Clinical pacing post-conditioning during revascularization after AMI.

Intermittent dyssynchrony, induced by ventricular pacing, during early reperfusion reduces infarct size in pre-clinical studies. We evaluated cardioprotection by pacing post-conditioning (PPC) in ST-segment elevation myocardial infarction in a randomized, controlled, single-center, single-blinded, first-in-man study. Patients with first ST-segment elevation myocardial infarction received either PPC plus percutaneous coronary intervention (PCI) (n = 30) or PCI (n = 30). PPC consisted of 10 episodes of 30-s right ventricular pacing. Infarct size was measured as the area under the curve of creatine kinase (CK) (primary endpoint) and by contrast-enhanced cardiac magnetic resonance. The CK area under the curve was not significantly different between study groups. Adjusted contrast-enhanced cardiac magnetic resonance data showed ∼25% smaller infarct size in PPC + PCI than in PCI patients after 4 days (p = 0.01), 4 months (p = 0.02), and 1 year of PCI (p = 0.08). In PPC + PCI, (uncomplicated) ventricular fibrillation (n = 3) and paroxysmal atrial fibrillation (n = 4) were observed as opposed to 1 and 0 cases in PCI, respectively. We conclude PPC is feasible and may induce cardioprotection during PCI treatment of ST-segment elevation myocardial infarction, but technical improvements are needed to improve safety. (PROTECT: Pacing to Protect Heart for Damage From Blocked Heart Vessel and From Re-opening Blocked Vessel[s]; NCT00409604).

Coronary spasm during cardiac electrophysiological study following isoproterenol infusion.

Sudden cardiac death (SCD) remains the leading cause of death in industrialized world. The majority of SCD is caused by ventricular fibrillation associated with structural and/or ischemic heart disease. Ventricular fibrillation represents the final common pathway for SCD and, thus, is an attractive target for ablation. According to class I recommendation level of evidence A, an implantable cardioverter defibrillator (ICD) should be implanted for such patients [1]. Other than programmed electrical extrastimulus technique, isoproterenol infusion is commonly used in invasive cardiac electrophysiology labs for arrhythmia induction. We hereby report a rare case of transient coronary spasm during isoproterenol infusion for ventricular tachycardia induction testing.

Effectiveness and safety of percutaneous coronary sinus-based mitral valve repair in patients with dilated cardiomyopathy (from the AMADEUS trial).

This report presents the procedural results from the AMADEUS trial that support coronary sinus (CS)-based percutaneous mitral annuloplasty. Despite therapeutic advances, functional mitral regurgitation (MR) continues to be a significant clinical problem for patients with dilated cardiomyopathy. CS approaches to mitral valve repair have been viewed with skepticism because of the distance of the CS/great cardiac vein from the mitral valve annulus and the potential to compress a coronary artery. This report presents the procedural results from the AMADEUS trial that support CS-based percutaneous mitral annuloplasty. Patients who met the inclusion criteria were eligible to receive a mitral annuloplasty device. Transesophageal echocardiography was used to assess changes in MR, angiography was used to assess the coronary arteries, and multislice computed tomography was used to evaluate the anatomic relations between the coronary venous system and the mitral valve. Acute MR reduction (grade 3.0 +/- 0.6 to 2.0 +/- 0.8, p <0.0001) and permanent implantation were achieved in 30 of 43 patients in whom an attempt was made. Additional measurements in 20 patients with implants showed reductions in the vena contracta (0.69 +/- 0.29 to 0.46 +/- 0.26 cm, p <0.0001), effective regurgitant orifice area (0.33 +/- 0.17 to 0.19 +/- 0.08 cm(2), p <0.0001), regurgitant volume (40 +/- 20 to 24 +/- 11 ml, p = 0.0005), and jet area/left atrial area (45 +/- 13% to 32 +/- 12%, p <0.0001). The coronary arteries were crossed in 36 patients (84%). Arterial compromise contributed to a lack of implantation in 6 patients (14%). No difference was found in the CS/great cardiac vein position relative to the annulus between the patients who did and did not have a reduction in MR. In conclusion, percutaneous mitral annuloplasty reduces MR and permanent implantation can be achieved in most eligible patients.

Percutaneous mitral annuloplasty for functional mitral regurgitation: results of the CARILLON Mitral Annuloplasty Device European Union Study.

BACKGROUND: Functional mitral regurgitation (FMR), a well-recognized component of left ventricular remodeling, is associated with increased morbidity and mortality in heart failure patients. Percutaneous mitral annuloplasty has the potential to serve as a therapeutic adjunct to standard medical care. METHODS AND RESULTS: Patients with dilated cardiomyopathy, moderate to severe FMR, an ejection fraction <40%, and a 6-minute walk distance between 150 and 450 m were enrolled in the CARILLON Mitral Annuloplasty Device European Union Study (AMADEUS). Percutaneous mitral annuloplasty was achieved through the coronary sinus with the CARILLON Mitral Contour System. Echocardiographic FMR grade, exercise tolerance, New York Heart Association class, and quality of life were assessed at baseline and 1 and 6 months. Of the 48 patients enrolled in the trial, 30 received the CARILLON device. Eighteen patients did not receive a device because of access issues, insufficient acute FMR reduction, or coronary artery compromise. The major adverse event rate was 13% at 30 days. At 6 months, the degree of FMR reduction among 5 different quantitative echocardiographic measures ranged from 22% to 32%. Six-minute walk distance improved from 307+/-87 m at baseline to 403+/-137 m at 6 months (P<0.001). Quality of life, measured by the Kansas City Cardiomyopathy Questionnaire, improved from 47+/-16 points at baseline to 69+/-15 points at 6 months (P<0.001). CONCLUSIONS: Percutaneous reduction in FMR with a novel coronary sinus-based mitral annuloplasty device is feasible in patients with heart failure, is associated with a low rate of major adverse events, and is associated with improvement in quality of life and exercise tolerance.

Elective high-risk percutaneous coronary interventions supported by extracorporeal life support.

This study investigated the feasibility of high-risk percutaneous coronary intervention (PCI) in hemodynamically unstable patients supported by modified cardiopulmonary bypass (extracorporeal life support [ELS]). Over a 38-month period, 15 patients (10 men, 5 women, mean age 72 +/- 9 years, mean ejection fraction 34 +/- 15%, angina pectoris New York Heart Association class III to IV) who were not eligible for coronary artery bypass grafting because of high co-morbidity underwent elective high-risk PCI supported by ELS. All lesions were technically challenging. ELS perfusion cannulas in the femoral artery and vein were surgically inserted and removed. Procedural success was achieved in 14 of 15 patients. After a mean perfusion duration of 88 +/- 37 minutes, all patients were weaned from the ELS in the catheterization laboratory. The patients were ventilated for 5.1 +/- 3.3 hours. Blood transfusion was given to 8 patients. Apart from 2 groin bleedings, no other complications occurred. Patients left our hospital after 3.2 +/- 2.8 days. Of the 4 patients who died during the 15 +/- 12-month follow-up, 1 died of a noncardiac cause. In conclusion, in highly selected patients ineligible for bypass surgery, ELS-supported PCI can be performed with promising short- and long-term clinical outcomes. This complex procedure is a safe alternative whenever other options for revascularization are exhausted.

Tropical endomyocardial fibrosis (Davies' disease): case report demonstrating the role of magnetic resonance imaging.

Tropical endomyocardial fibrosis (TEMF), a restrictive cardiomyopathy of unclear etiology, is an endemic disease in equatorial Africa, South America and India. The patients are usually young, the onset of the disease and its clinical manifestations insidious, and the prognosis poor. We currently present a 50-year-old Congolese female who was referred with symptoms of progressive right-sided heart failure due to isolated TEMF of the right ventricle. Surgical resection of regional endomyocardial fibrosis was not possible and our patient was referred for cardiac transplantation. Cardiac magnetic resonance imaging (CMR) demonstrated the primary and secondary structural and functional abnormalities. CMR seems ideally suited to diagnose this condition and monitor response to medical and/or surgical therapy.

Beating-heart surgical treatment of atrial fibrillation with microwave ablation.

BACKGROUND: In this feasibility study, early results are presented of our first series of patients with microwave ablation for atrial fibrillation (AF) on the beating heart. METHODS: From June 2001 until December 2001, a total of 24 patients underwent beating-heart epicardial ablation for AF. With a microwave antenna, the left and right pulmonary veins were isolated and connected to each other followed by amputation of the left atrial appendage. Subsequently, patients underwent either off-pump coronary artery bypass graft or valve surgery on pump. The mean age of the patients was 67.4 +/- 6 years. Three patients experienced paroxysmal atrial fibrillation and all others chronic AF. Mean left atrial diameter was 5.4 +/- 0.6 cm, and mean ablation time was 13 min. RESULTS: All procedures but one were completed successfully on the beating heart. All patients were in sinus rhythm after the procedure. A total of 15 patients experienced periods with postoperative AF during hospital stay; 9 of these patients were discharged with AF. All patients received either sotalol or amiodarone. At latest follow-up (3 to 9 months), 20 of 23 patients were in sinus rhythm. CONCLUSIONS: With microwave ablation, electrical isolation of the pulmonary veins can be achieved epicardially without cardiopulmonary bypass support.