Contribution of cardiac magnetic resonance imaging in the diagnosis of acute coronary syndrome with normal coronary angiography.

Background - Acute coronary syndrome with high level of troponin is a common pattern for emergency consultation. In 10% of cases, coronary angiography concluded that there were no significant coronary lesions. The contribution of cardiac magnetic resonance imaging (MRI) in the etiological investigation is increasing in these conditions. Aim - We analyzed the diagnostic value of cardiac MRI in case of acute coronary syndromes with elevated troponin and normal coronary angiography. Methods - It's a retrospective analytical study including 31 patients presenting with acute coronary syndrome with positive troponins and normal coronary angiography. All these patients underwent cardiac MRI. Results - The average age was 44.94 years. Cardiovascular risk factors were present in 38.70%. The average level of troponin was 4.85 ng/ml. Modification in the ST segment was noted in 87.1% of which 51.6% had ST elevated segment. Cardiac MRI was performed in the average of 8 days. MRI has contributed to the diagnosis in 77.4%: a myocardial infarction (MI) with no significant coronary lesions in 38.7% of cases, myocarditis in 29% of cases, Tako-Tsubo syndrome in 6.5% of cases and apical HCM in 3.2% of cases. MRI was normal in 22.6% of cases. Conclusions - The contribution of cardiac MRI is growing in the diagnostic management of patients with chest pain, elevated level of troponin and normal coronary angiography. The differential diagnoses have discriminating characteristics in MRI, allowing their identification with excellent diagnostic accuracy. The two main etiologies are myocardial necrosis and myocarditis.

[Acute myocardial infarction in elderly patients]. / Infarctus du myocarde chez le sujet âgé.

BACKGROUND: Age is the most important determinant of outcome for patients with acute coronary syndromes (ACS) and ischemic heart disease is the leading cause of death among elderly patients. AIM: To determine the epidemiologic particularities, the clinical presentation, and the treatment of Acute Myocardial Infarction (AMI) in patients over 65 years. METHODS: One hundred patients >65 years of age with myocardial infarction were hospitalized in intensive care of cardiologic unit of Military Hospital of Tunis between 2000 and 2008. Clinical characteristics, reperfusion therapy and outcomes of in-hospital period and for one year follow-up were seen for every patient. RESULTS: The mean age of our population was 77 years. Sex-ratio was 3/1.Our population was divided into tow groups; patients aged between 65 and 75 years (48 patients) and those aged more than 75 years (52 patients). Only 44 % of our patients had arrived at the hospital within the first 12 hours. STEMI was found in 65 % of our patients. At admission, 40 % had congestive heart failure (³ Killip II), 10 % were in cardiogenic shock. Urgent reperfusion therapy was given to 58 % of our patients; 33% received a thrombolytic therapy and 25 % were allocated to primary PCI. During in-hospital period, 40 % have developed congestive heart failure, 20 % have had a cardiogenic shock and 12 % were died. All these events were more frequent in patients aged over 75 years and reperfusion therapy was associated with best outcome. CONCLUSION: In our study invasive treatment such as fibrinolysis and PCI was associated to better outcome in acute period and at 12 months of follow up in elderly patients treated for AMI.

Multimodality imaging assessment of a caseous calcification of the mitral valve annulus.

Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

Bioresorbable vascular scaffold (BVS) for in-stent chronic total occlusion: Antegrade recanalization and IVUS-guided BVS implantation by radial access.

The completely absorbable stents represent one of the latest innovations in the field of interventional cardiology, prospecting the possibility of "vascular repair". In the published trials (ABSORB Cohort A and B, ABSORB EXTEND, and ABSORB II, III and IV) chronic total occlusions (CTOs) were considered an exclusion criteria. More recently the CTO-ABSORB pilot study demonstrated the safety and feasibility of bioresorbable vascular scaffold (BVS) use in case of CTO recanalization. We present the first case, to our knowledge, of in-stent occlusion successfully treated with an everolimus-eluting BVS and discuss its potential advantages in such kind of lesions.