Transcoronary pacing to assess myocardial viability prior to percutaneous coronary intervention: Pilot study to assess feasibility.

BACKGROUND: The assessment of myocardial viability is crucial before percutaneous coronary intervention (PCI) is carried out to ensure that the patient will gain benefit. Trans-coronary pacing (TCP) has previously been used to pace myocardium but may also provide information on myocardial viability. METHODS: Patients with a single, significant coronary stenosis requiring PCI were recruited. They underwent a cardiac MRI to assess myocardial viability. Prior to PCI, a coronary guidewire was used to measure pacing threshold, impedance, and R-wave amplitude in different myocardial segments to determine any association between the electrical parameters and myocardial viability. RESULTS: Eight patients were recruited and six patients underwent intervention. Pacing sensitivity did not demonstrate statistically significant differences between normal and scarred myocardium. Impedance demonstrated a mean of 304.8 ± 74.0 Ω in normal myocardium (NM), 244.1 ± 66.6 Ω in <50% myocardial scar (MS), and 222.3 ± 33.8 Ω in ≥50% MS. Pacing threshold demonstrated a mean of 1.960 ± 1.226 V in NM, 5.009 ± 2.773 V in <50% MS, and 3.950 ± 0.883 V in ≥50% MS. For both impedance and threshold, there was a significant difference among the groups (P = 0.12 and P = 0.002, respectively), and post hoc Tukey's pairwise comparison demonstrated significant differences between NM and scarred myocardium. No significant differences were found between <50% MS and ≥50% MS. CONCLUSIONS: Impedance and pacing threshold, measured during TCP, can be used to differentiate between normal myocardium and scarred myocardium. Further research is needed to determine whether TCP can discriminate between viable and nonviable myocardium.

Diagnosing coronary artery disease by sound analysis from coronary stenosis induced turbulent blood flow: diagnostic performance in patients with stable angina pectoris.

Optimizing risk assessment may reduce use of advanced diagnostic testing in patients with symptoms suggestive of stable coronary artery disease (CAD). Detection of diastolic murmurs from post-stenotic coronary turbulence with an acoustic sensor placed on the chest wall can serve as an easy, safe, and low-cost supplement to assist in the diagnosis of CAD. The aim of this study was to evaluate the diagnostic accuracy of an acoustic test (CAD-score) to detect CAD and compare it to clinical risk stratification and coronary artery calcium score (CACS). We prospectively enrolled patients with symptoms of CAD referred to either coronary computed tomography or invasive coronary angiography (ICA). All patients were tested with the CAD-score system. Obstructive CAD was defined as more than 50 % diameter stenosis diagnosed by quantitative analysis of the ICA. In total, 255 patients were included and obstructive CAD was diagnosed in 63 patients (28 %). Diagnostic accuracy evaluated by receiver operating characteristic curves was 72 % for the CAD-score, which was similar to the Diamond-Forrester clinical risk stratification score, 79 % (p = 0.12), but lower than CACS, 86 % (p < 0.01). Combining the CAD-score and Diamond-Forrester score, AUC increased to 82 %, which was significantly higher than the standalone CAD-score (p < 0.01) and Diamond-Forrester score (p < 0.05). Addition of the CAD-score to the Diamond-Forrester score increased correct reclassification, categorical net-reclassification index = 0.31 (p < 0.01). This study demonstrates the potential use of an acoustic system to identify CAD. The combination of clinical risk scores and an acoustic test seems to optimize patient selection for diagnostic investigation.

Tongguan capsule ameliorates coronary artery stenosis in a 40-year-old woman.

Cardiovascular disease is the leading cause of death worldwide, with coronary heart disease as the major contributor to this related mortality. There is a growing trend in the application of Chinese medicine in clinical practice for the treatment of coronary heart disease. However, there is a lack of knowledge surrounding the pharmacological, toxicological, and biological profiles of Chinese medicine. In this case report, we describe the therapeutic effects of Tongguan capsule in a 40-year-old woman diagnosed with stable angina pectoris. To the best of the authors' knowledge, this is the first case documented of the therapeutic effect of Tongguan capsule in the treatment of coronary heart disease.

Combined percutaneous coronary intervention and transcatheter aortic valve implantation in cardiogenic shock.

Transcatheter aortic valve implantation (TAVI) is a therapeutic option for patients with severe aortic valve stenosis and high surgical risk. Data concerning combined TAVI and percutaneous coronary intervention (PCI) as an alternative treatment to surgery in high-risk patients with aortic valve stenosis and concomitant coronary artery disease (CAD) are limited, and no prior cases of an emergency procedure in cardiogenic shock have been described. Herein is presented the case of a 53-year-old patient admitted in cardiogenic shock due to subacute myocardial infarction as well as high-grade aortic valve disease. Because of a prior history of mediastinal irradiation and the patient's unstable condition, an immediate percutaneous procedure was successfully performed with sequential transfemoral PCI and TAVI. The patient gradually recovered with a markedly improved left ventricular function and good quality of life. In conclusion, a single-stage combined approach is reasonable even in an emergency setting, and can lead to a good shortterm outcome. However, further reports and experience are needed to evaluate the feasibility of this approach.

Non-invasive characterization of the area-at-risk using magnetic resonance imaging in chronic ischaemia.

AIMS: we investigated the performance of quantitative stress perfusion magnetic resonance imaging (MRI) as a basis for identifying and characterizing the area-at-risk subtending a chronic coronary artery (CA) stenosis. METHODS AND RESULTS: pigs underwent a percutaneous copper-coated stent implantation in the circumflex CA (n = 11) or a sham operation (n = 5). After 6 weeks, angiography and MRI were performed including cine (rest, low- and high-dose dobutamine stress), dual-bolus first-pass perfusion (rest and adenosine stress), and contrast-enhanced imaging to quantify myocardial infarction (MI). Myocardial blood flow (MBF) was quantified based on Fermi-model deconvolution and compared with microsphere measurements. On the basis of Evan's blue staining, MBF thresholds to define the area-at-risk were determined by receiver-operating characteristic (ROC) analysis. CA stenosis was 94 ± 7% and infarct size (IS) 7.3 ± 3.1% of left ventricular mass. Segmental thresholds of hyperaemic MBF yielded the best performance for detecting area-at-risk. There was a good correlation between MRI and microsphere perfusion (r(2) = 0.84, P < .0001). The area-at-risk presented a mixed substrate of non-infarcted (non-MI), <50% infarcted (MI+), and >50% infarcted (MI++) segments. MBF was reduced in at-risk vs. remote segments at rest (non-MI, 0.50 ± 0.21; MI+, 0.47 ± 0.14; MI++, 0.42 ± 0.14; remote, 0.84 ± 0.25 mL/min/g) and during stress (non-MI, 0.69 ± 0.09; MI+, 0.66 ± 0.14; MI++, 0.51 ± 0.11; remote, 1.70 ± 0.36 mL/min/g). Segmental wall thickening showed different responses to stress (remote, progressive increase during incremental stress; non-MI, increase at low-dose and discontinued at high-dose; MI+, initial increase and decrease at high-dose; MI++, progressive decrease). CONCLUSION: quantitative hyperaemic perfusion MRI accurately defines segments in the area-at-risk in chronic ischaemia, which present with different functional response to stress related to segmental IS.

[Relationship among peripheral leucocytes, coronary stenosis and Chinese medicine syndromes in patients with coronary heart disease].

OBJECTIVE: To study the relationship among peripheral leucocytes, coronary artery stenosis and Chinese medicine syndromes in patients with coronary heart disease (CHD). METHODS: The Chinese medicine syndromes of 189 CHD patients were differentiated into six types: the turbidity-phlegm blood-stasis type (A), the qi-deficiency blood-stasis type (B), the cold-congealing blood-stasis type (C), the qi-stagnancy blood-stasis type (D), the qi-deficiency phlegm-stasis type (E) and the turbidity-phlegm blocking laterals type (F). Coronary angiography and peripheral leucocyte counting were performed simultaneously for determining the degree of blood-stasis by scoring (BSS), and the outcome of coronary angiography was evaluated depending Gensini scoring system. All data obtained were analyzed statistically. RESULTS: The highest BSS, that means the highest degree of coronary artery stenosis, was shown in patients of Chinese medicine type C, following with type A, B and D in order, the lowest level was found in the non-blood-stasis groups, namely, patients of Chinese medicine type E and F. Peripheral count of leucocytes were correlated with the BSS and Gensini score, count of mononuclear cell was individually correlated with BSS, and that of neutrophil was individually correlated with Gensini score. CONCLUSIONS: BSS and distribution of peripheral leucocytes were different in CHD patients of various Chinese medicine types, count of peripheral mononuclear cell is individually correlated with BSS, and that of neutrophil is individually correlated with Gensini score.

[Calcium scoring and coronary angiography performed with multislice spiral CT -- clinical experience]. / Koronarkalkquantifizierung und Koronarangiographie mittels Mehrzeilendetektorspiral-CT -- Klinische Erfahrungen.

PURPOSE: To report our clinical experience in calcium scoring and coronary angiography with multislice computer tomography (MSCT). MATERIAL AND METHODS: Cardiac four-row MSCT (Siemens, Volume Zoom, Erlangen, Germany) was performed in 60 patients, comprising 45 patients without known coronary vessel disease (CVD) and falling in an intermediate risk (group I) by calcium scoring, and 15 patients with multivessel disease by the combination of calcium scoring and MSCT coronary angiography (group II). Group I underwent analysis of risk factors as well as patient management in the form of risk profile modulation, indication for invasive selective coronary angiography (SCA) and supplemental myocardial diagnostic evaluation (e. g., SPECT). Agatston and volume scores (Virtuoso, Siemens, Erlangen, Germany) were calculated for calcium scoring. Group II had the calcium scoring and diagnostic accuracy of MSCT in detecting coronary artery stenosis evaluated according to established American Heart Association (AHA) criteria. SCA was used as gold standard. RESULTS: In group I, calcium scoring was positive in 27/45 (60 %) patients, with 14/27 (52 %) consecutively referred to SCA and 2/27 (7 %) to SPECT. SCA revealed significant coronary stenosis (> 60 %) in 5/27 (19 %) patients and SPECT detected myocardial ischemia in 0/2 patients. Patients with obstructive coronary vessel disease showed a significantly increased calcium score of > 300 together with a high risk profile. Patients with negative calcium score showed significantly less risk factors (p < 0.05). The use of calcium scoring in therapeutic procedures in the form of increased modulation of risk factors was documented in 21/45 (47 %) patients. In group II, sensitivity, specificity and diagnostic accuracy for the detection of high grade coronary artery stenosis were 64 %, 99 % and 96 %, and the Agatston and Volume scores were 333 +/- 123 and 334 +/- 136, respectively. CONCLUSION: MSCT can be applied as risk profile module for coronary screening of patients with intermediate risk. As non-invasive alternative for the evaluation of coronary vessel disease, it can be useful in some cases by providing additional information.