Superiority of wall motion score index over left ventricle ejection fraction in predicting cardiovascular events after an acute myocardial infarction.

BACKGROUND:: There are few data on the prognostic significance of the wall motion score index compared with left ventricle ejection fraction after an acute myocardial infarction. Our objective was to compare them after the hyperacute phase. METHODS:: Transthoracic echocardiograms were performed in 352 consecutive patients with myocardial infarction, after the first 48 hours of admission and before hospital discharge (median 56.3 hours (48.2-83.1)). We evaluated the ability of the wall motion score index and left ventricular ejection fraction to predict the combined endpoint (mortality and rehospitalization for heart failure) as a primary objective and the independent events of the combined endpoint as a secondary objective. RESULTS:: In 80.7% of patients, the wall motion score index was high despite having an ejection fraction >40%. No patient had an ejection fraction <55% with a normal index. After a follow-up of 30.5 months (24.2-49.5), both variables were predictors of the composite endpoint and all-cause mortality ( p<0.0001), although only the wall motion score index was a predictor of readmission for heart failure ( p=0.007). By multivariate analysis, a wall motion score index >1.8 proved to be the most powerful predictor of the composite endpoint (hazard ratio: 8.5; 95% confidence interval 3.7-18.8; p<0.0001). The superiority of the wall motion score index over ejection fraction was especially significant in patients with less myocardial damage (non-ST elevation myocardial infarction, or left ventricle ejection fraction >40%). CONCLUSIONS:: Both variables provide important prognostic information after a myocardial infarction. Beyond the hyperacute phase, wall motion score index is a more powerful prognostic predictor, especially in subgroups with less myocardial damage.

Percutaneous treatment of an anomalous left main arising from the opposite sinus with subpulmonic course.

Anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) is a rare malformation traditionally considered "malignant" in cases of interarterial course. Recently, a protective effect of the low interarterial subtype (between the aorta and the right ventricle outflow tract) has been described. We present an IVUS-guided percutaneous intervention in a patient with anomalous origin of the left coronary artery from the right coronary sinus presenting with anterior ischemia. In patients with ACAOS, the integration of complementary image techniques is recommended, defining the anomalous course of the vessel and providing an accurate assessment of the individual risk for each patient. The use of IVUS may be advisable, emerging as a really useful tool to complete the study and guide the treatment.

Atrioventricular Septum Pseudoaneurysm As Late Complication After Repeated Mitral Valve Replacement.

We report the case of a pulsatile mass found in a patient who presented for a routine echocardiogram. The mass turned out to be an exceedingly rare mitral-subannular pseudoaneurysm involving the membranous atrioventricular septum with systolic expansion protruding into right atrium, discovered late after repeated multiple valve replacement surgery. Although these pseudoaneurysms may present asymptomatically, surgical intervention might be indicated because of the risk of rupture. This report describes this rare finding, discusses possible pathophysiological mechanisms, and underscores the importance of multimodality imaging to achieve correct identification and delimitation to guide surgical intervention in such cases.

Noninvasive diagnosis of vulnerable coronary plaque.

Myocardial infarction and sudden cardiac death are frequently the first manifestation of coronary artery disease. For this reason, screening of asymptomatic coronary atherosclerosis has become an attractive field of research in cardiovascular medicine. Necropsy studies have described histopathological changes associated with the development of acute coronary events. In this regard, thin-cap fibroatheroma has been identified as the main vulnerable coronary plaque feature. Hence, many imaging techniques, such as coronary computed tomography, cardiac magnetic resonance or positron emission tomography, have tried to detect noninvasively these histomorphological characteristics with different approaches. In this article, we review the role of these diagnostic tools in the detection of vulnerable coronary plaque with particular interest in their advantages and limitations as well as the clinical implications of the derived findings.

Early gadolinium enhancement in hypertrophic cardiomyopathy: a potential premature marker of myocardial damage.

Early gadolinium enhancement (EGE), one CMR diagnostic criteria in acute myocarditis, has been related with hyperemia and capillary leakage. The value of EGE in hypertrophic cardiomyopathy (HCM) remains unknown. Our aim was to determine the prevalence of EGE in patients with HCM, and its relation with late gadolinium enhancement (LGE). The association of EGE with morphological and clinical parameters was also evaluated. Sixty consecutive patients with HCM and CMR from our center were included. All the clinical and complementary test information was collected prospectively in our HCM clinic. Left ventricular (LV) measurements were calculated from cine sequences. EGE and LGE were quantified with a dedicated software. Clinical events were collected from medical records. A slow wash-out pattern on EGE was detected in up to 68 % of the patients, being an isolated finding without LGE in 10 (16 %). This cohort showed a greater maximal LV wall thickness (20.1 ± 4 vs. 18.1 ± 3.5 mm, p = 0.010) and asymmetry ratio (1.86 ± 0.42 vs. 1.62 ± 0.46; p = 0.039). The percentage of EGE/slice and the difference with the percentage LGE/slice demonstrated a significant positive correlation with the maximal LV wall thickness (Rho 0.450 and 0.386 respectively). EGE also correlated with number of segments with LVH (LV hypertrophy) and the asymmetry ratio. Neither EGE nor LGE were associated with classical risk factors, the risk score for sudden cardiac death, or with major clinical events. EGE was a frequent finding in HCM, even in absence of LGE. This phenomenon showed a positive correlation with morphological markers of disease burden.

Effectiveness of the implementation of a simple radiation reduction protocol in the catheterization laboratory.

BACKGROUND AND PURPOSE: A reduction in radiation doses at the catheterization laboratory, maintaining the quality of procedures is essential. Our objective was to analyze the results of a simple radiation reduction protocol at a high-volume interventional cardiology unit. METHODS: We analyzed 1160 consecutive procedures: 580 performed before the implementation of the protocol and 580 after it. The protocol consisted in: the reduction of the number of ventriculographies and aortographies, the optimization of the collimation and the geometry of the X ray tube-patient-receptor, the use of low dose-rate fluoroscopy and the reduction of the number of cine sequences using the software "last fluoroscopy hold". RESULTS: There were no significant differences in clinical baseline features or in the procedural characteristics with the exception of a higher percentage of radial approach (30.7% vs 69.6%; p<0.001) and of percutaneous coronary interventions of chronic total occlusions after the implementation of the protocol (2.1% vs 6.7%; p=0,001). Angiographic success was similar during both periods (98.3% vs 99.2%; p=0.2). There were no significant differences between both periods regarding the overall duration of the procedures (26.9 vs 29.6min; p=0.14), or the fluoroscopy time (13.3 vs 13.2min; p=0.8). We observed a reduction in the percentage of procedures with ventriculography (80.9% vs 7.1%; p<0.0001) or aortography (15.4% vs 4.4%; p<0.0001), the cine runs (21.8 vs 6.9; p<0.0001) and the dose-area product (165 vs 71 Gyxcm(2); p<0.0001). CONCLUSIONS: With the implementation of a simple radiation reduction protocol, a 57% reduction of dose-area product was observed without a reduction in the quality or the complexity of procedures.

Does reducing ischemia time justify to catheterize firstly the culprit artery in every primary PCI?

No consensus exists about which coronary artery should be firstly catheterized in primary PCIs. Initial catheterization of the "culprit artery" could reduce reperfusion time. However, complete knowledge of coronary anatomy could modify revascularization strategy. The objective of the study was to analyze this issue in ST-elevation myocardial infarction patients undergoing primary PCI. PCIs were performed in 384 consecutive patients. Choice of ipsilateral approach (IA): starting with a guiding catheter for the angiography and PCI of the "culprit artery", or contralateral approach (CA): starting with a diagnostic catheter for the "non-culprit artery" and completing the angiography and PCI of the culprit with a guiding catheter was left to the operator. Differences between two approaches regarding reperfusion time, acute events or revascularization strategies were analyzed. There were no differences between two approaches regarding reperfusion time or clinical events. When the left coronary artery was responsible, IA was more frequent (76.4 vs 22.6 %), but when it was the right coronary artery, CA was preferred (20 vs 80 %); p < 0.0001. With CA, bare metal stents (BMS) were more used than drug eluting (DES) (60.8 vs 39.2 %) inversely than with IA (BMS 41.3 vs DES 59.7 %; p < 0.0001). With CA there were more patients with left main or multivessel disease in which revascularization was completed with non-urgent surgery (4.13 vs 2.4 %, p < 0.0001). Initial CA does not involve higher reperfusion time. Furthermore, overall knowledge of coronary anatomy offers more options in revascularization strategy and may imply a change in management. Despite the need to individualize each case, contralateral approach may be the first option with the exception of unstable patients.

Clinical outcomes after intravascular ultrasound and fractional flow reserve assessment of intermediate coronary lesions. Propensity score matching of large cohorts from two institutions with a differential approach.

AIMS: Assessment of intermediate coronary lesions can be done with fractional flow reserve (FFR) and intravascular ultrasound (IVUS). There are no randomised trials and only a small registry from one centre is available but this is subject to important bias. We sought to evaluate the clinical outcomes of an FFR strategy compared with an IVUS strategy for intermediate lesion assessment. METHODS AND RESULTS: We compared the outcome of patients assessed with FFR and IVUS in two centres with a differential approach. After propensity score matching 400 pairs of patients were included. Revascularisation was done when FFR was <0.75 or minimum lumen area was <4 mm2 in vessels >3 mm, and <3.5 mm2 in vessels 2.5-3 mm, along with plaque burden >50%. After FFR and IVUS, 72% and 51.2% of lesions, respectively, were left untreated (p<0.001). At one and two years no significant differences in MACE-free survival were observed in overall groups (97.7% at one year and 93.1% at two years in the FFR group and 97.7% at one year and 95.6% at two years in the IVUS group; p=0.35) and among those with deferred intervention (97.9% at one year and 94.2% at two years in the FFR group and 96.5% at one year and 93.6% at two years in the IVUS group; p=0.7). CONCLUSIONS: IVUS and FFR may be safely used to defer revascularisation of intermediate lesions. IVUS induces a higher degree of revascularisation but much lower than previously reported and does not affect the clinical outcome.