Clinical outcomes after successful revascularization of long chronic total occlusions using amphilimus-eluting polymer-free stent: a single center experience.

OBJECTIVE: Chronic total occlusions (CTOs) are complex lesions that usually require stenting of long segments, and, therefore more prone to restenosis and/or thrombosis. Polymer-free stents to avoid chronic inflammatory response in the vessel wall are a potential solution to reduce target lesion revascularization. We, therefore, investigated the clinical outcomes following successful amphilimus-eluting polymer-free stent implantation in long CTOs. PATIENTS AND METHODS: A total of 77 consecutive patients who underwent successful revascularization for long CTOs (lesion length ≥30 mm) using Cre8 stents were included. Baseline demographics, periprocedural characteristics, in-hospital events, and post-discharge long-term cardiovascular events were retrospectively screened for all patients. RESULTS: The Japanese CTO score was 1.58 ± 0.96, and the lesion length was 54.0 ± 9.89 mm. All cases were technically successful (n = 77, 100%), while procedural success was obtained in 74 patients (96.1%). Periprocedural complications were contrast-induced nephropathy (n = 4, 5.2%), coronary perforation (n = 3, 3.8%), residual dissection (n = 1, 1.3%), and femoral artery pseudoaneurysm (n = 1, 1.3%). Three patients (3.9%) presented periprocedural myocardial infarction requiring repeat percutaneous coronary intervention. At 25.0 ± 15.8 months follow-up, major adverse cardiac and cerebrovascular events were observed in 14 patients (18.1%). CONCLUSIONS: The Cre8 polymer-free drug- eluting stents seems safe and effective for percutaneous revascularization of long CTO lesions with a high success and low adverse event rate.

Cardiac Risk Assessment in Kidney Transplant Candidates: Clinical Usefulness of Different Guidelines.

Although cardiovascular (CV) assessment is recommended to minimize perioperative risk in all potential kidney transplant recipients, the utility and reliability of various assessment methods are not well established. In this study, we investigated the CV evaluations and outcomes of standardized CV assessment protocols (Lisbon and American Society of Transplantation [AST]) in potential kidney transplant recipients. Data were analyzed for 266 end-stage renal disease patients (mean age 45.4 ± 13 years, female-to-male ratio 126:140) accepted for kidney transplantation wait-listing. Patients were classified as low and high cardiac risk according to their first cardiac evaluation. Major cardiovascular events (CVEs) and deaths were recorded. At the end of follow-up (median 639 days), 72 (27.1%) patients underwent kidney transplantation. A total of 49 patients (18.4%) had CVEs and 42 (15.8%) patients died. Being over 45 years of age and having dialysis vintage over 1 year were found to be independent risk factors for CVEs. Forty-eight out of 60 high-risk patients evaluated with noninvasive tests had negative results. Twelve out of these 48 patients had a CVE in due course. Among 10 patients who underwent coronary angiography, 1 had a CVE and 1 died. The sensitivity and specificity of the AST guidelines (area under the curve = 0.647, P = .005, sensitivity 83%, specificity 54%) were higher than Lisbon. In conclusion, the predictive risk factors for CVEs were age over 45 years and dialysis vintage over a year. Our results also suggest that exercise electrocardiography and myocardial perfusion scintigraphy for cardiac evaluation are less sensitive in CVE prediction. We recommend clinicians to use the AST guidelines and to prioritize coronary angiography in pretransplant CV assessment.

Two-dimensional speckle tracking echocardiography is useful in early detection of left ventricular impairment in patients with Crohn's disease.

OBJECTIVE: Crohn's disease (CD) is a chronic inflammatory bowel disease that can affect the entire gastrointestinal tract. Cardiac involvement is considered very rare. Pericarditis, myocarditis, endocarditis, cardiomyopathy and complete heart block are some of the cardiac extraintestinal manifestations of CD. The aim of this study was to explore the left ventricular (LV) functions with two-dimensional (2D) speckle tracking echocardiography (STE) in patients with CD with normal cardiac functions. PATIENTS AND METHODS: We enrolled 50 consecutive patients with CD and 50 age and sex matched healthy controls. All patients underwent a transthoracic echocardiogram with evaluation of LV functions with 2D STE. RESULTS: Baseline characteristics were similar between patients with CD (24 male, mean age: 41.0 ± 13.9 years) and controls (24 male, mean age: 40.1 ± 7.3 years). Although conventional echocardiographic parameters were similar between two groups, global longitudinal strain was significantly lower in patients with CD compared to controls (19.6 ± 3.3 versus 21.2 ± 2.9, p = 0.014). Correlation analysis revealed that Crohn's Disease Activity Index is inversely correlated with LV global longitudinal strain (r = -0.703, p < 0.001) in patients with CD. We also evaluated inflammatory parameters such as CRP, erythrocyte sedimentation rate, and complete blood counts in patients with CD. Correlation analysis revealed that only platelet value is weakly correlated with Crohn's Disease Activity Index (r = 0.311, p = 0.083). CONCLUSIONS: Crohn's disease is associated with impairment in LV global longitudinal myocardial function. Crohn's Disease Activity Index is also strongly correlated with LV global longitudinal strain. 2D-STE may be an useful method for early detection of LV impairment in patients with CD.

A pedunculated left ventricular hemangioma initially misdiagnosed as thrombus in a woman with atypical chest pain.

The incidence of cardiac masses increased as echocardiography is becoming increasingly popular. Benign tumors of the heart constitute about 72% of all primary cardiac neoplasms and hemangioma accounts for 5-10% of benign cardiac tumors. Cardiac hemangiomas are generally asymptomatic and diagnosed incidentally during echocardiography or magnetic resonance imaging (MRI). We reported a 52-year-old woman presented with atypical chest pain and exertional dyspnea. The echocardiographic examination revealed a hyperechoic round mass in the left ventricle. With an initial diagnosis of left ventricular thrombus, the patient underwent cardiac MRI. The mass was found compatible with cardiac hemangioma. It was removed surgically and histopathologic evaluation identified a cardiac hemangioma. As reports of cardiac hemangioma are extremely rare and cardiac masses are mostly thought to be thrombi or myxomas (being the most common primary cardiac tumor), such hemangioma cases warrant attention as possibility of hemangioma should also be kept in mind.

Assessment of myocardial viability with cardiac magnetic resonance imaging.

With the rapid evolution of cardiovascular magnetic resonance imaging (MRI) techniques, cardiovascular MRI has become an important noninvasive diagnostic tool in cardiovascular disease. Cardiac MRI can provide high quality diagnostic information about cardiac and valvular function, coronary anatomy, coronary flow reserve and myocardial perfusion, myocardial viability, contractile reserve and cardiac metabolism. Besides, MRI can also provide prognostic information for certain cardiac diseases. Assessment of the viable myocardium is one of the major issues of the invasive cardiology. Viable myocardium has the potential for contractile recovery after reperfusion. The identification of viable myocardium is useful in predicting which patients will benefit from revascularization and have improved left ventricular ejection fraction and survival. The focus of the present article is on the clinical role of cardiac MRI in the detection of viable myocardium.

Large apical thrombus in a patient with persistent heart failure and hypereosinophilia: Löffler endocarditis.

Idiopathic hypereosinophilic syndrome is an uncommon leukoproliferative systemic disorder characterized by the overproduction of eosinophils and poor prognosis. A major source of morbidity and mortality of this syndrome is the associated cardiac involvement represented by endocardial thickening and mural thrombi. We report a 64-year-old woman with persistent symptoms of heart failure despite standard medical therapy. Echocardiography revealed reduced left ventricular filling due to a large apical mass; an abnormal diastolic filling pattern was also noticed. Complete blood count revealed remarkable hypereosinophilia. Cardiac magnetic resonance imaging demonstrated an apical thrombus and intense linear enhancement of the endocardium, which were compatible with Löffler endocarditis. Medical therapy, including corticosteroids and anticoagulation, was initiated promptly. The symptoms improved as the peripheral hypereosinophilia resolved in 15 days. The patient was asymptomatic at the 1-year follow-up visit with complete regression of the apical thrombus and no evidence of restrictive cardiomyopathy. We report this case to draw attention to this particularly rare condition with poor prognosis since quick and accurate diagnosis and prompt initiation of therapy may improve symptoms and survival.

The acute effect of cardiac pacing mode on endothelial vasodilation: prospective, double-blind, cross-over, comparative clinical study.

BACKGROUND: Compared to atrioventricular sequential pacing, ventricular demand pacing is known to have somewhat more deleterious hemodynamic effects, which probably arise from increased sympathetic tonus and inappropriate baroreceptor activation. Endothelial function is affected by various local and systemic factors including baroreceptor activity. The aim of this study was to explore whether cardiac pacing would have any effect on endothelial functions. METHODS: Twelve patients (six male, mean age: 75 +/- 9 years) with previously implanted DDD or VDDcardiac pacemakers were included. All patients had stable atrial rhythms during the study. Patients were randomized to either atrial-based pacing mode (VDD or DDD) or ventricular demand pacing mode (VVI) first, and then cross-over was performed with the other pacing mode. Endothelial function was assessed by brachial artery ultrasonography. Basal diameter of the brachial artery, and both flow-mediated dilation (FMD) and endothelium-independent vasodilation with nitroglycerin were measured 1 hour after each pacing mode. RESULTS: Compared to atrial-based pacing mode, ventricular demand pacing was associated with a significantly worse FMD both as absolute and percentage values (0.17 +/- 0.09 mm vs 0.28 +/- 0.11 mm, P = 0.015 and 4.84 +/- 2.37 % vs 7.00 +/- 2.88 %, P = 0.028, respectively). However, there was no significant difference in nitroglycerin-mediated vasodilation values between the two pacing sessions. CONCLUSIONS: Acute ventricular demand pacing (VVI pacing) is clearly associated with attenuation of FMD in patients with atrial-based pacing systems. The attenuation of endothelial vasodilation might have a role in hemodynamic and clinical deterioration in patients with VVI pacemakers.