Mammalian Target of Rapamycin Inhibition in Patients With ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Early inflammation following acute ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) affects myocardial infarct (MI) size and left ventricular remodeling. The mammalian target of rapamycin (mTOR) is involved in the enhanced inflammatory response and its inhibition has exerted beneficial effects on MI size in preclinical models of acute MI. OBJECTIVES: The CLEVER-ACS (Controlled Level Everolimus in Acute Coronary Syndromes) trial evaluated the effects of targeting inflammation by mTOR inhibition in patients with STEMI undergoing PCI. METHODS: CLEVER-ACS was a randomized, multicenter, international, double-blind, placebo-controlled trial. A total of 150 patients with STEMI undergoing PCI were randomly assigned to oral everolimus (days 1-3: 7.5 mg daily; days 4-5: 5.0 mg daily) or placebo for 5 days. The primary endpoint was the change in MI size. The secondary endpoint was the change in microvascular obstruction (MVO) from baseline (12 hours to 5 days after PCI) to 30 days as assessed by cardiac magnetic resonance imaging. RESULTS: The changes in MI size from baseline to 30 days, the primary endpoint, were -14.2 g (95% CI: -17.4 to -11.1 g) and -12.3 g (95% CI: -16.0 to -8.7 g) in the everolimus and placebo groups (P = 0.99). Corresponding changes in MVO were -4.8 g (95% CI: -6.7 to -2.9 g) and -6.3 g (95% CI: -8.7 to -4.0 g) in the everolimus and placebo groups (P = 0.14). Adverse events did not differ between the study groups. CONCLUSIONS: Among STEMI patients undergoing PCI, early mTOR inhibition with everolimus did not reduce MI size or MVO at 30 days. (CLEVER-ACS [Controlled Level Everolimus in Acute Coronary Syndromes; NCT01529554).

Patient-Specific Cardiac Magnetic Resonance Feature Tracking Approach for Scar Detection in Concomitant Ischemic and Non-Ischemic Heart Disease.

Aim: This study investigated a patient-specific approach of using cardiac magnetic resonance (CMR) feature tracking for scar detection in a heterogenous patient group with chronic ischemic and non-ischemic heart disease. Methods: CMR exams of 89 patients with concomitant chronic ischemic and non-ischemic heart disease (IHD+) as well as 65 patients with ischemic scars only (IHD) were retrospectively evaluated. In all patients, global (GCS) and segmental circumferential strain (SCS) was derived from native cine images using a dedicated software (Segment CMR, Medviso). After calculation of patient-specific median GCS (GCSmedian), segmental values from GCSmedian percentage plots were correlated with corresponding myocardial segments in late gadolinium enhancement (LGE). Results: Overall GCS ranged between -3.5% to -19.8% and average GCS was lower in IHD+ than in IHD (p <0.05). In IHD, 19% of all myocardial segments were infarcted, in IHD+ 16.6%. Additionally, non-ischemic LGE was present in 6.7% of segments in IHD+. Correlation of GCSmedian percentage plots with corresponding LGE showed that presence of ischemic scar tissue in a myocardial segment was very likely below a cut-off of 39.5% GCSmedian (87.5% sensitivity, 86.3% specificity, AUC 0.907, 95% CI 0.875-0.938, p < 0.05). Conclusion: In patient-specific GCSmedian percentage plots calculated from native cine images, ischemic scar tissue can be suspected in myocardial segments below the threshold of 40% GCSmedian (sensitivity 88%, specificity 86%), even in a heterogenous patient cohort with ischemic and non-ischemic heart disease.

[Non-invasive Imaging of Chronic Coronary Syndromes - CT Coronary Angiography and Stress Perfusion Cardiac MRI]. / Nicht-invasive Diagnostik der chronischen koronaren Herzkrankheit ­ CT-Koronarangio­graphie und Stress-MRT.

Non-invasive Imaging of Chronic Coronary Syndromes - CT Coronary Angiography and Stress Perfusion Cardiac MRI Abstract. Coronary artery disease (CAD) is amongst the leading causes of death worldwide. The European Society of Cardiology (ESC) has recently published new guidelines on diagnosis and management of chronic coronary syndromes. These guidelines emphasize the use of non-invasive imaging tests to assess CAD. Compared to previous versions of these guidelines, the pre-test probabilities of CAD based on age, sex and symptoms have been adjusted downward. Unless obstructive CAD can be excluded by clinical assessment alone, various strategies to diagnose CAD in symptomatic patients may be used: coronary CT angiography, non-invasive functional imaging for myocardial ischaemia, or invasive coronary angiography combined with functional evaluation. This review summarizes strengths and weaknesses of non-invasive cardiac imaging modalities with emphasize on coronary CT angiography and stress perfusion cardiac magnetic resonance (CMR) imaging.

Long-term follow-up after aortic root replacement with the Shelhigh® biological valved conduit: a word of caution!

OBJECTIVES: The aim of this study was to analyse long-term results of aortic root replacement with the Shelhigh® NR-2000C conduit. METHODS: From January 2001 to October 2005, 63 patients with a median age of 62 years underwent aortic root replacement with a Shelhigh® conduit. Aneurysm (27%), aortic valve endocarditis (30%) and acute type A aortic dissection (33%) were the predominant indications for the surgery. Fifty-four patients (86%) were entered in the follow-up study with the end-points of death, aortic root-related reoperation and endocarditis. RESULTS: The overall 30-day mortality rate was 8% (n = 5). The median follow-up was 9.5 years (range 0-14.2 years). In total, 13 (24%) deaths occurred during follow-up; of these, 4 were directly conduit-related. The overall estimated survival rates at 1, 5 and 10 years were 85 ± 5, 79 ± 6 and 71 ± 7%, respectively. Reoperation was necessary in 10 (19%) patients due to endocarditis (n = 5), aortic stenosis (n = 3), pseudoaneurysm due to detachment of the right coronary artery (n = 1) and detachment of the non-coronary leaflet (n = 1). The overall estimated rate of freedom from aortic root-related reoperation at 1, 5 and 10 years was 83 ± 5, 79 ± 6 and 64 ± 7%, respectively. Endocarditis of the prosthesis was reported in 9 (17%) patients; of whom, 5 patients required reoperation and 4 were treated medically. In 1 patient with endocarditis, a stroke was reported due to a thromboembolic event. CONCLUSIONS: The first long-term follow-up after aortic root replacement with the Shelhigh® BioConduit revealed a relatively high rate of death and very high rate of reoperations due to endocarditis, aorto-ventricular disconnection and structural valve failure. This may be potentially connected to the nature of the implanted valved conduit.

Extracellular matrix for reconstruction of cardiac structures after tumour resections.

OBJECTIVES: To describe the use of a new extracellular matrix patch as a means for atrial reconstruction in patients with cardiac tumours. METHODS: A new extracellular matrix patch was used to reconstruct atrial and neighbouring structures after tumour resections. In 1 case, it was used to reconstruct the atrial septum and the left atrial roof after excision of a huge myxoma. In a second case, it was used to reconstruct the right atrium, including the superior vena cava after excision of a primary cardiac sarcoma. In a third case, it was used to reconstruct both atria, the right-sided pulmonary venous confluence and the roof of the coronary sinus after excision of a metastasis of malignant melanoma. RESULTS: In all cases, reconstruction was successful and facilitated because of the flexible and thin character of the extracellular matrix, which also seemed to be advantageous with regards to haemostasis. CONCLUSIONS: Extracellular matrix patches are a potential alternative for pericardial patches for complex reconstructions of atrial structures because of their pliable characteristics and consecutively reduced need for haemostatic stitches.