Biatrial remodelling in atrial fibrillation: A three-dimensional and strain echocardiography insight.

BACKGROUND: Atrial remodelling has been poorly investigated in atrial fibrillation (AF), and few studies have focused on biatrial remodelling. AIM: To evaluate right atrial (RA) and left atrial (LA) remodelling in AF using global atrial reservoir strain and three-dimensional (3D) atrial volumes, according to rhythm outcome at mid-term follow-up. METHODS: Two-dimensional and 3D transthoracic echocardiography (TTE) were performed within 24hours after admission (M0) and at 6-month follow-up (M6) in patients admitted for AF. RA and LA variables were assessed: body surface area-indexed maximum 3D volume (Max 3D RA Voli, Max 3D LA Voli) and minimum 3D volume (Min 3D RA Voli, Min 3D LA Voli); atrial emptying fraction (3D RAEF, 3D LAEF); atrial expansion index (3D RAEI, 3D LAEI); and global RA and LA reservoir strain. RESULTS: Forty-eight consecutive patients were included prospectively. Three groups were identified depending on rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) in 25 (52.1%) patients; AF at M0 and AF at M6 (AF-AF) in 13 (27.1%) patients; and SR at M0 (spontaneous cardioversion before first TTE) and SR at M6 (SR-SR) in 10 (20.8%) patients. Between M0 and M6 in the AF-SR group, we found: significant decreases in Max 3D RA Voli (P=0.020), Min 3D RA Voli (P=0.0008), Max 3D LA Voli (P=0.001) and Min 3D LA Voli (P=0.0021); significant increases in 3D RAEF (P=0.037) and 3D RAEI (P=0.034); no significant differences in 3D LAEF and 3D LAEI; and significant increases in global RA and LA reservoir strain (both P<0.0001). There was no significant difference with regard to these variables in the AF-AF and SR-SR groups. CONCLUSION: 3D volume and strain analyses were useful in the evaluation of RA and LA reverse remodelling in successfully cardioverted patients with AF.

Prevalence, clinical characteristics and outcomes of high-risk patients treated for severe aortic stenosis prior to and after transcatheter aortic valve implantation availability.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has emerged as an effective treatment for high-risk patients with severe aortic stenosis (AS). The aim of our study was to compare the prevalence, characteristics and outcomes of high-risk patients treated prior to and after the availability of TAVI in our high-volume surgical institution. METHODS: Among 879 consecutive patients treated 2 years before ('pre-TAVI era') and after ('modern era') the availability of TAVI in our institution, 83 patients were at high risk [defined by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) >20%]. RESULTS: Among all patients treated for severe AS, the prevalence of high-risk patients was higher in the modern era (12.7 vs 4.9%, P < 0.0001). In the modern era, high-risk patients were treated by TAVI in 89% of cases. Despite similar logistic EuroSCORE (34.9 vs 34%, P = 0.96), the clinical characteristics of these patients have evolved: high-risk patients in the modern era were older (85.3 ± 5.9 vs 78.5 ± 6.5 years, P = 0.0005) and presented more frequently with New York Heart Association class III-IV (92.3 vs 61.1%, P = 0.003), while high-risk patients treated by surgical aortic valve replacement in the pre-TAVI era presented more frequently with a critical preoperative status (33.3 vs 7.7%, P = 0.01), lower left ventricular ejection fraction (41 ± 14 vs 49 ± 15%, P = 0.05) and a history of recent myocardial infarction (27.8 vs 6.1%, P = 0.02). The overall 1-year survival was not different for high-risk patients treated in the pre-TAVI era or in the modern era (61 ± 11 vs 68 ± 6%, P = 0.52). CONCLUSIONS: The availability of TAVI has increased the prevalence of high-risk patients treated for severe AS and changed the clinical features of this kind of patients who were rarely surgically treated before. The 1-year survival was similar between pre-TAVI and modern eras.

Patterns of use and potential impact of early beta-blocker therapy in non-ST-elevation myocardial infarction with and without heart failure: the Global Registry of Acute Coronary Events.

BACKGROUND: Early beta-blocker (BB) therapy improves outcomes in ST-segment elevation myocardial infarction; however, limited data are available on its early use and its impact in non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: We evaluated data from 7106 patients with NSTEMI, without contraindications to BBs, enrolled in the Global Registry of Acute Coronary Events between April 1999 and September 2004. Baseline characteristics, management, and outcomes were analyzed according to the use of oral (+/-intravenous) BB within 24 hours of presentation. Multivariable analysis was conducted adjusting for comorbidities using the Global Registry of Acute Coronary Events risk model (c statistic 0.83). RESULTS: Beta-blocker therapy was initiated within the first 24 hours in 76% of patients with NSTEMI (79% with Killip class I vs 62% with class II/III; P < .001). Failure to initiate BBs within the first 24 hours was associated with lower rates of subsequent BB therapy (P < .001) and other evidence-based therapies. Early BB therapy was correlated with lower hospital mortality for NSTEMI patients (OR 0.58, 95% CI 0.42-0.81) and for those with Killip class II/III (OR 0.39, 95% CI 0.23-0.68) with a trend toward lower mortality in the Killip class I group (OR 0.77, 95% CI 0.49-1.21). At 6 months postdischarge, early BB use was associated with lower mortality in NSTEMI patients (OR 0.75, 95% CI 0.56-0.997) with a trend toward lower mortality in patients with Killip class I or II/III. CONCLUSIONS: Many eligible patients do not receive early BB therapy. Treatment with early BBs may have a beneficial impact on hospital and 6-month mortality in all patients, including those presenting with heart failure.

Aortic insufficiency: defining the role of pharmacotherapy.

Major advances in the diagnostic, evaluation, and particularly surgical treatment of aortic regurgitation (AR) have redefined the role of medical treatment. In acute AR, aortic valve replacement (AVR) is the only life-saving treatment. Medical treatment may improve the hemodynamic state temporarily before surgery. Rationale of medical treatment in chronic AR is based on the natural history and pathophysiology of the disease. The primary goal is to optimize the time of the AVR. If there is any symptom and/or left ventricular (LV) dysfunction, early AVR is required. Vasodilators should only be considered as a short-term treatment before surgery if there is evidence of severe heart failure or as a long-term treatment if AVR is contraindicated because of cardiac or noncardiac factors. In asymptomatic patients with severe chronic AR and normal LV function (even if the left ventricle is moderately dilated), vasodilators may prolong the compensated phase of chronic AR, although proof of their efficacy in delaying AVR is limited. Nifedipine is the best evidence-based treatment in this indication. ACE inhibitors are particularly useful for hypertensive patients with AR. beta-Adrenoceptor antagonists (beta-blockers) may be indicated to slow the rate of aortic dilatation and delay the need for surgery in patients with AR associated with aortic root disease. Furthermore, they may improve cardiac performance by reducing cardiac volume and LV mass in patients with impaired LV function after AVR for AR.

[Prevention of in-stent restenosis: towards an in situ treatment?]. / Prévention des resténoses intrastent: vers un traitement in situ.

The use of intracoronary stents represent a major breakthrough in the armamentarium of interventional cardiology. Stents reduce significantly the incidence of recurrent stenosis (in-stent restenosis) via an improved post-procedure luminal diameter and an abrogation of the constrictive remodeling of the arterial wall. However, stent-related arterial injury results in intense proliferative and inflammatory responses and severe intimal hyperplasia, which, in 20% to 40% of the patients, may end up with clinically significant in-stent restenosis. Efficient prevention of in-stent restenosis has yet to be found. Systemic treatments have failed because they don't take into account the specific physiopathology and, most importantly, the focal nature of in-stent intimal hyperplasia. Hence, local prevention appears to be a straightforward approach to the unsolved issue of in-stent restenosis. In situ beta- or gamma-irradiation (brachytherapy) has received much attention as a curative treatment of in-stent restenosis but is not indicated for prevention. In contrast, drug-releasing stents have been tested in experimental models and have already provided very promising results in randomized clinical trials. Most of clinical studies have been performed with the antiproliferative agents sirolimus and paclitaxel, but other agents are under scrutiny. In addition, important research is carried out, in which the efficacy of antiproliferative genes is investigated. Clearly, drug-releasing stents are on the verge of profoundly modifying our practice of interventional cardiology. However, several questions remain unanswered as regard to the long term efficacy/toxicity and the cost-effectiveness of this new approach.