Marfan Sartan: a randomized, double-blind, placebo-controlled trial.

AIMS: To evaluate the benefit of adding Losartan to baseline therapy in patients with Marfan syndrome (MFS). METHODS AND RESULTS: A double-blind, randomized, multi-centre, placebo-controlled, add on trial comparing Losartan (50 mg when <50 kg, 100 mg otherwise) vs. placebo in patients with MFS according to Ghent criteria, age >10 years old, and receiving standard therapy. 303 patients, mean age 29.9 years old, were randomized. The two groups were similar at baseline, 86% receiving ß-blocker therapy. The median follow-up was 3.5 years. The evolution of aortic diameter at the level of the sinuses of Valsalva was not modified by the adjunction of Losartan, with a mean increase in aortic diameter at the level of the sinuses of Valsalva of 0.44 mm/year (s.e. = 0.07) (-0.043 z/year, s.e. = 0.04) in patients receiving Losartan and 0.51 mm/year (s.e. = 0.06) (-0.01 z/year, s.e. = 0.03) in those receiving placebo (P = 0.36 for the comparison on slopes in millimeter per year and P = 0.69 for the comparison on slopes on z-scores). Patients receiving Losartan had a slight but significant decrease in systolic and diastolic blood pressure throughout the study (5 mmHg). During the study period, aortic surgery was performed in 28 patients (15 Losartan, 13 placebo), death occurred in 3 patients [0 Losartan, 3 placebo, sudden death (1) suicide (1) oesophagus cancer (1)]. CONCLUSION: Losartan was able to decrease blood pressure in patients with MFS but not to limit aortic dilatation during a 3-year period in patients >10 years old. ß-Blocker therapy alone should therefore remain the standard first line therapy in these patients.

Mutations in myosin heavy chain 11 cause a syndrome associating thoracic aortic aneurysm/aortic dissection and patent ductus arteriosus.

We have recently described two kindreds presenting thoracic aortic aneurysm and/or aortic dissection (TAAD) and patent ductus arteriosus (PDA) and mapped the disease locus to 16p12.2-p13.13 (ref. 3). We now demonstrate that the disease is caused by mutations in the MYH11 gene affecting the C-terminal coiled-coil region of the smooth muscle myosin heavy chain, a specific contractile protein of smooth muscle cells (SMC). All individuals bearing the heterozygous mutations, even if asymptomatic, showed marked aortic stiffness. Examination of pathological aortas showed large areas of medial degeneration with very low SMC content. Abnormal immunological recognition of SM-MHC and the colocalization of wild-type and mutant rod proteins in SMC, in conjunction with differences in their coimmunoprecipitation capacities, strongly suggest a dominant-negative effect. Human MYH11 gene mutations provide the first example of a direct change in a specific SMC protein leading to an inherited arterial disease.

Major prognostic impact of persistent microvascular obstruction as assessed by contrast-enhanced cardiac magnetic resonance in reperfused acute myocardial infarction.

The aim of this study was to compare the prognostic significance of microvascular obstruction (MO) and persistent microvascular obstruction (PMO) as assessed by cardiac magnetic resonance (CMR) in patients with acute myocardial infarction (AMI). CMR was performed in 184 patients within the week following successfully reperfused first AMI. First-pass images were performed to evaluate extent of MO and late gadolinium-enhanced images to assess PMO and infarct size (IS). Major adverse cardiac events (MACE) were collected at 1-year follow-up. MO and PMO were found in 127 (69%) and 87 (47%) patients, respectively. By using univariate logistic regression analysis, high Global Registry of Acute Coronary Events (GRACE) risk score (odds ratio [OR] 95% confidence interval [CI]: 3.6 [1.8-7.4], p < 0.001), IS greater than 10% (OR [95% CI]: 2.7 [1.1-6.9], p = 0.036), left ventricular ejection fraction less than 40% (OR [95% CI]: 2.4 [1.1-5.2], p = 0.027), presence of MO (OR [95% CI]: 3.1 [1.3-7.3], p = 0.004) and presence of PMO (OR [95% CI]:10 [4.1-23.9], p < 0.001) were shown to be significantly associated with the outcome. By using multivariate analysis, presence of MO (OR [95% CI]: 2.5 [1.0-6.2], p = 0.045) or of PMO (OR [95% CI]: 8.7 [3.6-21.1], p < 0.001), associated with GRACE score, were predictors of MACE. Presence of microvascular obstruction and persistent microvascular obstruction is very common in AMI patients even after successful reperfusion and is associated with a dramatically higher risk of subsequent cardiovascular events, beyond established prognostic markers. Moreover, our data suggest that the prognostic impact of PMO might be superior to MO.

Utility of Cardiac Magnetic Resonance to assess association between admission hyperglycemia and myocardial damage in patients with reperfused ST-segment elevation myocardial infarction.

AIMS: to investigate the association between admission hyperglycemia and myocardial damage in patients with ST-segment elevation myocardial infarction (STEMI) using Cardiac Magnetic Resonance (CMR). METHODS: We analyzed 113 patients with STEMI treated with successful primary percutaneous coronary intervention. Admission hyperglycemia was defined as a glucose level >/= 7.8 mmol/l. Contrast-enhanced CMR was performed between 3 and 7 days after reperfusion to evaluate left ventricular function and perfusion data after injection of gadolinium-DTPA. First-pass images (FP), providing assessment of microvascular obstruction and Late Gadolinium Enhanced images (DE), reflecting the extent of infarction, were investigated and the extent of transmural tissue damage was determined by visual scores. RESULTS: Patients with a supramedian FP and DE scores more frequently had left anterior descending culprit artery (p = 0.02 and <0.001), multivessel disease (p = 0.02 for both) and hyperglycemia (p < 0.001). Moreover, they were characterized by higher levels of HbA1c (p = 0.01 and 0.04), peak plasma Creatine Kinase (p < 0.001), left ventricular end-systolic volume (p = 0.005 and <0.001), and lower left ventricular ejection fraction (p = 0.001 and <0.001). In a multivariate model, admission hyperglycemia remains independently associated with increased FP and DE scores. CONCLUSION: Our results show the existence of a strong relationship between glucose metabolism impairment and myocardial damage in patients with STEMI. Further studies are needed to show if aggressive glucose control improves myocardial perfusion, which could be assessed using CMR.

Do low-frequency electrical myostimulation and aerobic training similarly improve performance in chronic heart failure patients with different exercise capacities?

OBJECTIVE: To confirm that electrical myostimulation is a good alternative to conventional aerobic training in patients with chronic heart failure and to compare the effects of both training programmes in patients with different exercise capacities. PATIENTS AND METHODS: A total of 44 patients with stable chronic heart failure underwent 5 weeks of exercise training, with electrical myostimulation or conventional aerobic training programmes. At baseline and after the training period, patients performed a symptom-limited cardiopulmonary exercise test and a 6-min walk test. RESULTS: Oxygen uptake at the end of exercise (V.O2 peak) and at ventilatory threshold (V.O2 VT) increased after electrical myostimulation (p< 0.001) and conventional aerobic training (p< 0.001) training programmes. The slope of the relationship between V.O2 and workload was reduced after electrical myostimulation (p< 0.05), but not after conventional aerobic training. Recovery was improved after both training programmes (p< 0.05), and the distance walked in 6 min was increased (p< 0.001). These improvements were not statistically different between electrical myostimulation and conventional aerobic training. Moreover, electrical myostimulation induced greater improvements in patients with low exercise capacity, whereas conventional aerobic training induced improved performance in patients with average exercise capacity. CONCLUSION: Five weeks of electrical myostimulation and conventional aerobic training exercise training produced similar improvements in exercise capacity in patients with chronic heart failure. However, electrical myostimulation appears to be more effective in patients with low exercise capacity than in those with average exercise capacity.

Impact of fasting glycemia on short-term prognosis after acute myocardial infarction.

OBJECTIVE: The prognosis of patients with acute myocardial infarction (MI), according to the new criteria for impaired fasting glucose (IFG) (FG 100-126 mg/dl), has not been evaluated. RESEARCH DESIGN AND METHODS: A total of 2353 patients with acute MI and surviving at d 5 after admission were analyzed for short-term morbidity and mortality. FG was obtained at d 4 and 5. Patients were classified as diabetes mellitus (known diabetes or FG > or = 126 mg/dl), high IFG (110 < or = FG < 126 mg/dl), low IFG (100 < or = FG < 110 mg/dl), and normal fasting glucose (NFG) (FG < 100 mg/dl). RESULTS: Among the 2353 patients, 968 (41%) had diabetes mellitus, 262 (11%) had high IFG, 332 (14%) had low IFG, and 791 (34%) had NFG. Compared with NFG patients, 30-d cardiovascular mortality was increased in high but not low IFG subjects. In-hospital heart failure was increased in high IFG subjects (42 vs. 20% for NFG, P < 0.0001) but not low IFG subjects (21 vs. 20%). High IFG, but not low IFG, was an independent factor associated with 30-d cardiovascular mortality [odds ratio 2.33 (1.55-3.47)] and in-hospital heart failure [odds ratio 1.70 (1.36-2.07)]. The optimal threshold levels of FG on the receiver-operating characteristic curves were 114 and 112 mg/dl to predict mortality and in-hospital heart failure, respectively. CONCLUSION: The present study, based on a nonselected cohort of MI patients, underscores the high prevalence of IFG (25%) and highlights the clinical relevance of 110 mg/dl, but not 100 mg/dl, as a cutoff value to define the risk for worse outcome.

Comparison of the extent of delayed-enhancement cardiac magnetic resonance imaging with and without phase-sensitive reconstruction at 3.0 T.

OBJECTIVES: To evaluate phase-sensitive reconstructed images versus magnitude images generated by an inversion recovery pulse sequence for the determination of myocardial infarct size in delayed-enhancement cardiac magnetic resonance (DE-CMR) at 3 T. MATERIALS AND METHODS: Thirty patients were examined at 3 T and DE images were obtained 10 minutes after contrast agent administration using a phase-sensitive breath-hold segmented inversion recovery gradient echo sequence. From magnitude and phase images, the percentage of hyperenhanced myocardium was expressed. Contrast-to-noise ratio (CNR) measurements were performed in hyperenhanced and normal myocardium. RESULTS: We observed excellent correlation and concordance between hyperenhanced myocardium determined on phase-sensitive reconstructed and magnitude images. The mean CNR values were significantly higher in phase-sensitive reconstructed images compared with magnitude images (10.5 +/- 5.4 vs. 6.1 +/- 4.8; P < 0.001). CONCLUSIONS: DE-CMR with phase-sensitive reconstruction at 3.0 T provides similar results to magnitude images, but with a significantly greater CNR between infarcted and normal myocardium.

Mapping of familial thoracic aortic aneurysm/dissection with patent ductus arteriosus to 16p12.2-p13.13.

BACKGROUND: Three loci have been shown to be responsible for nonsyndromic familial thoracic aortic aneurysms (TAAs) and aortic dissections (ADs). We recently described a large family in which TAA/AD associates with patent ductus arteriosus (PDA) and provided genetic arguments for a unique pathophysiological entity. METHODS AND RESULTS: Genome-wide scan was performed in 40 subjects belonging to 3 generations in this large pedigree. Using the 7 TAA/AD cases as affected, we observed positive 2-point LOD scores on adjacent markers at chromosome 16p, with a maximum LOD score value of 2.73 at theta=0, a value that increased to 3.56 when 5 PDA cases were included. Multipoint linkage analysis yielded a maximum LOD score of 4.14 in the vicinity of marker D16S3103. Fine mapping allowed the observation of recombinant haplotypes that delimited a critical 20-cM interval at 16p12.2-p13.13. Automatic determination of aortic compliance with cine MRI showed that all subjects bearing the disease haplotype, even asymptomatic, displayed a very low level of aortic compliance and distensibility. Aortic stiffness was strongly associated with disease haplotype with a marked effect of age, indicating subclinical and early manifestation of the disease. CONCLUSIONS: Genetic analysis of this family identified a unique locus responsible for both TAA/AD and PDA at chromosome 16p12.2-p13.13 with aortic stiffness as an early hallmark of the disease. TAA/AD with PDA is a new monogenic entity among the genetically heterogeneous group of TAA/AD disease.

Relation of hyperglycemia to ST-segment resolution after reperfusion for acute myocardial infarction (from Observatoire des Infarctus de Côte-d'Or Survey [RICO]).

Hyperglycemia has been shown to be a powerful predictor of worse outcome after ST-segment-elevation myocardial infarction (STEMI), which could be related to impaired myocardial reperfusion. This study investigated the association between hyperglycemia and ST-segment resolution (STR) after thrombolysis. From the French regional Observatoire des Infarctus de Côte-d'Or survey, admission glucose in 371 patients with STEMIs who were treated by lysis<12 hours was analyzed. The single worst lead electrocardiogram before and 90 minutes after lysis was analyzed, and patients were divided into 3 groups according to the degree of STR: none (<30%), partial (30% to 70%), or complete (>or=70%). Of the 371 patients, 101 (27.2%) had no STR, 124 (33.4%) had partial STR, and 146 (39.4%) had complete STR. STR decreased with increasing glycemia (p=0.029), and patients with hyperglycemia (glycemia>or=11 mmol/L) were more likely to have no STR. Moreover, hyperglycemia was an independent predictor of incomplete STR even after adjustment for potential confounders (odds ratio 2.348, 95% confidence interval 1.212 to 4.547). In conclusion, the present study suggests a strong association between hyperglycemia and electrocardiographic signs of reperfusion in patients with STEMIs after lysis and suggests the usefulness of evaluating early glycemic control in the setting of reperfusion for acute myocardial infarction.

Automatic fuzzy classification of the washout curves from magnetic resonance first-pass perfusion imaging after myocardial infarction.

OBJECTIVES: We sought to investigate the diagnostic ability of cardiac magnetic resonance imaging (MRI) perfusion in acute reperfused myocardial infarction. The study used fuzzy logic to automatically classify signal intensity-time curves from myocardial segments into 3 categories: normal, hypointense, and Hyperintense. MATERIALS AND METHODS: Thirty-eight patients with myocardial infarction underwent short-axis cine-MRI and contrast-enhanced MRI to provide data on wall thickening and the transmural extent of infarction. Of these, 17 had a second cardiac MRI to ascertain the functional recovery in each segment. RESULTS: The fuzzy logic based classification performs well (kappa= 0.87, P < 0.01) in comparison with a visual approach. Segments providing "hypo" curves do not recover (Delta = 0.11 SD = 0.96) whereas segments demonstrating the other curve types recover (Delta = 1 SD = 1.98 for "hyper" curves and Delta = 1.54 SD = 1.77 for "normal" curves). CONCLUSIONS: The proposed automatic signal intensity-time curve classification has a prognostic value when studying the functional recovery of pathologic segments and clearly identifies the no-reflow phenomenon known to induce poor recovery.

Usefulness of MRI in the follow-up of patients with repaired aortic coarctation and bicuspid aortic valve.

BACKGROUND: The long-term outcome of repaired aortic coarctation may be complicated by dilatation of the ascending aorta notably in patients with bicuspid aortic valve. Magnetic resonance imaging was used to compare the size of the ascending aorta in patients with bicuspid or tricuspid aortic valve. METHODS: In 50 patients with a repair of aortic coarctation, the size of the ascending aorta was measured in a bicuspid aortic valve group (n=11) and a tricuspid aortic valve group (n=39). The aortic diameter was measured at the level of the sinus of Valsalva and at the widest part of the ascending aorta using magnetic resonance imaging. RESULTS: The mean age of patients at surgical repair was respectively 2.2+/-3.3 years for the bicuspid aortic valve group and 2.5+/-3.5 years for the tricuspid aortic valve group (p=NS) and the mean age at the time of the magnetic resonance imaging was 10.2+/-4.7 years and 9.3+/-5.9 years (p=NS) respectively. A significant difference in the aortic diameter was found between the bicuspid aortic valve group and the tricuspid aortic group both at the level of sinus of Valsalva (34.8+/-8.2 mm, 19.5+/-4.4 mm, respectively, p<0.01) and at the level of the ascending aorta (36.8+/-7.2 mm, 16.9+/-3.4 mm, respectively, p<0.01). CONCLUSIONS: The occurrence of ascending aortic dilatation is significantly associated with the presence of a bicuspid aortic valve. This requires long-term follow-up, which can be effectively performed by magnetic resonance imaging.

A new and simple method for distinguishing complete from incomplete block through the cavotricuspid isthmus.

BACKGROUND: A complete line of block (CLOB) in the cavotricuspid isthmus (CTI) is the endpoint of typical atrial flutter ablation. Before CTI block is obtained, a progressive CTI conduction delay due to an incomplete line of block (InLOB) can be difficult to distinguish from CLOB. The purpose of this study was to assess a new simple approach based on the changes in atrio-ventricular (AV) conduction delays during septal and lateral right atrial pacing, to distinguish a CLOB from an InLOB during typical atrial flutter (AFL) ablation. METHODS AND RESULTS: Forty patients who presented an InLOB before a CLOB, and a stable (AV) conduction delay at 600 ms cycle length pacing (when in sinus rhythm), during AFL ablation were included in this study. A 24-pole mapping catheter was positioned so that 2 adjacent dipoles bracketed the targeted CTI line of block (LOB), with proximal dipoles lateral to the LOB and distal dipoles in the coronary sinus. Two pacing sites were lateral (position L1 and L2) and one was septal (position S) to the LOB, with locations L1 and S closest to the LOB. During L1, L2 and S site pacing, the delay between the pacing artefact and the peak of the R wave in a surface ECG (lead II) was measured. We measured the following conduction delays (mean +/- SD in ms), during InLOB versus CLOB: (L1 to R) 320.5 +/- 68.0 versus 367.0 +/- 62.0, p = 0.001; (L2 to R) 333.0 +/- 59.0 versus 338.0 +/- 62.0, p = 0.663, (S to R) 259.4 +/- 51.5 versus 247.1 +/- 55.5, p = 0.987. We calculated the following data during an InLOB versus a CLOB: (L1R-L2R) -12.3 +/- 7 versus 20.2 +/- 12.7, p = 0.001; (L1R-SR) 51.1 +/- 21.5 versus 120.1 +/- 16.6, p < 0.05. The sensitivity, specificity, positive and negative predictive values for CLOB with (L1R-SR > 94 ms) and with (L1R-L2R > 0 ms) were respectively; 100%, 98%, 98% and 100%. CONCLUSIONS: This study establishes that lateral versus septal right atrial pacing sites combined with the measure of AV conduction delay on a surface ECG can be useful to distinguish a CLOB from an InLOB during AFL ablation.

Familial thoracic aortic aneurysm/dissection with patent ductus arteriosus: genetic arguments for a particular pathophysiological entity.

Thoracic aortic aneurysm and aortic dissection (TAA and AD) are an important cause of sudden death. Familial cases could account for 20% of all cases. A genetic heterogeneity with two identified genes (FBN1 and COL3A1) and three loci (3p24-25 or MFS2/TAAD2, 5q13-q14 and 11q23.2-24) has been shown previously. Study of a single family composed of 179 members with an abnormally high occurrence of TAA/AD disease. A total of 40 subjects from three generations were investigated. In addition to five cases of stroke and three cases of sudden death, there were four cases of AD and four cases of TAA in adults. In all, 11 cases of patent ductus arteriosus (PDA) were observed, two of which were associated with TAA and one with AD. Segregation analysis showed that the distribution of these vascular abnormalities was more likely compatible with a single genetic defect with an autosomal dominant pattern of inheritance. There were no clinical signs of Marfan, Elhers-Danlos vascular type or Char syndromes. Genetic linkage analysis was performed for seven genes or loci implicated in familial TAA/AD disease (COL3A1, FBN1, 3p24-25 or MFS2/TAAD2, 5q13-q14 and 11q23.2-q24), Char syndrome (TFAP2B) or autosomal recessive PDA (12q24). Using different genetic models, linkage with these seven loci was excluded. Familial TAA/AD with PDA is likely to be a particular heritable vascular disorder, with an as yet undiscovered Mendelian genetic basis.

Late neointimal tissue growth behind the stent after intravascular gamma-radiation.

PURPOSE: To determine the nature of the changes of the vascular wall after intravascular brachytherapy in stented arteries leading to incomplete stent apposition. METHODS AND MATERIALS: Stents were implanted in the infrarenal aortas of rabbits, and gamma-intravascular brachytherapy (18 Gy) or a sham radiation procedure was immediately implemented. The arteries were harvested at 6 months for histologic analyses. RESULTS: The external elastic lamina area, as well as the vascular wall area behind the stent, were significantly greater in irradiated vs. control arteries (8.94 +/- 0.68 mm2 vs. 6.87 +/- 0.40 mm2 [p <0.001] and 1.56 +/- 0.13 mm2 vs. 0.72 +/- 0.07 mm2 [p <0.001], respectively). The ratio of the intimal area behind the stent related to the total intimal area was greater in the irradiated segments (control vs. irradiated: 9.0% +/- 5.9% vs. 55.3% +/- 15.5%, p <0.05). Neointimal growth of the irradiated vessels outside the stent was characterized by marked fibrin depositions and an inflammatory response around the stent struts. CONCLUSION: Our study revealed the presence of a neointimal layer specifically located behind the stent, which represented the result of an unhealed fibrin-rich tissue growth process 6 months after intravascular brachytherapy.

Automatic determination of aortic compliance with cine-magnetic resonance imaging: an application of fuzzy logic theory.

RATIONALE AND OBJECTIVES: Aortic compliance is defined as the relative change in aortic cross-sectional area divided by the change in arterial pressure. Magnetic resonance imaging (MRI) is a useful imaging modality for the noninvasive evaluation of aortic compliance. However, manual tracing of the aortic contour is subject to important interobserver variations. To estimate the aortic compliance from cine-MRI, a method based on fuzzy logic theory was elaborated. MATERIALS AND METHODS: Seven healthy volunteers and eight patients with Marfan syndrome were examined using an ECG gated cine-MRI sequence. The aorta was imaged in the transverse plane at the level of the pulmonary trunk. A method based on fuzzy logic was developed to automatically detect the aortic contour. RESULTS: Through our robust automatic contouring method, the calculation of aortic cross-sectional areas allows an estimation of the aortic compliance. CONCLUSION: The aortic compliance can be obtained from a fuzzy logic based automatic contouring method, thereby avoiding the important interobserver variation often associated with manual tracing.

Glucose insulin potassium infusion improves systolic function in patients with chronic ischemic cardiomyopathy.

OBJECTIVE: We assessed the effects of glucose-insulin-potassium (GIK) by echocardiography in stable patients with ischemic dysfunction. METHODS: Twelve male patients with stable coronary disease (SCD) and ejection fraction (EF) <45% were studied for systolic function. GIK (glucose 30%, 300 insulin units and KCl 6 g/l) was infused at 1 ml/kg per h over 20 min. Hemodynamic and echocardiographic measurements were recorded at rest (T(0)), at the end (20 min) of GIK infusion (T+20), 20 and 40 min after the end of the infusion (T+40 and T+60). RESULTS: At T+20, a significant decrease in WMSI (wall motion score index) was observed compared with T(0) (2.16+/-0.14 vs. 2.30+/-0.16: P<0.05). An increase in EF was reported at T+40 and T+60 compared with T(0) (44.1+/-7.8% and 53.3+/-11.6% vs. 35.6+/-4.5%, respectively: P<0.01). A decrease in WMSI was observed at T+40 and T+60 compared with rest (2.02+/-0.17 and 1.93+/-0.11 vs. 2.30+/-0.16, respectively: P<0.01). CONCLUSION: Our present work suggests that GIK infusion improves systolic function in patients with SCD and ejection fraction <45%. Further studies are needed to determine if short-term GIK infusion could be useful for therapeutic or diagnostic strategies in these patients.

The extent of myocardial damage assessed by contrast-enhanced MRI is a major determinant of N-BNP concentration after myocardial infarction.

AIMS: To evaluate the relationship between N-terminal Pro-Brain Natriuretic Peptide (N-BNP) level and contrast-enhanced MRI in patients after acute myocardial infarction (MI). METHODS: Eighty-two patients were studied. Venous blood samples were obtained 3 days after MI and MRI was performed from 2 to 7 days after MI, with determination of left ventricular function and acquisition of perfusion data after injection of gadolinium-DTPA. First-pass images (FPI) and Delayed contrast-enhanced (CE) images were analyzed using a 17-segment model, and the extent of transmurality was determined by a visual score. RESULTS: Univariate analysis showed that age (P<0.001), sex (P<0.02), Left Ventricular Ejection Fraction (LVEF) <45% (P<0.002), creatinine (P<0.05) and delayed CE-MR images (P<0.006) were predictors of a supramedian N-BNP level. FPI was not a predictor in this univariate analysis (P<0.078). In a multivariate model, only age, LVEF <45% and delayed CE-MRI were associated with an increased N-BNP level. CONCLUSION: After MI, high N-BNP levels are dependent on the LVEF but also on the myocardial infarct size derived from the delayed CE-MR images.

Predictive value of myocardial tomoscintigraphy in asymptomatic diabetic patients after percutaneous coronary intervention.

OBJECTIVE: This study was designed to assess the prognostic value of myocardial tomoscintigraphy perfusion imaging after percutaneous coronary intervention (PCI) in asymptomatic diabetic patients. METHODS: One hundred and fourteen diabetic patients were followed up during 27+/-16 (mean+/-SD) months after the myocardial tomoscintigraphy. PCI-related events were studied after myocardial tomoscintigraphy stress testing and included major cardiac events (MACE) (cardiovascular death, myocardial infarction) and revascularization (bypass surgery or new PCI). Stress myocardial tomoscintigraphy imaging was performed 5+/-5 months after PCI and ischemia was considered as present if at least 2 contiguous segments were showing reversible defects. RESULTS: Persistent silent ischemia was found in 49/114 (43%) patients. No difference was observed between the two groups for MACE: four among the 65 (6%) non ischemic patients versus 2 among the 49 (4%) ischemic patients (NS). In contrast, 15 (31%) among the ischemic patients and 4 (6%) among the non ischemic patients underwent iterative revascularization (p<0.01). The relative risk of revascularization for patients with significant ischemia was 5.5 versus non ischemic patients (p<0.001). CONCLUSION: After PCI, in asymptomatic diabetic patients followed by myocardial tomoscintigraphy a high frequency of persistent silent ischemia was found and associated with a high risk for repeat interventional procedure, although no increase in major cardiac events was observed.

Bacterial endocarditis complicating mitral annular calcification: a clinical and echocardiographic study.

BACKGROUND AND AIM OF THE STUDY: Although described in a number of necropsy studies, endocarditis on mitral annular calcification (MAC) has rarely been reported during life. The study aim was to assess the frequency and specific features of bacterial endocarditis complicating MAC. METHODS: Data relating to 62 cases of infective endocarditis of the native mitral valve diagnosed with multiplane transesophageal echocardiography (TEE) over a five-year period were collected prospectively. RESULTS: Among 62 patients, 15 (24%) had vegetations originating from a calcified mitral annulus (group 1), while 47 had classic leaflet endocarditis (group 2). Group 1 patients differed significantly from group 2 patients with regard to: (i) higher incidence of diabetes mellitus and cancers; (ii) initial clinical presentation, with febrile coma or meningoencephalitis in 53% of cases; (iii) echocardiographic features, with significantly greater vegetations, presence of calcium-dense echoes within the vegetation, high frequency of ring abscess, and high frequency of para-annular ventriculoatrial leakage; and (iv) poorer clinical outcome, with 53% in-hospital mortality. CONCLUSION: MAC appears to be an underestimated predisposing factor for a particularly severe type of bacterial endocarditis. The use of multiplane TEE should improve current knowledge of this disease.

False Aneurysm of the Aortic Root and Right Ventricular Outflow Obstruction: An Unusual Complication of Surgically Treated Infective Endocarditis.

Aortic root abscess often complicates the course of aortic valve endocarditis. In severe cases, left ventricular-aortic discontinuity may occur, providing challenging technical problems for the surgeon. Moreover, surgical intervention sometimes takes place in a semi-emergency context, and the patches and prosthesis are sutured into friable tissues and subjected to high systemic pressures. Subsequently, paravalvular leaks and prosthesis dehiscence are not uncommon; postoperative false aneurysm of the aortic root is a much more unusual complication. We report one case of right ventricular outflow obstruction that occurred after surgical treatment of an aortic root abscess. Echocardiographic data were useful, but magnetic resonance imaging provided valuable information about the anatomic extent of the cavity. (ECHOCARDIOGRAPHY, Volume 13, January 1996)