A Comparison of Retrospective ECG-Gated CT and Surgical or Angiographical Findings in Acute Aortic Syndrome.

The best cardiac phases in retrospective ECG-gated CT for detecting an intimal tear (IT) in aortic dissection (AD) and an ulcer-like projection (ULP) in an intramural hematoma (IMH) have not been established. This study aimed to compare the detection accuracy of diastolic-phase and systolic-phase ECG-gated CT for IT in AD and ULP in IMH, with subsequent surgical or angiographical confirmation as the reference standard.In total, 81 patients (67.6 ± 11.8 years; 41 men) who underwent emergency ECG-gated CT and subsequent open surgery or thoracic endovascular aortic repair for AD (n = 52) or IMH (n = 29) were included. The accuracies of detecting IT and ULP were compared among only diastolic-phase, only systolic-phase, and both diastolic-phase and systolic-phase methods of retrospective ECG-gated CT; surgical or angiographical findings were used as the reference standard. The detection accuracy for IT and ULP using only diastolic-phase, only systolic-phase, and both diastolic-phase and systolic-phase methods of ECG-gated CT was 93% [95% CI: 87-97], 94% [95% CI: 88-97], and 95% [95% CI: 90-97], respectively. There were no significant differences in detection accuracy among the 3 acquisition methods (P = 0.55). Similarly, there were no significant differences in the accuracy of detecting IT in AD (P = 0.55) and ULP in IMH (P > 0.99) among only diastolic-phase, only systolic-phase, and both diastolic- and systolic-phase ECG-gated CT.Retrospective ECG-gated CT for detecting IT in AD and ULP in IMH yields highly accurate findings. There were no significant differences seen among only diastolic-phase, only systolic-phase, and both diastolic-phase and systolic-phase ECG-gated CT.

In Vivo Platelet Detection Using a Glycoprotein IIb/IIIa-Targeted Near-Infrared Fluorescence Imaging Probe.

Platelets play a prominent role in multiple diseases, in particular arterial and venous thrombosis and also in atherosclerosis and cancer. To advance the in vivo study of the biological activity of this cell type from a basic experimental focus to a clinical focus, new translatable platelet-specific molecular imaging agents are required. Herein, we report the development of a near-infrared fluorescence probe based upon tirofiban, a clinically approved small-molecule glycoprotein IIb/IIIa inhibitor (GPIIb/IIIa). Through in vitro experiments with human platelets and in vivo ones in a murine model of deep-vein thrombosis, we demonstrate the avidity of the generated probe for activated platelets, with the added benefit of a short blood half-life, thereby enabling rapid in vivo visualization within the vasculature.

Additive Value of CT to Age, Aortic Diameter, and Echocardiography in Diagnosis and Classification of Bicuspid Aortic Valve in Patients with Severe Aortic Stenosis.

PURPOSE: To develop and validate a CT diagnostic algorithm for bicuspid aortic valve (BAV) classification. MATERIALS AND METHODS: This retrospective study included 212 consecutive patients with severe aortic stenosis who underwent CT followed by aortic valve replacement (mean age, 71 years [range, 27-93 years]; 125 women; 37% with a BAV) from 2012 to 2017. BAV diagnosis and BAV category were determined by using the CT diagnostic algorithm developed and were compared with those attained through surgical diagnosis. Reproducibility and agreement were assessed using the Cohen kappa (κ) coefficient. The value of adding CT to age, aortic diameter index, and transthoracic echocardiography (TTE) was evaluated by using the area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), and decision-curve analysis. RESULTS: Intra- and interobserver reproducibility were good or excellent for all CT diagnoses (κ ≥ 0.6 for all). Agreement between CT and surgical diagnoses was excellent (κ = 0.90) for BAV detection and good (κ = 0.69) for BAV categorization. Sixteen percent (five of 31) of patients with functional BAV diagnosed by using CT received a diagnosis of congenital BAV at surgery. The addition of CT to age, aortic diameter, and TTE showed a higher AUC (with CT, 0.97 [95% CI: 0.91, 0.99] vs without CT, 0.91 [95% CI: 0.85, 0.95]; P = .003) and NRI (1.79 [95% CI: 1.65, 1.92], P < .001) and a higher net benefit among all BAV probabilities. CONCLUSION: CT diagnosis was consistent with surgical diagnosis and had an additive value over traditional diagnostic methods; however, there was a risk of overlooking congenital BAV in patients with functional BAV diagnosed by using CT.Supplemental material is available for this article.© RSNA, 2021.

A case report of stomach perforation during automatic mechanical chest compression following pulseless electrical activity due to cibenzoline intoxication.

BACKGROUND: The current report describes a case of stomach perforation, a rare but serious complication, that occurred during cardiopulmonary resuscitation following severe cibenzoline intoxication. CASE PRESENTATION: A woman aged in her 30s was brought into our hospital while receiving cardiopulmonary resuscitation for pulseless electrical activity. After starting extracorporeal membrane oxygenation (ECMO), her abdominal X-ray examination revealed free air in her abdomen. She was diagnosed with internal gastric perforation. An emergency operation was carried out while the circulation was maintained using ECMO. As the patient's blood cibenzoline concentration on admission was 3,868 ng/mL, she was diagnosed with cibenzoline intoxication caused by the self-intake of twice the prescribed dose. She was successfully weaned off ECMO and discharged alive with full recovery. CONCLUSION: We successfully treated a case of gastric perforation after pulseless electrical activity requiring ECMO support due to cibenzoline intoxication. Abdominal surgery can be carried out even if ECMO support is needed.

Noninvasive assessment of left ventricular end-diastolic pressure by deceleration time of early diastolic mitral annular velocity in patients with heart failure.

OBJECTIVE: To examine the diagnostic ability of the deceleration time of early mitral annular velocity (e'DT) as determined by tissue Doppler velocity image, a method for assessing LV filling pressure. BACKGROUNDS: Estimation of LV filling pressure by Doppler echocardiography requires a combination of various parameters. Therefore, there remains a need for a simple index in LV filling pressure estimation. The e' is known to be reduced and delayed with increased LV filling pressure during development of heart failure. Thus, we hypothesized that e'DT would be shortened as LV filling pressure is increased. METHODS: Simultaneous LV end-diastolic pressure (LVEDP) measurement and Doppler echocardiography were performed in 94 patients who were admitted to our hospital for heart failure. Exclusion criteria were atrial fibrillation, mitral valve surgery, and acute coronary syndrome. RESULTS: The e'DT in 31 patients with LVEDP >16 mm Hg (68±13 ms) was significantly shorter than that in 63 patients with LVEDP ≤16 mm Hg (103±27 ms). Both e'DT and early transmitral flow velocity (E)/e' were significantly correlated with LVEDP. In 30 patients with 10-14 E/e', significance of correlation in e'DT was remained, while E/e' was not. The area under the ROC curve for prediction of LVEDP >16 mm Hg for e'DT was greater than that for E/e' (0.91 vs 0.74, P=.046). CONCLUSION: The e'DT is useful to assess LV filling pressure, especially in 10-14 E/e'. This simple tissue Doppler index may be a potential parameter for easily distinguishing between mild and severe heart failures.

Immunohistochemical identification of Propionibacterium acnes in granuloma and inflammatory cells of myocardial tissues obtained from cardiac sarcoidosis patients.

BACKGROUND: Although rare, cardiac sarcoidosis (CS) is potentially fatal. Early diagnosis and intervention are essential, but histopathologic diagnosis is limited. We aimed to detect Propionibacterium acnes, a commonly implicated etiologic agent of sarcoidosis, in myocardial tissues obtained from CS patients. METHODS AND RESULTS: We examined formalin-fixed paraffin-embedded myocardial tissues obtained by surgery or autopsy and endomyocardial biopsy from patients with CS (n = 26; CS-group), myocarditis (n = 15; M-group), or other cardiomyopathies (n = 39; CM-group) using immunohistochemistry (IHC) with a P. acnes-specific monoclonal antibody. We found granulomas in 16 (62%) CS-group samples. Massive (≥14 inflammatory cells) and minimal (<14 inflammatory cells) inflammatory foci, respectively, were detected in 16 (62%) and 11 (42%) of the CS-group samples, 10 (67%) and 10 (67%) of the M-group samples, and 1 (3%) and 18 (46%) of the CM-group samples. P. acnes-positive reactivity in granulomas, massive inflammatory foci, and minimal inflammatory foci were detected in 10 (63%), 10 (63%), and 8 (73%) of the CS-group samples, respectively, and in none of the M-group and CM-group samples. CONCLUSIONS: Frequent identification of P. acnes in sarcoid granulomas of originally aseptic myocardial tissues suggests that this indigenous bacterium causes granuloma in many CS patients. IHC detection of P. acnes in massive or minimal inflammatory foci of myocardial biopsy samples without granulomas may be useful for differentiating sarcoidosis from myocarditis or other cardiomyopathies.

Effects of intravenous bolus injection of nicorandil on renal artery flow velocity assessed by color Doppler ultrasound.

BACKGROUND: Previous animal studies have shown that a potassium channel opener, nicorandil, provokes vasodilation in renal microvasculature and increases renal blood flow. We conducted a clinical study that aimed to evaluate the effect of nicorandil on renal artery blood flow in comparison with nitroglycerin by using color Doppler ultrasound. METHODS: The present study enrolled 40 patients with stable coronary artery disease who had no renal arterial stenosis and renal parenchymal disease. The patients received intravenous administration of nicorandil (n=20) or nitroglycerin (n=20). Before and after the administration, renal artery blood flow velocity was measured by color-guided pulsed-wave Doppler. RESULTS: The peak-systolic, end-diastolic, and mean renal artery blood flow velocities before the administration were not different between the nicorandil group and the nitroglycerin group. The peak-systolic (79±15cm/s to 99±21cm/s, p<0.001; and 78±19cm/s to 85±19cm/s, p=0.004), end-diastolic (22±5cm/s to 28±8cm/s, p<0.001; and 24±6cm/s to 26±6cm/s, p=0.005) and mean (41±6cm/s to 49±9cm/s, p<0.001; and 43±9cm/s to 45±9cm/s, p=0.009) renal artery flow velocities increased significantly in either group. The nominal changes in the peak-systolic (20±10cm/s vs. 7±8cm/s, p<0.001), end-diastolic (5±4cm/s vs. 2±3cm/s, p=0.001), and mean (8±5cm/s vs. 2±2cm/s, p<0.001) renal artery blood flow velocities were significantly greater in the nicorandil group compared with the nitroglycerin group. CONCLUSION: Intravenous nicorandil increased renal artery blood flow velocity in comparison with nitroglycerin. Nicorandil has a significant effect on renal hemodynamics.

Impact of functional focal versus diffuse coronary artery disease on bypass graft patency.

BACKGROUND: Pressure guidewire pullback recording can differentiate between functional focal and diffuse disease types in coronary artery disease. The aim of this study was to compare the outcome of coronary artery bypass graft (CABG) patency between patients with functional focal versus diffuse disease types in recipient coronary arteries. METHODS AND RESULTS: We investigated 89 patients who underwent pressure guidewire pullback in the left anterior descending (LAD) artery before CABG using internal mammary artery (IMA). Based on the pressure guidewire pullback data, the LAD lesions were classified into functional focal disease (abrupt pressure step-up; n=58) or functional diffuse disease (gradual pressure increase; n=31). Follow-up computed tomography (CT) angiography was conducted within 1year after CABG to assess the bypass graft patency. Pre CABG, LAD angiographic percent diameter stenosis (57±10% vs. 54±12%, p=0.228) and fractional flow reserve (FFR) (0.68±0.07 vs. 0.69±0.07, p=0.244) were not different between the functional focal and diffuse disease groups. The CABG procedure characteristics were similarly comparable between the two groups. In the follow-up CT angiography after CABG, occlusion or string sign of the IMA graft to LAD was more frequently observed in the functional diffuse disease group than in the functional focal disease group (26% vs. 7%, p=0.021). CONCLUSION: In CABG, functional diffuse disease in the recipient coronary artery was associated with an increased risk of the graft failure in comparison with functional focal disease.

Myocardial Damage Detected by Two-Dimensional Speckle-Tracking Echocardiography in Patients with Extracardiac Sarcoidosis: Comparison with Magnetic Resonance Imaging.

BACKGROUND: The aim of this study was to determine whether two-dimensional speckle-tracking echocardiography can identify the myocardial damage detected by delayed enhancement (DE) magnetic resonance imaging via the differences in myocardial deformation in patients with extracardiac sarcoidosis who showed no structural and functional abnormalities in the heart. METHODS: Forty-five patients with biopsy-proven extracardiac sarcoidosis were analyzed retrospectively. Patients with abnormal electrocardiographic and echocardiographic findings, including ventricular arrhythmias, heart block, regional wall motion abnormalities, valvular heart disease, and cardiomyopathy, were excluded. Ten age-matched healthy control subjects were recruited as a control group. Comprehensive echocardiography and DE magnetic resonance imaging were performed, and circumferential, longitudinal, and radial strain were consecutively assessed using two-dimensional speckle-tracking echocardiographic software in a 16-segment model of the left ventricle in accordance to the presence (DE+) or absence (DE-) of DE. RESULTS: Among the 45 patients, 36 segments in 13 patients showed DE. DE+ segments had lower peak circumferential strain than DE- and control segments (-14 ± 5% vs -28 ± 7% vs -30 ± 7%, P < .0001). Peak longitudinal strain in DE+ segments was significantly decreased compared with control segments (-19 ± 4% vs -23 ± 5%, P = .005). However, peak radial strain was similar among the three groups: 41 ± 17% in DE+ segments, 45 ± 23% in DE- segments, and 46 ± 18% in control segments (P = .50). CONCLUSIONS: Circumferential and longitudinal strain via two-dimensional speckle-tracking echocardiography can identify the myocardial damage detected by DE magnetic resonance imaging in patients with extracardiac sarcoidosis.

Long-term outcome after deferral of revascularization in patients with intermediate coronary stenosis and gray-zone fractional flow reserve.

BACKGROUND: A strategy of deferred percutaneous coronary intervention for coronary stenosis with fractional flow reserve (FFR) 0.75-0.80, termed the gray zone, remains a matter of debate. The aim of this study was to assess the safety of deferring revascularization for patients with FFR 0.75-0.80 compared with those with FFR >0.80. METHODS AND RESULTS: We assessed 3-year clinical outcome in 150 patients with angiographically intermediate stenosis who had revascularization deferred on the basis of FFR ≥ 0.75 (FFR 0.75-0.80, n=56; FFR >0.80, n=94). Target vessel failure (TVF), defined as a composite of cardiac death, target vessel-related myocardial infarction (MI), and ischemia-driven target vessel revascularization (TVR) was evaluated during follow-up. Cardiac death was observed in 1 patient with FFR 0.75-0.80. There was no target vessel-related MI in either group. The incidence of ischemia-driven TVR was higher in patients with FFR 0.75-0.80 than in those with FFR >0.80 (14% vs. 3%, P=0.020). TVF-free survival was significantly worse for the patients with FFR 0.75-0.80 than those with FFR >0.80 (hazard ratio, 5.2; 95% confidence intervals: 1.4-19.5; P=0.015). CONCLUSIONS: Patients with FFR 0.75-0.80 were at higher risk of TVF mainly due to TVR than those with FFR >0.80.

Effect of atorvastatin therapy on fibrous cap thickness in coronary atherosclerotic plaque as assessed by optical coherence tomography: the EASY-FIT study.

BACKGROUND: The detailed mechanism of plaque stabilization by statin therapy is not fully understood. OBJECTIVES: The aim of this study was to assess the effect of lipid-lowering therapy with 20 mg/day of atorvastatin versus 5 mg/day of atorvastatin on fibrous cap thickness in coronary atherosclerotic plaques by using optical coherence tomography (OCT). METHODS: Seventy patients with unstable angina pectoris and untreated dyslipidemia were randomized to either 20 mg/day or 5 mg/day of atorvastatin therapy. OCT was performed to assess intermediate nonculprit lesions at baseline and 12-month follow-up. RESULTS: Serum low-density lipoprotein cholesterol level was significantly lower during therapy with 20 mg/day compared with 5 mg/day of atorvastatin (69 mg/dl vs. 78 mg/dl; p = 0.039). The increase in fibrous cap thickness was significantly greater with 20 mg/day compared with 5 mg/day of atorvastatin (69% vs. 17%; p < 0.001). The increase in fibrous cap thickness correlated with the decrease in serum levels of low-density lipoprotein cholesterol (R = -0.450; p < 0.001), malondialdehyde-modified low-density lipoprotein (R = -0.283; p = 0.029), high-sensitivity C-reactive protein (R = -0.276; p = 0.033), and matrix metalloproteinase-9 (R = -0.502; p < 0.001), and the decrease in grade of OCT-derived macrophages (R = -0.415; p = 0.003). CONCLUSIONS: Atorvastatin therapy at 20 mg/day provided a greater increase in fibrous cap thickness in coronary plaques compared with 5 mg/day of atorvastatin. The increase of fibrous cap was associated with the decrease in serum atherogenic lipoproteins and inflammatory biomarkers during atorvastatin therapy. (Effect of Atorvastatin Therapy on Fibrous Cap Thickness in Coronary Atherosclerotic Plaque as Assessed by Optical Coherence Tomography: The EASY-FIT Study; NCT00700037).

Assessment of cardiac sarcoidosis with advanced imaging modalities.

Sarcoidosis is a chronic systemic disease of unknown etiology that is characterized by the presence of noncaseating epithelioid granulomas, usually in multiple organs. Several studies have shown that sarcoidosis might be the result of an exaggerated granulomatous reaction after exposure to unidentified antigens in genetically susceptible individuals. Cardiac involvement may occur and lead to an adverse outcome: the heart mechanics will be affected and that causes ventricular failure, and the cardiac electrical system will be disrupted and lead to third degree atrioventricular block, malignant ventricular tachycardia, and sudden cardiac death. Thus, early diagnosis and treatment of this potentially devastating disease is critically important. However, sensitive and accurate imaging modalities have not been established. Recent studies have demonstrated the promising potential of cardiac magnetic resonance imaging (MRI) and (18)F-fluoro-2-deoxyglucose positron emission tomography ((18)F-FDG PET) in the diagnosis and assessment of cardiac sarcoidosis (CS). In this review, we discuss the epidemiology, etiology, histological findings, and clinical features of sarcoidosis. We also introduce advanced imaging including (18)F-FDG PET and cardiac MRI as more reliable diagnostic modalities for CS.

Early abnormality detected by speckle-tracking echocardiography in a patient with suspected cardiac sarcoidosis.

A 56-year-old female was admitted to our hospital because of respiratory symptoms. Her admission ECG showed normal sinus rhythm and standard echocardiographic evaluation showed no structural or functional abnormalities. She was diagnosed as having sarcoidosis by imaging modalities and mediastinum lymph node biopsy. In this case, 2-dimensional speckle-tracking echocardiography (STE) demonstrated abnormal regional myocardial function and delayed enhancement cardiac magnetic resonance imaging revealed a high intensity area in the same segments. This case suggests that STE is potentially useful for the detection of cardiac sarcoidosis in the early phase.

Late stent thrombosis after discontinuation of dual anti-platelet therapy in off-label use of paclitaxel-eluting stent visualized by optical coherence tomography-3-vessel OCT study.

We observed late stent thrombosis image by optical coherence tomography (OCT) in vessels with off-label paclitaxel-eluting stents (PES) implantation. A 59-year-old Japanese man was treated with a single on-label PES for chronic coronary artery disease in the left circumflex artery. After 9 months, he was implanted with two linked PESs in the left anterior descending artery (LAD) and a single PES in the right coronary artery (RCA). He was examined for suspicion of a colon tumor by fiberscope after discontinuation of dual anti-platelet therapy without consultation. He complained of chest pain and was transferred to our center. Emergency coronary angiography demonstrated thrombotic total occlusion of the proximal LAD in the two linked PESs. After thrombus aspiration therapy, OCT was performed to evaluate the stents in the 3 vessels. The off-label two linked PESs demonstrated the same average neo-intimal hyperplasia (NIH) thickness and percentage of uncovered stent struts compared with the on-label PES in the RCA by visualized OCT image. However, the heterogeneity of NIH in the LAD stent was significantly higher than the stents in the other two vessels. The implantation of the two linked off-label and the heterogeneity of NIH may increase hyperplatelet coagulability more than on-label single PES use.