Spontaneous Coronary Artery Dissection: A Review of Epidemiology, Pathophysiology and Principles of Management.

Spontaneous coronary artery dissection (SCAD) is a sudden rupture of coronary artery wall leading to false lumen and intramural hematoma formation. It commonly occurs in young and middle-aged women lacking typical cardiovascular risk factors. Fibromuscular dysplasia and pregnancy are strongly associated with SCAD. To date, the "inside-out" and "outside-in" are the 2 proposed hypothesis for the pathogenesis of SCAD. Coronary angiography is the gold standard and first line diagnostic test. Three types of SCAD have been described according to coronary angiogram. Intracoronary imaging modalities are reserved for patients with ambiguous diagnosis or to guide percutaneous coronary intervention view the increased risk of secondary iatrogenic dissection. The management of SCAD includes conservative approach, coronary revascularization strategies accounting for percutaneous coronary intervention and coronary artery bypass graft, and long-term follow-up. The overall prognosis of patients with SCAD is favorable marked by a spontaneous healing in a large proportion of cases.

Epidemiology, Pathophysiology, Diagnosis, and Principles of Management of Takotsubo Cardiomyopathy: A Review.

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a reversible syndrome commonly found among patients presenting for acute coronary syndromes, especially women. With the COVID-19 pandemic, the incidence of takotsubo cardiomyopathy was dramatically increased. However, this clinical cardiac entity remains underdiagnosed, largely due to the interplay with acute coronary syndrome. The pathophysiology of takotsubo cardiomyopathy is miscellaneous, including coronary vasospasm, microcirculatory dysfunction, catecholamine surge, and sympathetic overdrive. Diagnosing takotsubo cardiomyopathy requires a high index of clinical suspicion and multimodality tests. To date, there are no guidelines for the management of takotsubo cardiomyopathy. Thus, available data are derived from case series, retrospective analyses, and experts' opinions. Heart failure medicines were investigated in takotsubo cardiomyopathy patients. Evidence supports the benefits of angiotensin-converting enzyme inhibitors and angiotensin receptors blockers use on mortality and recurrence rates, while results from use of beta-blockers are controversial. In complicated cases, inotropes are preferred over vasopressors, except in the presence of left ventricular outflow tract obstruction, in which medical therapy is limited to fluids administration and beta-blockers. Use of oral vitamin K antagonist can benefit patients at high thrombo-embolic risk for up to 3 months. Mechanical supports are reserved for refractory hemodynamically unstable cases. This review aims to provide an update on the epidemiology, diagnosis, and outcomes of takotsubo cardiomyopathy, and an extended discussion on the management of complicated and non-complicated cases.

Quantitative assessment of tricuspid regurgitation using right and left ventricular stroke volumes obtained from tomographic equilibrium radionuclide ventriculography.

BACKGROUND: Quantitative assessment of valve regurgitation using volumetric method by comparing right and left ventricular stroke volumes is still under investigations. AIMS: To investigate the accuracy of tomographic equilibrium radionuclide ventriculography (t-ERV) for the quantification of tricuspid regurgitation (TR). METHODS AND RESULTS: Sixty-one patients (44 men; mean age 59 ± 12 years) who underwent both t-ERV and transthoracic echocardiography (TTE) studies within 2 weeks for right ventricular systolic function assessment were eligible for inclusion. A sub-group of 22 patients underwent both t-ERV and CMR. Patients with mitral/aortic regurgitation by TTE were excluded of the study. TR regurgitant volume (RVol) was calculated using the proximal isovelocity surface area (PISA) method from TTE and the volumetric method (right ventricular stroke volume minus left ventricular stroke volume) from t-ERV. There was a significant correlation between RVol as assess by ERV and by TTE (R = 0.95, P < 0.0001). Intraclass correlation coefficient between TTE and ERV for TR quantification was 0.95 (P < 0.0001). Among patients who underwent CMR, the correlation between RVol obtained by TTE and by t-ERV and CMR were R = 0.81 and R = 0.75, respectively (all P < 0.0001). CONCLUSION: TR assessment using the t-ERV correlates well with PISA from TTE in patients referred for right ventricular systolic function assessment.

Cost-Effectiveness of Drug-Eluting Stents in Elderly Patients With Coronary Artery Disease: The SENIOR Trial.

BACKGROUND: Elderly patients receive bare metal stents instead of drug-eluting stents (DES) to shorten the duration of dual antiplatelet therapy (DAPT). The SENIOR trial compared outcomes between these 2 types of stents combined with a short duration of DAPT. A significant decrease in the number of patients with at least 1 major adverse cardiac and cerebrovascular event (MACCE) was noted in the DES group. OBJECTIVES: The objective of this article was to perform an economic evaluation of the SENIOR trial. METHODS: This evaluation was performed separately in 5 participating countries using pooled patient-level data from all study patients and country-specific unit costs and utility values. Costs, MACCEs, and quality-adjusted life-years (QALYs) were calculated in both arms at 1 year, and an incremental cost-effectiveness ratio was estimated. Uncertainty was explored by probabilistic bootstrapping. RESULTS: A total of 1200 patients underwent randomization. The average total cost per patient was higher in the DES group. The number of MACCEs and average QALYs were not statistically different between the 2 groups. The 1-year incremental cost-effectiveness ratio for each country of reference ranged from €13 752 to €20 511/MACCE avoided and from €42 835 to €68 231/QALY gained. The scatter plots found a wide dispersion, reflecting a large uncertainty surrounding the results. But in each country studied, 90% of the bootstrap replications indicated a higher cost for greater effectiveness for the DES group. Assuming a willingness to pay of €50 000/QALY, there was between a 40% and 50% chance that the use of DES was cost-effective in 4 countries. CONCLUSION: The use of DES instead of bare metal stents combined with a short duration of DAPT in elderly patients induced higher cost for greater effectiveness in each of the 5 countries studied.

Feasibility and accuracy of gated blood pool SPECT equilibrium radionuclide ventriculography for the assessment of left and right ventricular volumes and function in patients with left ventricular assist devices.

BACKGROUND: Left ventricular assist devices (LVADs) require serial assessment of right and left ventricular (RV & LV) volumes and function. Because the RV is not assisted, its function is a critical determinant of the hemodynamic and contributes significantly to postoperative morbidity and mortality. We evaluated the feasibility and the accuracy of tomographic-equilibrium radionuclide ventriculography (t-ERV) for the assessment of patients with LVADs. METHODS: Twenty-four patients with LVAD underwent t-ERV. Because of the limited acoustic window, transthoracic echocardiography (TTE) was only feasible in 19 patients. Functional evaluation including six-minute walk test (6MWT) and peak oxygen consumption (POC) was performed in 18 patients. Nine patients underwent a cardiac multidetector computed tomography (MDCT). Eight patients underwent a second evaluation by ERV 4.3 ± 1.4 months later. RESULTS: Reliability between t-ERV and MDCT for LV end-diastolic volume, LV end-systolic volume, LV ejection fraction, RV end-diastolic volume, RV end-systolic volume, and RV ejection fraction (RVEF) was 0.900 (P = .001), 0.911 (P = .001), 0.765 (P = .021), 0.728 (P = .042), 0.875 (P = .004), and 0.781 (P = .023), respectively. There was no correlation between t-ERV and RV systolic parameters assessed by TTE. RVEF was correlated with POC (R = 0.521; P = .027). A cut-off value of 40% for RVEF measured by t-ERV could discriminate patients with poor functional status (P = .048 for NYHA stage; P = .016 for 6MWT and P = .007 for POC). CONCLUSION: t-ERV is a simple, reproducible, and an accurate technique for the assessment of RV function in patients with LVADs and warrants consideration in the evaluation and monitoring of symptomatic patients.

Serial Assessment of Strut Coverage of Biodegradable Polymer Drug-Eluting Stent at 1, 2, and 3 Months After Stent Implantation by Optical Frequency Domain Imaging: The DISCOVERY 1TO3 Study (Evaluation With OFDI of Strut Coverage of Terumo New Drug Eluting Stent With Biodegradable Polymer at 1, 2, and 3 Months).

BACKGROUND: To assess the vessel-healing pattern of Ultimaster drug-eluting stent using optical frequency domain imaging. Our hypothesis is that biodegradable polymer-based drug-eluting technology allows complete very early strut coverage. METHODS AND RESULTS: The DISCOVERY 1TO3 study (Evaluation With OFDI of Strut Coverage of Terumo New Drug Eluting Stent With Biodegradable Polymer at 1, 2, and 3 Months) is a prospective, single-arm, multicenter study. A total of 60 patients with multivessel disease requiring staged procedure at 1 month were treated with Ultimaster. Optical frequency domain imaging was acquired at baseline, 1, 2, and 3 months. The primary end point is optical frequency domain imaging-assessed strut coverage at 3 months. Mean age of patients was 67.2±9.9 years, and 73.3% were male, and 36.7% presented with acute coronary syndrome. A total of 132 lesions were treated, with average 1.4 lesions per patient treated at baseline and 1.1 lesions treated at 1 month. Strut coverage at 3 months of single implanted stents (n=71, primary end point) was 95.2±5.2% and of combined single and overlapped stents was 95.4±4.9%. Strut coverage of combined single and overlapped stents at 1 (n=49) and 2 months (n=38) was 85.1±12.7% and 87.9±10.8%, respectively. The median neointimal hyperplasia thickness was 0.04, 0.05, and 0.06 mm, whereas mean neointimal hyperplasia obstruction was 4.5±2.4%, 5.2±3.4%, and 6.6±3.3% at 1, 2, and 3 months, respectively. CONCLUSIONS: Nearly complete strut coverage was observed in this complex population very early after implantation of Ultimaster drug-eluting stent. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01844843.

The medical history of adults with complex congenital heart disease affects their social development and professional activity.

BACKGROUND: In recent decades, advances in surgery and therapeutic catheterization have steadily increased the life expectancy and prevalence of adults with congenital heart disease (CHD). AIMS: We assessed medical and psychosocial variables of adults with CHD, according to the disease complexity. METHODS: We included, from a single-centre observational cohort study, 135 consecutive adults with CHD (median age of 40 years, interquartile range: 28.0-51.0) followed in our cardiology unit, who answered a questionnaire assessing daily activity and psychosocial functioning. Disease complexity was classified according to the Bethesda conference. RESULTS: Cardiac malformation complexity was simple in 61 (45.2%), moderate in 50 (37.0%) and complex in 24 (17.8%) patients. Cardiac surgery had been performed in 86.5% of moderate and complex patients. Complications (such as heart failure, arrhythmia and pulmonary hypertension) were mainly observed in the complex group (P=0.003). Physical activity was lower in the complex group (no activity in 58.8%, but sport previously contraindicated in 50% of these; P=0.03). Education level tended to be lower in the complex and moderate groups than in the simple group (respectively, 31.2% and 33.3% vs. 45.7% had passed the Baccalaureate; P=0.47). The pass rate was lower in patients with complications (P=0.037) or more than one cardiac surgery (P=0.03). In the complex group, 56.3% of patients were unemployed (P=0.048). CONCLUSIONS: Complexity of heart disease and medical history affect education level and employment of adults with CHD. Academic education of children with a complex defect and career counselling are important to prevent unemployment among adults with CHD.

Assessment of valvular surfaces in children with a congenital bicuspid aortic valve: preliminary three-dimensional echocardiographic study.

BACKGROUND: Congenital bicuspid aortic valve (BAV) is the most common congenital heart defect and may be responsible for aortic stenosis early in life. However, its pathogenesis remains unclear. A relationship between the severity of aortic stenosis and valvular surfaces has not been reported in the paediatric population. AIMS: To assess the feasibility of three-dimensional transthoracic echocardiographic planimetry in congenital BAV in children and to evaluate the influence of valvular asymmetry and aortic valve area (AVA) on stenosis severity. METHODS: Seventy consecutive children with BAV were included in this prospective single-centre study. Using the multiplanar review mode, surfaces were measured by planimetry (in systole for AVA and diastole for cusp surfaces). The degree of stenosis was assessed by instantaneous aortic Doppler. Results are expressed as medians and first and third quartiles. RESULTS: Median age was 5.6 years (2.2-11.5). Feasibility was 97%. Intra- and interobserver concordances were excellent for the measurement of cusp surfaces and AVA. Among the 70 children, 25 had aortic stenosis. The small/large cusp ratio was strongly associated with aortic stenosis (P<0.001). The area under the receiver operating characteristic curve was 0.89 (95% confidence interval 0.82-0.97). The best cut-off value for differentiating stenotic from non-stenotic valve was 0.75, with 84% sensitivity and 83% specificity. When indexed for body surface area, AVA was significantly smaller (P=0.031) in case of stenotic BAV (1.51cm(2) [0.99-2.28]) compared with non-stenotic BAV (1.99cm(2) [1.57-2.52]). CONCLUSIONS: Three-dimensional echocardiographic planimetry is a feasible and reproducible method for assessing aortic surfaces in congenital BAV. Aortic stenosis seems to strongly depend on the asymmetry of the valve.

Reproducibility and factors influencing the assessment of the SYNTAX score in the left main Xience study.

BACKGROUND: As assessment of SYNTAX score is made by visual estimate of coronary angiography, discrepancies between evaluations by different observers and the impact of observer experience have not yet been evaluated. METHODS: Using the data of 166 patients with unprotected left main lesions treated with the second generation everolimus-eluting stent, we sought to analyze SYNTAX score assessment provided by one junior and two independent senior observers and to assess the impact of the quality of angiographies on the reproducibility of SYNTAX score determination. Intra-observer variability was assessed by a senior observer by analyzing 50 sets of angiograms after an interval of at least 6 weeks. RESULTS: The weighted kappa value for the inter-observer reproducibility of SYNTAX score classified as tertiles, according to SYNTAX trial, was 0.71 and the intra-observer weighted kappa value was 0.79. When compared with junior's measurements, SYNTAX score assessed by senior investigators was 0.46 and 0.50. Changes in SYNTAX score classification were arbitrarily responsible for changes in weighted kappa values. Angiograms showing the higher rates of discrepancies between observers were of lower quality, when compared with random angiograms. SYNTAX score was closely correlated to 1-year incidence of major adverse cerebro- and cardiovascular events for both junior and senior readers. CONCLUSIONS: SYNTAX score was slightly underestimated by junior reader, when compared with experienced operators. Inter- and intra-observer reproducibility of experienced operators was very acceptable. SYNTAX score evaluation was clearly related to the quality of angiograms. SYNTAX score was correlated to 1-year incidence of major cardiac and cerebrovascular events (MACCE) in all readers.

Arterial ultrasound screening as a tool for coronary risk assessment in asymptomatic men and women.

One of the imaging tests most commonly used to assess cardiovascular diseases (CVDs) in daily practice is Doppler ultrasonography of the carotid and femoral arteries. We included 2709 participants with no history or symptoms of CVD; they had a risk factor assessment and a carotid and femoral ultrasonography at baseline. Incident cases of definite coronary events were recorded during a median follow-up of 6 years. Approximately, 63% of the sample presented abnormalities (carotid stenosis >50%, carotid plaque, femoral plaque, increased intima-media thickness [IMT]). A moderately increased IMT (>0.63 mm) or the presence of carotid or femoral artery plaque was related to prognosis. The associations persisted after adjustment for pretest risk, treatment with statins, and other Doppler ultrasonography abnormalities. The hazard ratio increased significantly with the number of abnormalities (varying from 2.35 [1.16-4.74] to 14.83 [6.47-33.9]).

The effect of internal thoracic artery grafts on long-term clinical outcomes after coronary bypass surgery.

OBJECTIVES: We sought to compare long-term outcomes after coronary bypass surgery with and without an internal thoracic artery graft. METHODS: We analyzed clinical outcomes over a median follow-up of 6.7 years among 3,087 patients who received coronary bypass surgery as participants in one of 8 clinical trials comparing surgical intervention with angioplasty. We used 2 statistical methods (covariate adjustment and propensity score matching) to adjust for the nonrandomized selection of internal thoracic artery grafts. RESULTS: Internal thoracic artery grafting was associated with lower mortality, with hazard ratios of 0.77 (confidence interval, 0.62-0.97; P = .02) for covariate adjustment and 0.77 (confidence interval, 0.57-1.05; P = .10) for propensity score matching. The composite end point of death or myocardial infarction was reduced to a similar extent, with hazard ratios of 0.83 (confidence interval, 0.69-1.00; P = .05) for covariate adjustment to 0.78 (confidence interval, 0.61-1.00; P = .05) for propensity score matching. There was a trend toward less angina at 1 year, with odds ratios of 0.81 (confidence interval, 0.61-1.09; P = .16) in the covariate-adjusted model and 0.81 (confidence interval, 0.55-1.19; P = .28) in the propensity score-adjusted model. CONCLUSIONS: Use of an internal thoracic artery graft during coronary bypass surgery seems to improve long-term clinical outcomes.

Gender disparity in 48-hour mortality is limited to emergency percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Previous studies indicate that mortality from acute coronary syndromes is higher in women than in men, especially in case of interventional strategy. AIM: To assess whether the in-hospital mortality rate differs between genders during the first 48h after emergency percutaneous coronary intervention for ST-elevation myocardial infarction (emergency PCI-STEMI) or after non-emergency PCI. METHODS: All patients treated with PCI between January 2005 and June 2008 were included. The primary endpoint was frequency of death within 48h after the PCI procedure; secondary endpoints included frequency of recurrent myocardial infarction, new PCI or coronary artery bypass graft surgery, stroke, and major vascular or renal complications. Data were analysed via logistic regression with and without propensity-score matching. RESULTS: More than 9000 patients underwent PCI. In the emergency PCI-STEMI group (n=1753), 48-hour mortality occurred in 2.2% of men and 4.9% of women (p=0.004). However, gender disparity occurred only in elderly patients; the rate was significantly (p=0.02) higher in women (8.1%) than in men (3.3%) aged > or =75 years. There was no evidence of gender disparity in the non-emergency PCI group (n=7336) or in secondary endpoints for either PCI group. Similar results were obtained in pair analyses of men and women with matching propensity scores. CONCLUSIONS: Elderly women have a disproportionately high in-hospital mortality rate during the first 48h after emergency PCI for treatment of STEMI; however, there is no gender discrepancy in younger patients or patients of any age who receive non-emergency procedures.

Prevalence of cardiovascular risk factors in men with stable coronary heart disease in France and Spain.

BACKGROUND: Cigarette smoking, raised blood pressure, unfavourable lipid concentrations, diabetes and - more indirectly - obesity, are responsible for most coronary heart disease events in developed and developing countries. AIMS: The objective of our study was to compare prevalence, treatment and control of cardiovascular risk factors in two samples of men with stable coronary heart disease, recruited in France and Spain. METHODS: Standardized measurements of body mass index, systolic and diastolic blood pressures, plasma lipids, glycaemia, and smoking were collected and drug use was registered. Cross-sectional comparisons were made between French and Spanish samples. RESULTS: Data from 982 individuals were analysed (420 French and 562 Spanish men). Current smoking was more frequent in Spain (p<0.001), whereas hypertension and uncontrolled blood pressure were more frequent in France (p<0.001). Mean concentrations of low-density lipoprotein cholesterol and triglycerides were significantly higher in France (p<0.001). No significant differences were observed regarding obesity, high-density lipoprotein cholesterol and diabetes. More than 97% of participants presented with at least one of the following conditions: hypertension, dyslipidaemia, diabetes, obesity or smoking. Antiplatelet agents, calcium inhibitors, diuretics and hypoglycaemic drugs were used more frequently in France, whereas angiotensin-converting enzyme inhibitors and lipid-lowering treatments were used more frequently in Spain. CONCLUSION: Prevalence of cardiovascular risk factors is high among French and Spanish patients with stable coronary heart disease, with differences between countries regarding the distribution of the various risk factors. A great proportion of patients do not reach the recommended levels for risk factor control.

Additional prognostic value of physical examination, exercise testing, and arterial ultrasonography for coronary risk assessment in primary prevention.

BACKGROUND: The choice of noninvasive tests used in primary prevention of cardiovascular diseases must be based on medical evidence. The aim of this study was to assess the additional prognostic value, over conventional risk factors, of physical examination, exercise testing, and arterial ultrasonography, in predicting a first coronary event. METHODS: A prospective cohort study was conducted between 1996 and 2004 (n = 2,709), with follow-up in 2006 (response rate 96.6%). Participants had no history or symptoms of cardiovascular disease and had a standardized physical examination, a cardiac exercise testing, and carotid and femoral ultrasonography at baseline. Incident cases of definite coronary events were recorded during follow-up. RESULTS: Over the Framingham risk score, femoral bruit, positive exercise test, intima-media thickness >0.63 mm, and a femoral plaque provided significant additional information to the prediction model. The addition of the exercise test to the traditional risk factors, then the intima-media thickness and lastly the presence of femoral plaques, produces incremental increases in the area under the receiver operating characteristic curve (0.73-0.78, P = .02) and about a 50% increase in the positive predictive value (15.8%-31.4%), with no effect on the negative predictive value (96.4%-96.9%). CONCLUSION: Physical examination, exercise testing, and arterial ultrasonography provide incremental information on the risk of coronary event in asymptomatic adults. Exercise testing and femoral ultrasonography also improve the accuracy of the risk stratification.

Cost effectiveness of sirolimus-eluting stents compared with bare metal stents in acute myocardial infarction: insights from the TYPHOON trial.

BACKGROUND: Drug-eluting stents have been shown to reduce the rate of repeat revascularization after percutaneous coronary intervention for acute myocardial infarction (AMI) as compared with bare metal stents (BMS). A few studies have reported the cost effectiveness of sirolimus-eluting stents (SES) in several countries, but none in the particular setting of AMI in France. OBJECTIVES: To assess the cost effectiveness of SES compared with BMS in a pre-specified subgroup of French patients with AMI in the randomized, multicentre TYPHOON trial. METHODS: A prospective economic evaluation was conducted for the 337 patients in the TYPHOON trial who were enrolled in the French centres. In the TYPHOON trial, patients with AMI with ST-segment elevation less than 12 hours after the onset of chest pain were randomized to undergo percutaneous coronary intervention with either SES or BMS. Data on clinical outcomes and resource use were collected prospectively over a 1-year follow-up period (from October 2003 to October 2005). Unit costs were applied to the resource utilization data. The main outcome measure was the incremental cost-effectiveness ratio (ICER) for additional cost per target-vessel revascularization (TVR) avoided. The perspective of the study was the French healthcare system and costs were expressed in 2007 values. RESULTS: SES significantly reduced the rate of TVR (6.6% vs 22.2% with BMS, p < 0.0001). There was no difference in the rate of death, recurrent myocardial infarction or stent thrombosis after 1 year of follow-up between the SES and BMS groups. Mean index admission costs, including the angioplasty procedure, were increased by 282 Euro per patient in the SES group, mostly driven by the price of the SES. Mean follow-up costs were 140 Euro per patient lower in the SES group. Mean aggregate 1-year costs showed a euro 1142 per-patient increase in the SES group compared with the BMS group. The ICER was 7321 Euro per TVR avoided. CONCLUSIONS: In this pre-specified subgroup analysis of the TYPHOON trial, the use of SES in patients with AMI with ST-segment elevation less than 12 hours after the onset of chest pain reduced the rate of TVR compared with BMS. However, SES had a debatable ICER for the payer if it was based only on the specific benefit of TVR avoided.

Risk of neurological decompression sickness in the diver with a right-to-left shunt: literature review and meta-analysis.

OBJECTIVE: Literature review and meta-analysis to review the evidence of relationship between the presence of right-to-left shunts (RLSs) and the occurrence of neurological decompression sickness (DCS) in divers. DATA SOURCES: MEDLINE, Google Scholar, and Health Technology Assessment databases. STUDY SELECTION: Five case-control studies in which the prevalence of a RLS in a group of divers with neurological DCS was compared with that of a group of divers with no history of DCS, 3 cross-transversal studies in which the prevalence of RLS was measured in divers with neurological DCS, and 4 cross-transversal studies in which the prevalence of RLS was measured in divers with no history of DCS were reviewed. DATA EXTRACTION: Only case-control studies were retained for meta-analysis. DATA SYNTHESIS: This meta-analysis gathers 5 studies and 654 divers. The combined odds ratio of neurological DCS in divers with RLS was 4.23 (3.05-5.87). The meta-analysis including only large RLS found a combined odds ratio of 6.49 (4.34-9.71). CONCLUSIONS: Because of a low incidence of neurological DCS, increase in absolute risk of neurological DCS due to RLS is probably small. Thus, in recreational diving, the systematic screening of RLS seems unnecessary. In professional divers, because of a chronic exposition and unknown consequences of cerebral asymptomatic lesions, these results raise again the benefit of the transcranial Doppler in the screening and quantification of the RLS, independently of their location.

Comparison of accuracy of aortic valve area assessment in aortic stenosis by real time three-dimensional echocardiography in biplane mode versus two-dimensional transthoracic and transesophageal echocardiography.

Our aim was to validate the clinical feasibility of assessment of the area of the aortic valve orifice (AVA) by real time three-dimensional echocardiography (RT3DE) in biplane mode by planimetry and to compare it with the echo-Doppler methods more commonly used to evaluate valvular aortic stenosis (AS).RT3DE in biplane mode is a novel technique that allows operators to visualize the aortic valve orifice anatomy in any desired plane orientation. Its usefulness and accuracy have not previously been established. Using this technique, we studied a series of patients with AS and compared the results with those obtained by two-dimensional transesophageal echocardiography (TEE) planimetry and two-dimensional transthoracic echocardiography using the continuity equation (TTE-CE). RT3DE planimetries in biplane mode were measured by two independent observers. Bland-Altman analysis was used to compare these two methods.Forty-one patients with AS were enrolled in the study (15 women, 26 men, mean age 73.5 +/- 8.2 years). RT3DE planimetry was feasible in 92.7%. Average AVA determined by TTE-CE was 0.76 +/- 0.20 cm, by TEE planimetry 0.73 +/- 0.1 cm, and by RT3DE planimetry 0.76 +/- 0.20 cm(2). The average differences in AVA were-0.001 +/- 0.254 cm(2) and 0.03 +/- 0.155 cm(2) (RT3DE/TEE). The correlation coefficient for AVA (RT3DE/TTE-CE) was 0.82 and for AVA (RT3DE/TEE) it was 0.94, P < 0.0001. No significant intra- and interobserver variability was observed. In conclusion, RT3DE in biplane mode provides a feasible and reproducible method for measuring the area of the aortic valve orifice in aortic stenosis.

Assessment of atrial septal defect size with 3D-transesophageal echocardiography: comparison with balloon method.

BACKGROUND: Transcatheter closure of atrial septal defect (ASD) is an alternative approach to surgery in selected patients. Balloon stretched diameter (BSD) is considered as the standard way of measuring ASD size. Three-dimensional transesophageal echocardiography (3D-TEE) provides views of the ASD allowing its measurement and identifying its spatial relation with neighboring structures. Our aim was to compare the BSD and 3D-TEE methods to measure the ASD size before transcatheter closure. METHODS AND RESULTS: Seventy-six consecutive patients were enrolled for ASD device closure. Three-dimensional transesophageal echocardiography and balloon sizing were adequately performed in 70 patients before the defect closure. The mean maximal diameter measured by 3D-TEE was 20 +/- 15 mm (range 10-28) while the mean BSD was 22 +/- 4.8 mm (range 9-31). When comparing the 3D-TEE and transcatheter measurements, there was a good correlation between the two methods (y = 3.15 + 0.77x; r = 0.8). The defect as viewed by 3D-TEE was unique in 54 patients and multiple in 16 patients. In patients with a single defect, the correlation between the two methods was high (y = 1.74 + 0.84x; r = 0.85) while patients with multiple ASDs, the correlation was poor (y = 12.4 + 0.4x; r = 0.45). Transcatheter closure was performed successfully in 86%. The mean size of the Amplatzer device was 23 +/- 4.8 mm (range 4-32). The reference to choose the size of the device was the BSD in single defects and the 3D-TEE maximal diameter in multiple defects. CONCLUSION: Three-dimensional transesophageal echocardiography and transcatheter methods are two complementary techniques for the success of transcatheter ASDs closure.

DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction.

AIM: To determine whether late recanalization of an occluded infarct artery after acute myocardial infarction is beneficial. METHODS AND RESULTS: Two hundred and twelve patients with a first Q-wave myocardial infarction (MI) and an occluded infarct vessel were enrolled. After coronary and left ventricular contrast angiography, patients were randomized to percutaneous revascularization (PTCA, n=109), carried out 2-15 days after symptom onset or medical therapy (n=103). The primary endpoint was a composite of cardiac death, non-fatal MI, or ventricular tachyarrhythmia. The majority had single-vessel disease and less than one-third had involvement of the left anterior descending artery. The use of pharmacological therapy was high in both groups. At six months, left ventricular ejection fraction was 5% higher in the invasive compared with the medical group (P=0.013) and more patients had a patent artery (82.8% vs 34.2%, P<0.0001). Restenosis was seen in 49.4% of patients in the PTCA group. At a mean of 34 months of follow-up, the occurrence of the primary endpoint was similar in the medical and PTCA groups (8.7% vs 7.3% respectively, P=0.68), but the overall costs were higher for PTCA. The secondary endpoint combining the primary endpoint with admission for heart failure was also similar between groups (12.6% vs 10.1% in the medical and PTCA groups, respectively, P=0.56). CONCLUSIONS: Systematic late PTCA of the infarct vessel was associated with a higher left ventricular ejection fraction at six months, no difference in clinical outcomes, and higher costs than medical therapy. These results must be interpreted with caution given the small size and low risk of the population.