Adjunctive laser-stimulated stem-cells therapy to primary reperfusion in acute myocardial infarction in humans: Safety and feasibility study.

BACKGROUND: Low-level laser therapy (LLLT) has photobiostimulatory effects on stem cells and may offer cardioprotection. This cell-based therapy may compliment primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: In this randomized control trial, our primary objective was to determine the safety and feasibility of LLLT application to the bone marrow in patients with STEMI undergoing PPCI. METHODS: We randomly assigned patients undergoing PPCI to LLLT or non-laser therapy (NLT). In the LLLT group, 100 s of laser therapy was applied to the tibia bone prior to PPCI, as well as 24 and 72 h post-PPCI. In the control group, the power source was turned off. The primary outcome was the difference in door-to-balloon (D2B) time, and additional outcomes included differences in circulating cell counts, cardiac enzymes, and left-ventricular ejection fraction (LVEF) at pre-specified intervals post-PPCI. RESULTS: Twenty-four patients were randomized to LLLT (N = 12) or NLT (N = 12). No adverse effects of the treatment were detected. The D2B time was not significantly different between the groups (41 ± 8 vs 48 ± 1 min; P = 0.73). Creatinine Phosphokinase area under the curve, was lower after LLLT (22 ± 10) compared to NLT (49 ± 12), but this was not statistically significant (P = 0.08). Troponin-T was significantly lower after LLLT (2.7 ± 1.4 ng/mL) in comparison to NLT (5.2 ± 1.8 ng/mL. P < 0.05). At 9 months, LVEF improved in both groups without a significant difference between LLLT (55 ± 9%) and NLT (52 ± 9%; P = 0.90). CONCLUSION: LLLT is a safe and feasible adjunctive cell-based therapy to PPCI that may benefit ischemic myocardium.

Intramyocardial dissecting hematoma: Two case reports and a meta-analysis of the literature.

Until recently, diagnosis of intramyocardial dissecting hematoma (IDH) was performed during necropsy or at surgery. During the recent years, echocardiography has permitted clinical suspicion, which usually needed confirmation with magnetic resonance imaging (MRI). In this study, we tried to define clinical and imaging features of IDH and predictors of mortality. We searched the literature for proven cases of IDH and analyzed them together with 2 of our cases. A total of 40 cases of IDH (2 our original and 38 literature cases) were included. Mean age was 60. In 32 cases, IDH was a complication of myocardial infarction (MI), in 66% anterior, a mean time from symptoms to diagnosis was 9 days. Thirty-eight % underwent surgery. In-hospital mortality was 23%. Multivariate analysis showed that the strongest independent predictor of mortality (42%) was EF < 35%; in patients with age >60, mortality risk was 44%; and in the presence of MI or late diagnosis (>24 hours since symptoms started), mortality risk was 50%. In summary, IDH is a diagnostic challenge. A high level of suspicion is needed for prompt diagnosis. Management of these patients is based on individual clinical and imaging parameters. Low EF, age > 60, and late diagnosis, all are predictors of in-hospital mortality.

Prevalence and Significance of Restrictive Filling Pattern in an Echocardiography Laboratory.

BACKGROUND: A cardiac restrictive filling patterns are associated with unfavorable prognoses. Cardiac interventions may change the natural history of patients. OBJECTIVES: To investigate the prevalence of restrictive filling pattern in routine echocardiographic examinations and their association with morbidity and mortality. METHODS: The clinical and echocardiographic data of patients with newly diagnosed restrictive filling pattern were analyzed and summarized. RESULTS: Among 8000 patients who underwent an echocardiographic examination in our hospital in 2013, a restrictive filling pattern was identified in 256. Of these, 134 showed a restrictive filling pattern that was newly diagnosed. Mean age was 69 years. Hypertension, diabetes, and ischemic heart disease were found in 81%, 60%, and 53%, respectively. Left ventricular ejection fraction was 42% ± 16%. Severe valvular abnormalities were found in 18%. During follow-up (29 ± 15 months), 40% of patients died. The strongest predictor of mortality (73%) was moderate or more advanced aortic stenosis, P = 0.005. Renal failure was an important independent predictor of mortality (53%, P < 0.05). A very high E/E' ratio ≥ 20, was another independent mortality predictor (50%, P < 0.03). Patients who died were less likely to have undergone cardiac interventions than those who survived (26% vs. 45%, P < 0.03). CONCLUSIONS: Prevalence of restrictive filling among echocardiographic studies is 3.2%. In a half of these, the restrictive filling pattern is a new diagnosis. Patients who are diagnosed with a new restrictive filling pattern have higher mortality rates. Patients with restrictive filling should be evaluated thoroughly for possible coronary artery or valvular heart disease.

Assessment and Management of Acute Severe Mitral Regurgitation in the Intensive Care Unit.

BACKGROUND AND AIM OF THE STUDY: Acute severe mitral regurgitation (MR) is a serious medical condition. Whilst clear guidelines exist regarding the management of chronic MR, acute severe MR is usually treated on an individual basis. Currently, few data exist regarding acute MR in the era of primary coronary interventions (PCI). The present study included patients admitted to the Department of Cardiology during recent years with acute severe MR of different etiologies, and an analysis of these data in the light of previous investigations. METHODS: The digital database of the present authors' hospital was searched for patients diagnosed with severe MR between 2008 and 2015. From a total of 228 patients identified, 19 with primary MR and 17 with secondary (functional) MR were admitted to the Department of Cardiology. The clinical data and outcome of these patients were analyzed. RESULTS: Among patients with MR due to acute myocardial infarction (MI), 13 had functional MR and six had MR due to mechanical complications, namely rupture of the papillary muscle or chordae tendineae. Among patients with MR not in the setting of MI, 13 had primary MR and four had functional MR. Patients with MR due to acute MI were more often in cardiogenic shock or had pulmonary edema and had a higher mortality. The strongest predictor of mortality was the presence of shock, followed by female gender, hypertension, age ≥68 years; previous MI and pulmonary edema were also predictors of mortality. In patients with acute MI and secondary MR, PCI to the culprit coronary artery was associated with a lesser degree of MR on follow up. CONCLUSIONS: Patients with severe MR are at high risk of in-hospital death. Patients with functional MR are likely to benefit from prompt PCI to the culprit artery, and for those with primary MR urgent surgery is life-saving.

Speckle Tracking Imaging in Normal Stress Echocardiography.

OBJECTIVES: Exercise stress echocardiography is a widely used modality for the diagnosis and follow-up of patients with coronary artery disease. During the last decade, speckle tracking imaging has been used increasingly for accurate evaluation of cardiac function. This work aimed to assess speckle-tracking imaging parameters during nonischemic exercise stress echocardiography. METHODS: During 2011 to 2014 we studied 46 patients without history of coronary artery disease, who completed exercise stress echocardiography protocol, had normal left ventricular function, a nonischemic response, and satisfactory image quality. These exams were analyzed with speckle-tracking imaging software at rest and at peak exercise. Peak strain and time-to-peak strain were measured at rest and after exercise. Clinical follow-up included a telephone contact 1 to 3 years after stress echo exam, confirming freedom from coronary events during this time. RESULTS: Global and regional peak strain increased following exercise. Time-to-peak global and regional strain and time-to-peak strain adjusted to the heart rate were significantly shorter in all segments after exercise. Rest-to-stress ratio of time-to-peak strain adjusted to the heart rate was 2.0 to 2.8. CONCLUSIONS: Global and regional peak strain rise during normal exercise echocardiography. Peak global and regional strain occur before or shortly after aortic valve closure at rest and after exercise, and the delay is more apparent at the basal segments. Time-to-peak strain normally shortens significantly during exercise; after adjustment to heart rate it shortens by a ratio of 2.0 to 2.8. These data may be useful for interpretation of future exercise stress speckle-tracking echocardiography studies.

When Cardioversion May Be Complicated.

BACKGROUND: In recent years cardioversion of atrial fibrillation has become a routine procedure, enabling symptomatic functional improvement in most cases. However, some patients develop complications after cardioversion. Identifying these individuals is an important step toward improving patient outcome. OBJECTIVES: To characterize those patients who may not benefit from cardioversion or who may develop complications following cardioversion. METHODS: We retrospectively analyzed 186 episodes of cardioversion in 163 patients with atrial fibrillation who were admitted to our cardiology department between 2008 and 2013 based on their clinical and echocardiographic data. Patients were divided into two groups: those with uncomplicated cardioversion, and those who developed complications after cardioversion. RESULTS: Of the 186 episodes, cardioversion was done in 112 men (60%) and 74 women (40%), P < 0.00001. Complications after cardioversion occurred in 25 patients (13%). These patients were generally older (72 vs. 65 years, P < 0.01), were more often diabetic (52% vs. 27%, P = 0.005), had undergone emergency cardioversion (64% vs. 40%, P = 0.01), had left ventricular hypertrophy (left ventricular mass 260 vs. 218 g, P = 0.01), had larger left atrium (left atrial volume 128 vs. 102 ml, P < 0.009), and more often died from complications of cardioversion (48% vs. 16%). They had significant mitral regurgitation (20% vs. 4%, P = 0.03) and higher pulmonary artery pressure (50 vs. 42 mm Hg, P < 0.02). CONCLUSIONS: People with complications after cardioversion tend to be older, are more often diabetic and more often have severe mitral regurgitation. In these patients, the decision to perform cardioversion should consider the possibility of complications.

Routine Laboratory Indices as Predictor of Neurological Recovery in Post-Resuscitation Syndrome Patients Treated with Therapeutic Hypothermia.

BACKGROUND: Hypothermia is associated with improved outcome in selected survivors of cardiac arrest but no single metric enables proper prediction of neurological outcome. OBJECTIVES: To explored the association between routine laboratory indices of patients treated by hypothermia for cardiac arrest and their neurological outcome. METHODS: We retrospectively collected data from survivors of cardiac arrest treated with hypothermia for 24 hours and grouped them according to their neurological outcome to either "poor" or "favorable". Routine laboratory indices were collected at constant time intervals up to one week of admission. A comparison between the laboratory values in both groups was performed. RESULTS: Between May 2008 to November 2011, 41 consecutive patients with a mean age of 54.3 ± 16.7 years were included in this study. No significant correlation was found between routine laboratory indices and the neurological outcome. The temporal trend of decay in the serum glucose values and the ratio of polymorphonuclears to white blood cells during the first 72 hours after admission was steeper in the favorable outcome group (P for trend < 0.05). CONCLUSIONS: No single routine laboratory index was associated with neurological outcome of survivors of cardiac arrest treated with hypothermia. The temporal trends in both serum glucose and polymorphonuclear ratio signal a more intense inflammatory response associated with poor outcome.

Cardiac Rupture: New Features of the Old Disease.

OBJECTIVES: Myocardial rupture is a rare but a fatal complication of acute myocardial infarction. During recent years, treatment strategies of acute myocardial infarction have changed. Primary percutaneous coronary interventions have replaced fibrinolytic therapy, thus reducing one of the major risk factors for myocardial rupture. In this work, we describe a group of patients who suffered myocardial rupture, none of whom were treated with thrombolytic therapy. METHODS: The digital database of our hospital was searched for all patients who experienced myocardial rupture between 2008 and 2015. The demographic, clinical, angiographic and echocardiographic data of these patients were analyzed. RESULTS: Out of 2,380 patients admitted with acute myocardial infarction, 12 (0.5%) developed myocardial rupture. The mean age was 78 years, and there were 7 males and 5 females. Ten patients already had pericardial effusion on admission. Seven patients underwent coronary angiography, whilst primary percutaneous intervention was performed in 4 patients. Six patients entered the operating room and all survived the procedure. All patients who were treated conservatively died due to rupture. Factors related to the treatment strategy were advanced age (≥ 90 years) and cognitive impairment. CONCLUSIONS: The risk of myocardial rupture may be diminished by primary coronary intervention during myocardial infarction, but mortality remains high. An early, comprehensive echocardiographic examination and rapid surgery may contribute to improved survival.

Detection of small subendocardial infarction using speckle tracking echocardiography in a rat model.

BACKGROUND: It is challenging to detect small nontransmural infarcts visually or automatically. As it is important to detect myocardial infarction (MI) at early stages, we tested the hypothesis that small nontransmural MI can be detected using speckle tracking echocardiography (STE) at the acute stage. METHODS: Minimal nontransmural infarcts were induced in 18 rats by causing recurrent ischemia-reperfusion of the left anterior descending (LAD) coronary artery, followed by a 30-min ligation and by reperfusion. A week later, the scar size was measured by histological analysis. Each rat underwent three echocardiography measurements: at baseline, 1 day post-MI, and 1 week post-MI. To measure the peak circumferential strain (CS), peak systolic CS, radial strain (RS), and time-to-peak (TTP) of the CS, short-axis view of the apex was analyzed by a STE program. The TTP was normalized by the duration of the heart cycle to create percent change of heart cycle. RESULTS: Histological analysis after 1 week showed scar size of 4±6% at the anterior wall. At 24 h post-MI, the peak CS, peak systolic CS, and RS were reduced compared to baseline at the anterior wall due to the MI, and at the adjacent segments-the anterior septum and lateral wall, due to stunning (P<.05). However, only the anterior wall, the genuine damaged segment, showed prolonged TTP vs baseline (baseline 36%, 24 h 48%, P<.05). CONCLUSION: The TTP of the CS can distinguish between regions adjacent to MI (stunned or tethered) and MI, even in small nontransmural infarcts.

Strain Analysis in the Detection of Myocardial Infarction at the Acute and Chronic Stages.

BACKGROUND: Myocardial ischemia causes contractile dysfunction in ischemic, stunned, and tethered regions with larger infarcted zones having a negative prognostic impact on patients' outcomes. To distinguish the infarcted myocardium from the other regions, we investigated the diagnostic potential of circumferential strain (CS) and radial strain (RS) during the acute and chronic stages of myocardial infarction. METHODS: Ten pigs underwent 90-minute occlusion of the left anterior descending artery, followed by reperfusion. Echocardiography was performed at baseline, after 90-minute occlusion, and at 2 hours, 30, and 60 days postreperfusion. CS and RS were measured using speckle tracking echocardiography. Subsequently, the pigs were sacrificed, and histological analysis for infarct size was performed. RESULTS: After 90-minute occlusion, reduced strains were detected for all segments (infarcted anterior wall - baseline: CS: -17.6 ± 5.7%, RS: 54.4 ± 16.9%; 90 min: CS: -10.3 ± 3.0%, RS: 23.3 ± 7.0%; tethered posterior wall - baseline: CS: -18.4 ± 3.5%, RS: 68.7 ± 21.1%; 90 min: CS: -10.7 ± 6.4%, RS: 34.5 ± 14.7%, P < 0.001). However, postsystolic shortening was detected only in the infarcted segments, and the time-to-peak CS was 25% longer (P < 0.05). At 30 and 60 days postreperfusion, time-to-peak CS could only detect large scars in the anterior and anterior-septum walls (P < 0.05), while peak CS also detected smaller scars in the lateral wall (P < 0.05). RS failed to distinguish between normal, stunned/tethered, and infarcted myocardium. CONCLUSIONS: During occlusion and 2 hours postreperfusion, time-to-peak CS could distinguish between infarcted and stunned/tethered myocardial segments, while at 30 and 60 days postreperfusion, peak CS was the best detector of infarction.

Role of Negative Trans-Thoracic Echocardiography in the Diagnosis of Infective Endocarditis.

BACKGROUND: The search for the presence of vegetations in patients with suspected infective endocarditis is a major indication for trans-esophageal echocardiographic (TEE) examinations. Advances in harmonic imaging and ongoing improvement in modern echocardiographic systems allow adequate quality of diagnostic images in most patients. OBJECTIVES: To investigate whether TEE examinations are always necessary for the assessment of patients with suspected infective endocarditis. METHODS: During 2012-2014 230 trans-thoracic echo (TTE) exams in patients with suspected infective endocarditis were performed at our center. Demographic, epidemiological, clinical and echocardiographic data were collected and analyzed, and the final clinical diagnosis and outcome were determined. RESULTS: Of 230 patients, 24 had definite infective endocarditis by clinical assessment. TEE examination was undertaken in 76 of the 230 patients based on the clinical decision of the attending physician. All TTE exams were classified as: (i) positive, i.e., vegetations present; (ii) clearly negative; or (iii) non-conclusive. Of the 92 with clearly negative TTE exams, 20 underwent TEE and all were negative. All clearly negative patients had native valves, adequate quality images, and in all 92 the final diagnosis was not infective endocarditis. Thus, the negative predictive value of a clearly negative TTE examination was 100%. CONCLUSIONS: In patients with native cardiac valves referred for evaluation for infective endocarditis, an adequate quality TTE with clearly negative examination may be sufficient for the diagnosis.

Foreign bodies in the heart.

BACKGROUND: Foreign bodies in the heart are rare, may reach the heart by different ways, and cause serious complications. X-ray, computerized tomography, and echocardiography are main diagnostic modalities. Foreign body can be removed surgically, percutaneously or can be managed conservatively. In this work, we analyzed 100 published cases of a foreign body in the heart and 4 cases that were identified in our hospital. METHODS: We searched the literature for foreign body in the heart and found 100 published previously cases. Additional 4 cases were identified in our echo laboratory. A total series of 104 patients with a foreign body in the heart were analyzed for the etiology, clinical presentation, symptoms, complications and management. RESULTS: Mean patients' age was 46, there were more men than woman 73 versus 31 [P < 0.00005]. The most common foreign bodies were parts of inferior vena cava filters and devices implanted for relieving hydrocephalus. Foreign bodies in the heart were symptomatic in 56% of patients. Right heart chambers were occupied more often. A total of 20% presented within the first 24 hours and 30% of patients presented years after the penetration of the foreign body. A majority of foreign bodies reached the heart by migration [88%]. Mortality was reported in 4 patients [3.8%]. Here 54% of the patients underwent surgical and 29% percutaneous removal of the foreign body, while 14% were followed conservatively. CONCLUSION: Foreign bodies in the heart may present with a wide variety of symptoms. Physicians should be aware of this rare and peculiar complications which may be fatal. Larger devices may result in more severe complications.

[ONE YEAR FOLLOW-UP OF PATIENTS AFTER CARDIAC ARREST TREATED WITH THERAPEUTIC HYPOTHERMIA: PROSPECTIVE COHORT STUDY COMPARED WITH HISTORICAL CONTROL].

BACKGROUND: Mild therapeutic hypothermia has been shown to reduce mortality and neurological morbidity in post cardiac arrest survivors. These beneficial effects had initially been reported in retrospective studies and subsequently more evidence has been gathered by two cornerstone randomized control trials. All these studies focused on the acute outcome and the clinical status at the time of hospital discharge. The main goal of this study was to describe the long term effects of therapeutic hypothermia in this population. PATIENTS AND METHODS: A prospective cohort with a historical control group was used in this study. All consecutive patients eligible for therapeutic hypothermia after cardiac arrest were enrolled. These patients were compared to an historical control group of patients who had met the same criteria of treatment with therapeutic hypothermia, but were not treated since it was not yet available. Patients' records and clinical assessment at 1 week, one, six and twelve months follow-up were collected. RESULTS: In the present study 54 consecutive patients were recruited prospectively, treated with mild hypothermia and 41 patients served as the historical control group for a similar period of time. The cooling group was significantly younger than the control group, 54 ± 16.3 versus 61.1 ± 14.5 years (p < 0.04). Peripheral arterial embolism complication was more common in the hypothermia group. 11.1% versus 0% (p < 0.035). No other clinically meaningful differences were found. In this respect, the beneficial trend towards reduced neurological outcome and mortality was observed in favor of the cooling group, which was statistically significant at six months follow-up (p < 0.044). Beyond 6 months the differences did not reach statistical significance. CONCLUSION: In the current phase of the study, a tendency in favor of mild cooling was observed in the short and medium term outcomes in patients resuscitated after out of hospital cardiac arrest due to fatal arrhythmia. The current results indicate that in spite of high survival rates after the acute stage in the cooling group, the long term mortality rate in this group is still high.

Does chronic atrial fibrillation induce cardiac remodeling?

AIM: The aim of this study was to compare cardiac structure and function in patients with chronic atrial fibrillation (CAF), as opposed to patients with paroxysmal atrial fibrillation (PAF), and normal control subjects. METHODS AND RESULTS: This study included 83 patients, divided into 3 groups: group A, 32 patients with CAF for ≥6 months; group B, 29 patients in sinus rhythm with a documented history of PAF; and group C, 22 patients without history of atrial fibrillation. Patients with CAF were older (71 years vs. 64 in group B, and 64 in group C). Apart from age, groups were clinically similar. After careful clinical evaluation, comprehensive echocardiography studies were performed including cardiac chambers' size, systolic and diastolic left ventricular function. Left atrium (LA) volume index was significantly larger in CAF than PAF and control patients: 39 ± 13 versus 34 ± 9 versus 25 ± 8 (P < 0.003). Left ventricular ejection fraction was lower in CAF: 53.8 ± 7 versus 61.6 ± 6.7 versus 58.4 ± 5.2% (P < 0.001). Isovolumic relaxation time was shorter in CAF, 65 ± 16 versus 82 ± 21 versus 81 ± 13 msec (P < 0.001). E/Vp was significantly greater in CAF 2.6 ± 0.8 versus 1.7 ± 0.4 versus 1.7 ± 0.5 (P < 0.001). Additional diastolic parameters were also significantly different. CONCLUSION: These findings demonstrate that in patients with CAF structural and functional cardiac changes occur. Patients with CAF as opposed to both normal subjects and patients with PAF have larger left atria and reduced systolic and diastolic left ventricular function.

Atrial Fibrillation Ablation Success Rate - A Retrospective Multicenter Study.

Atrial fibrillation (AF) has become a major health and economic burden. Pulmonary veins isolation (PVI) based ablation for rhythm control of AF is well established. Furthermore, recent studies show its superiority over anti-arrhythmic therapy. However, most of these studies were performed in highly experienced centers, that may not necessarily reflect real world outcomes. We evaluated the outcome (success rate and complications) of 300 consecutive procedures, performed on 291 patients (during 2014-2015) of a major HMO. All had undergone PVI for AF by experienced electrophysiologists in 8 medical centers (85% RF technique). Data were retrospectively collected using computerized medical records. Variables included demographic and clinical characteristics, acute procedural success and complications, long term success rate based on multiple ECGs and Holter monitoring. The average age was 63 years, 61% were male, 79% had paroxysmal AF. Sinus rhythm at 2 years was considered success. The overall success rate of maintaining sinus rhythm at 2 years was 56%. Success rate correlated significantly with age and standard risk factors. Those patients in whom the index procedure was the first ablation, success rate was 78%. Sixty-one patients underwent a second ablation with success rate of 64%, 32 underwent a 3rd/4th procedure with success rate of 56%. The probability to be in sinus rhythm after 2 years regardless of the number of ablations was 78%. Thirty-five percent of the patients were still on anti-arrhythmic therapy at 2 years post procedure. Complication rate was 6.6% (2.5% serious), among them 2 deaths, 1 procedure related. PVI in a real-world large unselected population is a valid therapeutic option for AF with an overall 2-year success rate of 56%. In our group higher complication rate was observed compared to the reported rate in the literature. The use of cryo-ablation for PVI and further improvements in both technique and experience may improve both efficacy and safety profile.

Layer-specific strain analysis: investigation of regional deformations in a rat model of acute versus chronic myocardial infarction.

Myocardial infarction (MI) injury extends from the endocardium toward the epicardium. This phenomenon should be taken into consideration in the detection of MI. To study the extent of damage at different stages of MI, we hypothesized that measurement of layer-specific strain will allow better delineation of the MI extent than total wall thickness strain at acute stages but not at chronic stages, when fibrosis and remodeling have already occurred. After baseline echocardiography scans had been obtained, 24 rats underwent occlusion of the left anterior descending coronary artery for 30 min followed by reperfusion. Thirteen rats were rescanned at 24 h post-MI and eleven rats at 2 wk post-MI. Next, rats were euthanized, and histological analysis for MI size was performed. Echocardiographic scans were postprocessed by a layer-specific speckle tracking program to measure the peak circumferential strain (S(C)(peak)) at the endocardium, midlayer, and epicardium as well as total wall thickness S(C)(peak). Linear regression for MI size versus S(C)(peak) showed that the slope was steeper for the endocardium compared with the other layers (P < 0.001), meaning that the endocardium was more sensitive to MI size than the other layers. Moreover, receiver operating characteristics analysis yielded better sensitivity and specificity in the detection of MI using endocardial S(C)(peak) instead of total wall thickness S(C)(peak) at 24 h post-MI (P < 0.05) but not 2 wk later. In conclusion, at acute stages of MI, before collagen deposition, scar tissue formation, and remodeling have occurred, damage may be nontransmural, and thus the use of endocardial S(C)(peak) is advantageous over total wall thickness S(C)(peak).

Left ventricular function in acute inflammatory peri-myocardial diseases - new insights and long-term follow-up.

BACKGROUND: Until recently acute inflammatory peri-myocardial syndromes have been associated with global rather regional left ventricular (LV) dysfunction. Recent advances in cardiac imaging with echocardiographic techniques and magnetic resonance imaging (MRI) permit comprehensive evaluation of global and regional LV function. Our study was aimed to assess regional LV function in 100 patients with acute perimyocarditis, and correlate these findings with the clinical presentation. METHODS: We report on 100 patients with acute perimyocarditis admitted during 2008-2011, in whom LV function was assessed by semi-quantitative wall motion score analysis on conventional echo. Long-term mortality and recurrent hospitalization were also assessed. RESULTS: Wall motion score in 100 patients with acute perimyocarditis demonstrated a significant predominance of regional wall motion abnormalities in the infero-postero-lateral LV wall. These data correspond well with speckle tracking results of a subgroup of these patients published earlier. Recent MRI data show frequent late enhancement of contrast in the infero-lateral region of the LV in patients with perimyocarditis. These observations were useful in re-classification of our patients into one of the following groups: pure or predominant pericarditis, and pure or predominant myocarditis. Over a mean period of 37 months, there was no mortality. Though recurrent hospitalizations were rather frequent, no significant differences were observed among groups. CONCLUSIONS: Regional wall motion abnormalities in the infero-postero-lateral segments of the LV are frequent in patients with acute perimyocarditis. Detailed echocardiographic examination early in the course of the disease should become a major factor in the clinical differentiation among the various clinical presentations of acute inflammatory peri-myocardial syndromes. The long-term outcome of these patients appears to be benign, though recurrent hospitalizations are not infrequent.

Can dobutamine stress echocardiography induce cardiac troponin elevation?

BACKGROUND: Elevation of cardiac troponin (cTn) is considered specific for myocardial damage. Elevated cTn and echocardiogrpahic documentation of wall motion abnormalities (WMAs) that were recorded after extreme physical effort raise the question whether dobutamine stress echo (DSE), can also induce elevation of troponin. METHODS: we prospective enrolled stable patients (age >18 years) referred to DSE. The exam was performed under standardized conditions. Blood samples for cTnI were obtained at baseline and 18-24 hours after the test. We aimed to compare between the clinical and echocardiographic features of patients with elevated cTnI and those without cTnI elevations. RESULTS: Fifty-seven consecutive patients were included. The average age was 64.4 ± 10.7, 73% of the patients were males, and nearly half of the patients were known to have ischemic heart disease. Two of the patients were excluded due to technical difficulty. No signs of ischemia were recorded in 25 (45.4%). Among the patients with established ischemia on DSE, 12 (22%) had mild ischemia, 13 (23.6%) had moderate and 5 (9%) had severe ischemia. Angiography was performed in 13 (26%) of the patients, of which 7 had PCI and one was referred to bypass surgery. None of the patients had elevated cTnI 18-24 hours after the DSE. CONCLUSIONS: Our results indicate that there is no elevation of cTn despite the occurrence of significant WMAs on DSE. We conclude that cTnI cannot be used as an additional diagnostic tool during pharmacological stress test performed to evaluate the presence and severity of ischemia.

Speckle tracking imaging in acute inflammatory pericardial diseases.

BACKGROUND: Left ventricular (LV) function in acute perimyocarditis is variable. We evaluated LV function in patients with acute perimyocarditis with speckle tracking. METHODS: Thirty-eight patients with acute perimyocarditis and 20 normal subjects underwent echocardiographic examination. Three-layers strain and twist angle were assessed with a speckle tracking. Follow-up echo was available in 21 patients. RESULTS: Strain was higher in normal subjects than in patients with perimyocarditis. Twist angle was reduced in perimyocarditis--10.9° ± 5.4 versus 17.6° ± 5.8, P < 0.001. Longitudinal strain and twist angle were higher in normal subjects than in patients with perimyocarditis and apparently normal LV function. Follow-up echo in 21 patients revealed improvement in longitudinal strain. CONCLUSIONS: Patients with acute perimyocarditis have lower twist angle, longitudinal and circumferential strain. Patients with perimyocarditis and normal function have lower longitudinal strain and twist angle. Short-term follow-up demonstrated improvement in clinical parameters and longitudinal strain despite of residual regional LV dysfunction.