Acute Myocardial Infarction: Changes in Patient Characteristics, Management, and 6-Month Outcomes Over a Period of 20 Years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015.

BACKGROUND: ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) management has evolved considerably over the past 2 decades. Little information on mortality trends in the most recent years is available. We assessed trends in characteristics, treatments, and outcomes for acute myocardial infarction in France between 1995 and 2015. METHODS: We used data from 5 one-month registries, conducted 5 years apart, from 1995 to 2015, including 14 423 patients with acute myocardial infarction (59% STEMI) admitted to cardiac intensive care units in metropolitan France. RESULTS: From 1995 to 2015, mean age decreased from 66±14 to 63±14 years in patients with STEMI; it remained stable (68±14 years) in patients with NSTEMI, whereas diabetes mellitus, obesity, and hypertension increased. At the acute stage, intended primary percutaneous coronary intervention increased from 12% (1995) to 76% (2015) in patients with STEMI. In patients with NSTEMI, percutaneous coronary intervention ≤72 hours from admission increased from 9% (1995) to 60% (2015). Six-month mortality consistently decreased in patients with STEMI from 17.2% in 1995 to 6.9% in 2010 and 5.3% in 2015; it decreased from 17.2% to 6.9% in 2010 and 6.3% in 2015 in patients with NSTEMI. Mortality still decreased after 2010 in patients with STEMI without reperfusion therapy, whereas no further mortality gain was found in patients with STEMI with reperfusion therapy or in patients with NSTEMI, whether or not they were treated with percutaneous coronary intervention. CONCLUSIONS: Over the past 20 years, 6-month mortality after acute myocardial infarction has decreased considerably for patients with STEMI and NSTEMI. Mortality figures continued to decline in patients with STEMI until 2015, whereas mortality in patients with NSTEMI appears stable since 2010.

Applicability and accuracy of pretest probability calculations implemented in the NICE clinical guideline for decision making about imaging in patients with chest pain of recent onset.

OBJECTIVES: To analyse the implementation, applicability and accuracy of the pretest probability calculation provided by NICE clinical guideline 95 for decision making about imaging in patients with chest pain of recent onset. METHODS: The definitions for pretest probability calculation in the original Duke clinical score and the NICE guideline were compared. We also calculated the agreement and disagreement in pretest probability and the resulting imaging and management groups based on individual patient data from the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT). RESULTS: 4,673 individual patient data from the CoMe-CCT Consortium were analysed. Major differences in definitions in the Duke clinical score and NICE guideline were found for the predictors age and number of risk factors. Pretest probability calculation using guideline criteria was only possible for 30.8 % (1,439/4,673) of patients despite availability of all required data due to ambiguity in guideline definitions for risk factors and age groups. Agreement regarding patient management groups was found in only 70 % (366/523) of patients in whom pretest probability calculation was possible according to both models. CONCLUSIONS: Our results suggest that pretest probability calculation for clinical decision making about cardiac imaging as implemented in the NICE clinical guideline for patients has relevant limitations. KEY POINTS: • Duke clinical score is not implemented correctly in NICE guideline 95. • Pretest probability assessment in NICE guideline 95 is impossible for most patients. • Improved clinical decision making requires accurate pretest probability calculation. • These refinements are essential for appropriate use of cardiac CT.

Correction to: Applicability and accuracy of pretest probability calculations implemented in the NICE clinical guideline for decision making about imaging in patients with chest pain of recent onset.

The original version of this article, published on 19 March 2018, unfortunately contained a mistake. The following correction has therefore been made in the original: The names of the authors Philipp A. Kaufmann, Ronny Ralf Buechel and Bernhard A. Herzog were presented incorrectly.

[Non-invasive imaging tests for detecting coronary artery disease in symptomatic stable patients. Is diagnostic performance sufficient for guiding strategy?]. / Détection de la maladie coronaire par les examens non invasifs d'imagerie cardiaque chez le patient symptomatique stable: la seule performance diagnostique est-elle suffisante pour guider la stratégie?

Several non-invasive imaging techniques are currently available for coronary artery disease detection in stable patients with chest pain: exercise electrocardiogram, myocardial scintigraphy, stress echocardiography, stress MRI, positron emission tomography and computed tomography coronary angiography. According to recent guidelines from the European Society of Cardiology, the diagnosis process shall be guided by the coronary risk of the patient. The first recommended step is to clinically assess the probability of coronary artery disease. Thereafter, the choice of technique will be driven by usual parameters such as availability, local expertise and the contraindications of each test. Although detection of coronary artery disease by non-invasive tests follows different pathophysiological pathways, diagnostic value appears comparable. Therefore, choice of a diagnostic test must also take into consideration other factors such as the risks and hazards of imaging techniques as well as cost-efficiency parameters.

Cardiac resynchronization therapy plus coupled pacing improves acutely myocardial function in heart failure patients.

BACKGROUND: Coupled pacing (CP), which consists of an additional beat delivered after ventricular refractory period, has been proposed to reduce ventricular rate and increase ventricular contractility. We hypothesized that CP may be added to cardiac resynchronization therapy (CRT) to improve CRT effect in heart failure (HF) patients. METHODS: The study included 20 consecutive HF patients in sinus rhythm referred for CRT-defibrillator (CRT-D) implantation (baseline left ventricular ejection fraction [LVEF] 27 ± 6%, baseline QRS duration 149 ± 33 ms, age = 63 ± 11 years). CP associated with CRT (CRT + CP) was delivered during CRT-D implantation from the right and left ventricular leads simultaneously. Echocardiography data were collected at baseline, during CRT and CRT + CP to assess changes in LVEF, cardiac output (CO), longitudinal global strain assessed by speckle tracking, and LV dyssynchrony (opposing wall delay using tissue Doppler imaging). RESULTS: Compared to the conventional CRT, heart rate (HR) markedly decreased during CRT + CP (79 ± 20 beats/min vs 51 ± 8 beats/min, P < 0.0001) and was associated with a significant increase in LVEF (30 ± 8% vs 35 ± 8%, P = 0.0002) and peak of longitudinal global strain (-6 ± 2% vs -8 ± 2%, P < 0.0001). Importantly, during CRT + CP, CO increased (3.8 ± 1.0 L/min vs 4.4 ± 1.4 L/min, P = 0.004) and cardiac synchronicity remained unchanged (38 ± 24 ms for CRT alone vs 27 ± 18 ms for CRT + CP, P = 0.1). CONCLUSION: In sinus rhythm HF patients, acute CP application in addition to CRT decreases HR and contributes to myocardial contractility and CO improvement without deleterious impact on ventricular synchronicity.

Diuretics in normotensive patients with acute pulmonary embolism and right ventricular dilatation.

BACKGROUND: The benefit of load expansion is controversial in acute pulmonary embolism (PE). The aim of this study was to evaluate the benefit of furosemide in cases of normotensive acute PE. METHODS AND RESULTS: We retrospectively included 70 consecutive normotensive patients (systolic blood pressure ≥ 90 mmHg) admitted for acute PE with right ventricular dilation. Overall, 40 patients were treated during the first 24h by repeated bolus of furosemide (78 ± 42 mg, range 40-160 mg) and 30 patients received isotonic saline solution (1.6 ± 0.9L). Severity of hemodynamic status was similar in both groups, but patients in the furosemide group were older and had a greater creatinine level. At 24h, only the furosemide group had a decreased shock index (0.82 ± 0.22 vs. 0.63 ± 0.16, P<0.0001) with improved systolic blood pressure (118 ± 18 vs. 133 ± 17 mmHg, P<0.0001), and creatinine levels. After treatment, there were fewer patients with simplified pulmonary embolism severity index ≥ 1 in the diuretic group (45% vs. 55%, P=0.03) than in the fluid expansion group (47% vs. 40%, P<0.0001). Finally, oxygen requirement at 24h decreased only in the diuretic group (75% to 47%, P=0.0004), and in-hospital survival without death and PE-related shock were similar between the 2 groups. CONCLUSIONS: In normotensive PE with RV dilatation, diuretics may improve hemodynamics and oxygenation requirement.

Outcomes of pseudo-severe aortic stenosis under conservative treatment.

AIMS: In the setting of low-flow/low-gradient aortic stenosis (LF/LGAS), outcomes of pseudo-severe aortic stenosis (AS) remain poorly described. This study was aimed to assess the outcome of patients with pseudo-severe AS under conservative treatment. METHODS AND RESULTS: Among 305 patients from the European Registry of LF/LGAS, the outcomes of the 107 patients followed under conservative treatment were analysed. Based on the results of dobutamine echocardiography, patients were divided into group IA [left ventricular (LV) contractile reserve present with true-severe AS, n = 43], group IB [pseudo-severe AS (n = 29) defined as LV contractile reserve with a final aortic valve area ≥1.2 cm(2) and a mean transaortic pressure gradient <40 mmHg at peak dobutamine infusion], or group II (exhausted LV contractile reserve, n = 35). The rate of death within 5 years was significantly lower in the group IB (43 ± 11%, n = 10), when compared with the group IA (91 ± 6%, n = 33; P = 0.001) and the group II (100%, n = 23; P < 0.001). The Cox proportional hazard model analysis demonstrated that the hazard ratio for death in the group IB remained significantly lower than in the other groups, even after adjustment for currently established risk factors. Furthermore, the 5-year survival of pseudo-severe AS patients was comparable with that of propensity-matched patients with systolic heart failure and no evidence of valve disease. CONCLUSION: In patients with pseudo-severe AS, the 5-year survival under conservative treatment is better than in true-severe AS and comparable with that of propensity-matched patients with LV systolic dysfunction and no evidence of valve disease. Further studies are needed to define optimal therapeutic management in these patients.

Prognostic significance and normal values of 2D strain to assess right ventricular systolic function in chronic heart failure.

BACKGROUND: Normal values and the prognostic significance of right ventricle (RV)-2D strain in chronic heart failure (CHF) patients are unknown. METHODS AND RESULTS: Between 2005 and 2010, we prospectively enrolled 43 controls and 118 stable CHF patients. Standard echocardiographic variables, tricuspid annular plane systolic excursion, peak systolic velocity of tricuspid annular motion using tissue Doppler imaging, and RV and left ventricle (LV) 2D-strain were measured. The primary outcome was death or emergency transplantation or emergency ventricular assist device implantation or acute heart failure. RV-2D strain was measurable in 39 controls (58±17 years, 50% men), whose median value was 30% (95% confidence interval [95%CI], 39%; 20%); and in 104 CHF patients (80% men, mean age 57±11 years, and mean LV ejection fraction 29%±8%), whose median value was 19% (95%CI, 34%; 9%). During the mean follow-up of 37±14 months, 44 experienced the primary outcome. By Cox proportional hazards multivariate analysis, only RV-2D strain and log B-type natriuretic peptide independently predicted experiencing the primary outcome within the first year. The best RV-2D strain cut-off by receiver-operating characteristics analysis was 21%, and patients with values >21% were at greatest risk (χ(2)-log-rank test=14.1, P<0.0001). CONCLUSIONS: RV-2D strain is a strong independent predictor of severe adverse events in patients with CHF and may be superior to other systolic RV or LV echocardiographic variables.

Transcatheter aortic valve implantation: early results of the FRANCE (FRench Aortic National CoreValve and Edwards) registry.

AIMS: Transcatheter aortic valve implantation is a therapeutic alternative for high-surgical-risk patients with severe symptomatic aortic stenosis. Two models of prosthesis are currently commercialized in France, which can be implanted either via a transarterial or a transapical approach. The aim of the study was to evaluate in a national French registry the early safety and efficacy of transcatheter aortic valve replacement (AVR) using either the Edwards SAPIEN™ or CoreValve™ in high-surgical-risk patients with severe aortic stenosis. METHODS AND RESULTS: The multicentre national registry was conducted in 16 centres between February 2009 and June 2009, under the authority of the French Societies of Cardiology and Thoracic and Cardio-Vascular Surgery. The primary endpoint was mortality at 1 month. Two hundred and forty-four high-surgical-risk patients (logistic EuroSCORE ≥20%, STS ≥10%, or contra-indication to AVR) were enrolled. Mean age was 82 ± 7 years and 43.9% were female. Edwards SAPIEN and CoreValve were implanted in 68 and 32% of patients, respectively. The approaches used were transarterial (transfemoral: 66%; subclavian: 5%) or transapical in 29%. Device success rate was 98.3% and 30-day mortality was 12.7%. Severe complications included stroke (3.6%), tamponade (2%), acute coronary occlusion (1.2%), and vascular complications (7.3%). Pacemaker was required in 11.8%. At 1 month, 88% of patients were in NYHA class II or less. CONCLUSION: This prospective registry reflects the real-life experience of transcatheter aortic valve implantation in high-risk elderly patients in France. The early results are satisfactory in terms of feasibility, short-term haemodynamic and functional improvement, and safety. Longer term follow-up will be further assessed.

Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction.

CONTEXT: The contemporary decline in mortality reported in patients with ST-segment elevation myocardial infarction (STEMI) has been attributed mainly to improved use of reperfusion therapy. OBJECTIVE: To determine potential factors-beyond reperfusion therapy-associated with improved survival in patients with STEMI over a 15-year period. DESIGN, SETTING, AND PATIENTS: Four 1-month French nationwide registries, conducted 5 years apart (between 1995, 2000, 2005, 2010), including a total of 6707 STEMI patients admitted to intensive care or coronary care units. MAIN OUTCOME MEASURES: Changes over time in crude 30-day mortality, and mortality standardized to the 2010 population characteristics. RESULTS: Mean (SD) age decreased from 66.2 (14.0) to 63.3 (14.5) years, with a concomitant decline in history of cardiovascular events and comorbidities. The proportion of younger patients increased, particularly in women younger than 60 years (from 11.8% to 25.5%), in whom prevalence of current smoking (37.3% to 73.1%) and obesity (17.6% to 27.1%) increased. Time from symptom onset to hospital admission decreased, with a shorter time from onset to first call, and broader use of mobile intensive care units. Reperfusion therapy increased from 49.4% to 74.7%, driven by primary percutaneous coronary intervention (11.9% to 60.8%). Early use of recommended medications increased, particularly low-molecular-weight heparins and statins. Crude 30-day mortality decreased from 13.7% (95% CI, 12.0-15.4) to 4.4% (95% CI, 3.5-5.4), whereas standardized mortality decreased from 11.3% (95% CI, 9.5-13.2) to 4.4% (95% CI, 3.5-5.4). Multivariable analysis showed a consistent reduction in mortality from 1995 to 2010 after controlling for clinical characteristics in addition to the initial population risk score and use of reperfusion therapy, with odds mortality ratios of 0.39 (95%, 0.29-0.53, P <.001) in 2010 compared with 1995. CONCLUSION: In France, the overall rate of cardiovascular mortality among patients with STEMI decreased from 1995 to 2010, accompanied by an increase in the proportion of women younger than 60 years with STEMI, changes in other population characteristics, and greater use of reperfusion therapy and recommended medications.

Left ventricle remodelling is associated with sleep-disordered breathing in non-ischaemic cardiopathy with systolic dysfunction.

Sleep-disordered breathing (SDB) is associated with left ventricle (LV) remodelling in patients with normal LV function. Sleep-disordered breathing is common in chronic heart failure (CHF) with systolic LV dysfunction, and may contribute to LV remodelling and CHF progression. Our aim was to determine the consequence of SDB on LV geometry in patients with CHF. We hypothesised that SDB severity was correlated with the degree of LV hypertrophy (LVH). One-hundred and sixty patients with CHF with a non-ischaemic systolic LV dysfunction were assessed by overnight polygraphy and echocardiography. Patients were classified in four groups according to their apnoea-hypopnoea index (AHI): <5 (no-SDB); 5-14 (mild); 15-29 (moderate); ≥30 (severe). Left ventricular mass index (LVM Ind) was calculated using the usual echocardiographic M-Mode parameters. Their mean age, New York Heart Association and left ventricular ejection fraction were, respectively: 56 ± 13 years, 2.4 ± 0.8 and 30 ± 10%, and 77% were men. Body mass index, interventricular septal and posterior LV wall thicknesses, and LVM Ind were significantly increased in severe SDB versus no-SDB. LVM Ind was correlated to the AHI (R = 0.27, P = 0.0006) and, using logistic regression, AHI was the unique independent factor of LVH in this population. In non-ischaemic CHF, SDB severity is associated with LV remodelling.

Acute myocarditis: diagnostic value of contrast-enhanced cine steady-state free precession MRI sequences.

OBJECTIVE: MRI has become the primary tool for assessment of myocardial inflammation in patients with suspected acute myocarditis. Optimal diagnostic performance is achieved with late gadolinium-enhanced sequences, but cine balanced steady-state free precession (SSFP) MRI sequences are routinely used to evaluate cardiac function. Our aim was to prospectively assess the diagnostic value of unenhanced and contrast-enhanced cine SSFP MRI sequences in comparison with late gadolinium-enhanced sequences for imaging of patients with strong evidence of acute myocarditis. SUBJECTS AND METHODS: Eighteen patients with strong evidence of acute myocarditis underwent 1.5-T cardiac MRI. Unenhanced and contrast-enhanced cine SSFP images and late gadolinium-enhanced images were obtained. The images were analyzed both qualitatively and quantitatively. Data were analyzed with analysis of variance and the Bonferroni test or paired Student t test. RESULTS: Areas of high signal intensity were detected in 28% (5/18), 94% (17/18), and 89% (16/18) of patients on unenhanced cine, contrast-enhanced cine, and late gadolinium-enhanced images. In one patient, contrast-enhanced cine images revealed subepicardial areas of high signal intensity that were not visible on late gadolinium-enhanced images. The location and transmural nature of involved segments matched on contrast-enhanced cine and late gadolinium-enhanced images (both, r = 0.91, p < 0.0001). The contrast-to-noise ratio was significantly higher on contrast-enhanced cine images than on late gadolinium-enhanced images (p < 0.05). CONCLUSION: Contrast-enhanced cine MRI is a valuable tool for detection of lesions of acute myocarditis and should be recommended for routine clinical MRI.

Impact of acoustic window on accuracy of longitudinal global strain: a comparison study to cardiac magnetic resonance.

AIMS: To evaluate the impact of acoustic window on the feasibility and accuracy of longitudinal global strain (global-ε) by speckle tracking for assessing left ventricular (LV) systolic function. METHODS AND RESULTS: The study included 70 patients (57 ± 17 years, 64% men), 28 selected patients with a suboptimal image quality (IQ) defined by three or more segments (4 ± 3 segments/patient) with wall motion score not analysable visually and 42 patients with an optimal two-dimensional (2D) echocardiography IQ. Left ventricular ejection fraction (LVEF) by Simpson's biplane method (2D-EF), global-ε by speckle tracking, and peak systolic mitral annulus velocity [systolic tissue Doppler imaging (S-TDI)] were compared with LVEF by cardiac magnetic resonance (EF-CMR; 45 ± 18%, range 9-76%). Speckle-tracking analysis was feasible in all segments with an optimal acoustic window and in 85% (103/121) of segments poorly visualized. Global-ε similarly correlated with LVEF by CMR in patients with and without optimal IQ (r = 0.81 vs. 0.82 for good vs. poor IQ). In contrast, 2D-EF (r = 0.76) and S-TDI (r = 0.64) less correlated with LVEF by CMR in patients with a suboptimal IQ. Importantly, IQ only impacted on 2D-EF inter-observer reproducibility (9 ± 5 vs. 24 ± 22% for good vs. poor IQ) but not on global-ε reproducibility (9 ± 1 vs. 8 ± 7% for good vs. poor IQ). CONCLUSION: In patients with a limited acoustic window, longitudinal strain by speckle tracking remains accurate and reproducible for assessing global and regional LV systolic function.

Valvuloarterial impedance does not improve risk stratification in low-ejection fraction, low-gradient aortic stenosis: results from a multicentre study.

OBJECTIVES: In a multicentre series of patients with low-ejection fraction/low-gradient aortic stenosis (LEF/LGAS), we evaluated the prognostic impact of valvuloarterial impedance (Zva). BACKGROUND: Zva in AS, a measure of global afterload taking into account systemic arterial compliance, has been proposed for risk stratification in paradoxical LGAS. We hypothesized that Zva could help risk stratification in LEF/LGAS. METHODS AND RESULTS: We retrospectively calculated Zva (5.6 ± 1.7 mmHg/mL/m(2)) of 184 consecutive patients (mean age: 71 ± 10 years) with severe symptomatic LEF/LGAS (valve area ≤1 cm2;, EF ≤40%, mean transaortic pressure gradient ≤40 mmHg) included between 1995 and 2005 in a multicentre registry. Zva was higher in patients with LVEF at rest ≤20% (6.6 ± 2.3 vs. 5.5 ± 1.6; P = 0.05) and correlated negatively with LVEF at rest (R = -0.25; P = 0.001). Zva was lower in patients without contractile reserve (CR) on dobutamine stress echocardiography (DSE) compared with patients with true severe AS (5.3 ± 1.3 vs. 5.8 ± 1.8 mmHg/mL/m(2); P = 0.048). Zva and the variation in stroke volume during DSE were positively correlated (P = 0.0001) but Zva did not allow distinction between true and pseudo-severe AS (5.8 ± 1.8 vs. 5.3 ± 1.8 mm Hg/mL/m(2); P = 0.30). In the total population, Zva was not predictive of long-term mortality. In the 128 patients who underwent aortic valve replacement, Zva was not predictive of operative death and of long-term mortality. CONCLUSIONS: Increased Zva is related to low LVEF and more frequent CR on DSE in LEF/LGAS. However, Zva did not allow an accurate distinction between true and pseudo-severe AS and failed to predict operative and long-term mortality after aortic valve replacement, in LEF/LGAS.

[Role of non-invasive cardiovascular imaging techniques in the evaluation of coronary artery disease]. / Apport des méthodes d'imagerie non invasives pour l'évaluation de la maladie coronaire.

Several cardiovascular imaging techniques have seen major technical improvements in recent years. Visualization of coronary arteries--so important for diagnosis and patient management--is routinely performed by coronarography, but new, less invasive techniques such as computed tomography are now available. Evaluation of myocardial function, which may be impaired in case of myocardial hypoperfusion, can now be achieved non invasively by means of echocardiography or scintigraphy. New imaging techniques, and MRI in particular, can provide useful complementary information. Knowledge of the respective advantages and limitations of these techniques is crucial if physicians are to use them appropriately in their daily practice, thereby avoiding redundant or useless tests and improving patient management.

Risk score for predicting outcome in patients with asymptomatic aortic stenosis.

BACKGROUND: The management of patients with asymptomatic severe aortic stenosis remains controversial. We sought to develop a continuous risk score for predicting the midterm development of symptoms or adverse events in this setting. METHODS AND RESULTS: We prospectively followed 107 patients with asymptomatic aortic stenosis (aged 72 years [63 to 77]; 35 women; aortic-jet velocity, 4.1 m/s [3.5 to 4.4]) at a single center in France. Predefined end points for assessing outcome were the occurrence within 24 months of death or aortic valve replacement necessitated by symptoms or by a positive exercise test. Variables independently associated with outcome were used to build a score that was validated in an independent cohort of 107 patients from Belgium. Independent predictors of outcome were female sex, peak aortic-jet velocity, and B-type natriuretic peptide at baseline. Accordingly, the score could be calculated as follows: Score=[peak velocity (m/s) x 2]+(natural logarithm of B-type natriuretic peptide x 1.5)+1.5 (if female sex). Event-free survival after 20 months was 80% for patients within the first score quartile compared with only 7% for the fourth quartile. Areas under the receiver operating characteristic curve for the score were 0.90 and 0.89 in the development and validation cohorts, respectively. CONCLUSIONS: If further validation is achieved, this score may be useful to predict outcome in individual patients with asymptomatic aortic stenosis to select those who might benefit from early surgery.

Relation of the ischaemic substrate to left ventricular remodelling by cardiac magnetic resonance at 1.5 T in rabbits.

OBJECTIVES: Contrast-enhanced cardiac magnetic resonance (CMR) for infarct sizing has been validated in large animals, but studies and follow-up are restricted. We sought to (1) validate CMR for assessment of myocardial area at risk (MAR) and infarct size (IS) in a rabbit model of reperfused myocardial infarction (MI); (2) analyse the relation between ischaemic substrates and subsequent left ventricular (LV) remodelling. METHODS: Experimental reperfused acute MI was induced in 16 rabbits. Ten animals underwent cross-registered cine and contrast-enhanced CMR and histopathology at day 3 for assessment of MAR and IS (group 1). The remaining six rabbits underwent serial CMR for the study of LV remodelling (group 2). RESULTS: In group 1, mean IS was 12.7 +/- 6.4% and 12.7 +/- 6.9% of total LV myocardial mass on CMR (late-enhancement technique) and histopathology (P = 0.52; r = 0.93). No significant difference occurred between CMR and histopathology for the calculation of MAR and IS/MAR ratio (P = 0.18 and P = 0.17), whereas correlations were strong (r = 0.92 and r = 0.95). In group 2, mean LV end-diastolic, end-systolic volumes and LV mass were significantly increased at 3 weeks compared with measurements at day 3 (P < 0.01). Significant correlations between initial IS and the increase in LV end-diastolic volume (r = 0.66) and the increase in LV mass (r = 0.48) were observed, as well as correlations between initial MAR and the increase in LV end-diastolic volume (r = 0.70) and the increase in LV mass (r = 0.37). CONCLUSIONS: Comprehensive CMR provides accurate assessment of IS and MAR in reperfused rabbit MI. Infarct size is closely related to LV remodelling. Through the infarct size/MAR ratio, this approach has great potential for assessing interventions aimed at cardioprotection.

Transseptal puncture using minimally invasive echocardiography during atrial fibrillation ablation.

AIMS: To assess the usefulness of miniature transoesophageal echocardiography using a 10 F intracardiac probe (ICE-TEE) for transseptal catheterization during atrial fibrillation (AF) ablation. METHODS AND RESULTS: Intracardiac echocardiography probe was used transoesophageally in 79 consecutive patients (56 ± 11 years, 73% male) referred for AF ablation (60% paroxysmal and 38% persistent) to guide transseptal puncture. Transseptal catheterization monitored by ICE-TEE was well tolerated and successfully performed in all patients without any sedation. No mechanical oesophageal complication was noted. Moreover, the mean duration between ICE-TEE probe insertion and successful transseptal puncture was 4.5 min and the mean time of ICE-TEE was 10 min. Finally, no tamponade occurred during the AF ablation procedure. CONCLUSION: Intracardiac echocardiography-TEE is safe and well tolerated for the guidance of transseptal catheterization during AF ablation. Moreover, this technique was performed without requiring any anaesthesia.

Usefulness of trans-oesophageal echocardiography using intracardiac echography probe in guiding patent foramen ovale percutaneous closure.

AIMS: To evaluate the use of intracardiac echocardiography probe through oesophageal route (ICE-TEE) for the monitoring of percutaneous foramen ovale (PFO) closure procedure. METHODS AND RESULTS: The study was conducted in 50 patients divided into two groups: in group I (n = 24), accuracy of ICE-TEE in assessing the inter-atrial septum (IAS) was compared with standard TEE, and in group II, we used ICE-TEE to monitor 26 consecutive patients referred for PFO closure. In group I, IAS was constantly visualized with a close correlation between ICE-TEE and standard TEE for IAS excursion (r = 0.9, P < 0.0001). In group II, ICE-TEE allowed to rule out four patients (three without PFO and one with septal atrial defect associated) and identified three complications during PFO closure procedure (pericardial effusion, inadequate device deployment, and cardiac thrombus). Finally, device implantation was successfully performed in the 22 patients with no residual shunt and thrombus observed after 3 months. CONCLUSION: ICE-TEE could be used to monitor PFO closure procedure.