparing men and women. RESULTS: Of the 2645 patients (59.3±8.7 years), 69.1% were men. DSCE was positive in 23.4% of male patients, while in females, the respective percentage was 14.3%. There was statistically significant difference between the two groups with regard to end point occurrence (11.6% vs. 6.1%, p<0.05). Multivariate analysis revealed that the DSCE response was the strongest predictor of adverse outcomes (Exp(B)=51.9, p<0.05) in both groups. The predictive model including DSCE results along with clinical data performed well without significant differences between males and females (C-index 0.93 vs. 0.87 respectively, p=NS). CONCLUSION: DSCE has a strong prognostic value for patients with known or suspected CAD, regardless of patient gender. This makes DSCE an attractive screening option for women in whom CAD assessment can be challenging.