Relationship between myocardial bridging and fatal ventricular arrhythmias in patients with hypertrophic cardiomyopathy: the HCM-MB study.

BACKGROUND: Myocardial bridging (MB) and hypertrophic cardiomyopathy (HCM) are associated with the risk of fatal ventricular arrhythmias (VAs). The goal of the study was to determine the relationship between MB and fatal VAs in HCM patients with implantable cardiac defibrillators (ICD). METHODS: A total of 108 HCM patients (mean age: 46.6 ± 13.6 years; male: 73) were enrolled in this retrospective study. All patients underwent transthoracic echocardiography and coronary computed tomography angiography. Fatal VAs including sustained ventricular tachycardia and ventricular fibrillation were documented in ICD records. RESULTS: There were documented fatal VAs in 29 (26.8%) patients during a mean follow-up time of 71.3 ± 30.9 months. Compared with the other groups, the fatal VA group had a higher incidence of the following: presence of MB (82.8 vs. 38%, p < 0.001), deep MB (62.1 vs. 6.3%, p < 0.001), very deep MB (24.1 vs. 0%, p < 0.001), long MB (65.5 vs. 11.4%, p < 0.001), presence of > 1 MB (17.2 vs. 0%, p = 0.001), and MB of the left anterior descending artery (79.3 vs. 17.7%, p < 0.001) . Sudden cardiac death (SCD) risk score (hazard ratio: 1.194; 95% CI: 1.071-1.330; p = 0.001) and presence of MB (hazard ratio: 3.815; 95% CI: 1.41-10.284; p = 0.008) were found to be independent predictors of fatal VAs in HCM patients. CONCLUSIONS: The current data suggest that the SCD risk score and presence of MB were independent risk factors for fatal VAs in patients with HCM. In addition to conventional risk factors, the coronary anatomical course can provide clinicians with valuable information when assessing the risk of fatal VAs in HCM patients.

The effect of successful lower extremity revascularization on aortic stiffness in patients with peripheral arterial disease.

OBJECTIVE: Peripheral arterial disease (PAD) is a global health problem and associated with poor outcomes. It causes increased arterial stiffness. The association of PAD with aortic arterial stiffness was investigated in previous studies. However, there is limited data regarding the effect of peripheral revascularization on arterial stiffness. The aim of our study is to investigate the effect of peripheral revascularization on aortic stiffness parameters in patients with symptomatic PAD. METHODS: A total of 48 patients with PAD who underwent peripheral revascularization were included in the study. Echocardiography was performed before and after the procedure, and aortic stiffness parameters were obtained by using aortic diameters and arterial blood pressure measurements. RESULTS: Post-procedural aortic strain (5.1 [1.3-14] vs. 6.3 [2.8-6.3], p = 0.009) and aortic distensibility (0.2 [0.0-0.9] vs. 0.3 [0.1-1.1], p = 0.001) measurements were significantly increased compared to pre-procedural values. Patients were also compared according to the lesion laterality, site and treatment methods. It was found that the change in aortic strain (p = 0.031) and distensibility (p = 0.043) were significantly higher in unilateral lesion compared to bilateral lesion. Also, the change in aortic strain (p = 0.042) and distensibility (p = 0.033) were significantly higher in iliac site lesion compared to superficial femoral artery (SFA) site lesion. Moreover, the change in aortic strain was significantly higher (p = 0.013) in patients treated with stent compared to only balloon angioplasty. CONCLUSION: Our study showed that successful percutaneous revascularization significantly reduced aortic stiffness in PAD. The change in aortic stiffness was significantly higher in unilateral lesions, iliac site lesions and stent-treated lesions.

Serum sortilin as a predictor of stroke in patients with intermediate carotid artery stenosis.

BACKGROUND: Sortilin was an important molecular protein involved in the pathogenesis of atherosclerosis. Besides, serum sortilin was associated with adverse cerebrovascular events. Atherosclerotic stenosis in the carotid artery is a major etiology for ischemic stroke. The risk of stroke in patients with intermediate carotid artery stenosis (CAS) was unknown. Hence, the aim of the present study was to evaluate the relationship between serum sortilin levels and stroke in patients with intermediate CAS. METHODS: A total of 195 intermediate CAS patients were included in this cross-sectional study. The patients were divided into two groups as symptomatic (N = 95) and asymptomatic (N = 100) patients. Patients with a transient ischemic attack (TIA), retinal ischemic event, or ischemic stroke resulting from the narrowed carotid artery were considered to be symptomatic. Serum sortilin concentrations were measured using the enzyme-linked immunosorbent assay. RESULTS: Serum sortilin level was significantly higher in the symptomatic group than in the severe asymptomatic group (1.53 ± 0.25 ng/mL vs 1.34 ± 0.19 ng/mL, p < 0.001). Besides, high serum sortilin levels (odds ratio = 4.91, 95% confidence intervals 1.24-19.51, p = 0.023) were identified as independent predictors of symptomatic carotid plaque. In the receiver operating characteristic curve analysis, serum sortilin levels higher than 1.34 ng/mL predicted stroke/TIA with a sensitivity of 66.3% and a specificity of 67% (AUC = 0.725, p < 0.001). CONCLUSIONS: Serum sortilin level is increased in the presence of symptomatic intermediate CAS and may have clinical value in the management of patients with carotid artery disease.

Dynamic thiol/disulphide homeostasis in patients with hypertrophic cardiomyopathy.

BACKGROUND: In addition to the genetic complexity of hypertrophic cardiomyopathy (HCM), there must be other disease-modifying factors that contribute to its highly variable clinical and phenotypic expression. The authors aimed to investigate serum thiol/disulphide homeostasis as a proxy for oxidative stress using a novel automated assay in patients with HCM. METHODS: This cross-sectional study was conducted on 119 patients with HCM and 52 without HCM. The methods used to measure dynamic thiol/disulphide homeostasis as calorimetric and duplex quantities were developed in 2014. RESULTS: Median serum native thiol levels were significantly lower in patients with HCM than in those without (312.5 µmol/L [285-370 µmol/L] vs 421 µmol/L [349-469.5 µmol/L]; p < 0.001). Serum total thiol levels and disulphide levels were considerably lower than those in the control group ([844.68 ± 195.99 µmol/L vs 1158.92 ± 243.97 µmol/L; p < 0.001], [259.13 ± 65.66 µmol/L vs 375.02 ± 79.99 µmol/L; p < 0.001], respectively). Serum disulphide/native thiol ratios and disulphide/total thiol ratios were significantly lower in HCM patients than in controls (0.80 ± 0.09 vs 0.92 ± 0.05; p < 0.001 and 0.31 [0.30-0.32] vs 0.32 [0.32-0.33]; p < 0.001). Finally, reduced thiol ratios were higher and oxidized thiol ratios were significantly lower in patients with HCM than in controls. CONCLUSIONS: Despite the fact that antioxidant capacity was impaired, the extracellular environment remained in a reducing state by keeping serum disulphide/native thiol ratios low. Therefore, the authors speculate that HCM may behave similarly to tumours with respect to serum thiol-disulphide levels.

Acute myocardial infarction complicated with ventricular septal rupture and intracranial hemorrhage.

Ventricular septal rupture (VSR) is a rare but fatal complication of acute myocardial infarction (AMI) with an associated mortality that ranges from 41% to 80%. The treatment consists of supplemental oxygenation, afterload reduction, intraaortic balloon pump, and surgical repair. In selected patients, extracorporeal membrane oxygenation (ECMO) and/or percutaneous closure of the defect can be considered if anatomically appropriate. Echocardiography evaluates the morphology and location of the defect, anatomical concerns for percutaneous closure, and accompanying pathologies. We present a 48-year-old man with inferior myocardial infarction and basal VSR who was not a candidate for percutaneous closure. Surgery was planned, but he died from extensive subarachnoid and intracranial hemorrhage.

Infarction of the septomarginal band and tricuspid papillary muscle rupture related to alcohol septal ablation for hypertrophic cardiomyopathy.

We presented a 77-year-old man with hypertrophic obstructive cardiomyopathy applied with flail tricuspid leaflet and severe tricuspid regurgitation leading to right heart failure 2 months after the failed septal ablation. The ruptured anterior tricuspid papillary muscle resulted from infarction of the base of anterior papillary muscle of the right ventricle (RV) confirmed by magnetic resonance imaging. As the septomarginal band is frequently lit up by intracoronary contrast that particular attention should be paid to the RV papillary muscles. And, if the papillary muscles or the RV free wall is brightened, then the use of that septal artery should be avoided.

Evaluation of Tp-e Interval, Tp-e/QT Ratio, and Tp-e/QTc Ratio in Patients with Asymptomatic Arrhythmogenic Right Ventricular Cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by progressive replacement of ventricular myocytes with variable amounts of fibrous and adipose tissue. Several studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with malignant ventricular arrhythmias. The aim of this study was to evaluate repolarization dispersion measured from the 12-lead surface electrocardiogram (including Tp-e interval, Tp-e/QT, and Tp-e/QTc ratio) in asymptomatic ARVD patients METHODS: We selected 27 patients with asymptomatic ARVD and 27 age- and gender-match young, healthy volunteers. RESULTS: Tp-e interval, Tp-e/QT and Tp-e/QTc ratio were also significantly higher in ARVD group compared to the control group (all P < 0.001). There were negative correlation between S global and Tp-e, Tp-e/QT, Tp-e/QTc ration (r = -0.57, P = 0.02; r = -0.85, P = 0.02; r = -0.63, P < 0.01; respectively). There were also negative correlation between Sm global and Tp-e, Tp-e/QT, Tp-e/QTc ration (r = -0.61, P < 0.01; r = -0.67, P < 0.01; r = -0.68, P < 0.01; respectively). Moreover, Em global were negative correlation between Tp-e, Tp-e/QT, and Tp-e/QTc (r = - 0.64, P < 0.001, r = - 0.75, P < 0.01; r = -0,69, P < 0.01; respectively) CONCLUSION: In conclusion, we have presented strong evidence suggesting that Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were increased in asymptomatic ARVD patients.

Left atrial remodeling in patients undergoing percutaneous mitral valve repair with the MitraClip system: an advanced echocardiography study.

BACKGROUND: The goal of this study was to determine changes in left atrial (LA) function with two-dimensional speckle tracking echocardiography (2DSTE) and real-time full-volume three-dimensional echocardiography (RT3DE) after percutaneous mitral valve repair with the MitraClip system. Furthermore, we investigated whether baseline and/or changes in LA function after MitraClip repair had any impact on prognosis. METHODS: A total of 25 consecutive patients (age: 57±12 years, 76% male) with moderate-to-severe or severe mitral regurgitation (MR) were included. Patients underwent 2DSTE and RT3DE before the clip implantation and after the 12-month follow-up. Prognostic data were also recorded via the use of telephone calls and follow-up visits for 12 months after the procedure. RESULTS: Compared with the baseline, the LA reservoir strain (LA-Res) (7.66±4.3% vs 11.15±7.5%, P<.001) and LA contraction strain (LA-Pump) (4.64±4.3% vs 7.63±5.8%, P=.001) improved significantly after MitraClip repair; significant improvements were also seen in three-dimensional (3D) minimum LA volume index (LAV min) and maximum LA volume index (LAV max). On the other hand, conventional LA indices did not change. In total, eleven major adverse cardiac events (MACE) were observed at the 1-year follow-up. In univariate analyses, the preprocedural echocardiographic parameters that were associated with the MACE within 1 year after MitraClip repair were 3D-LAV min and LA-Res. Furthermore, these indices significantly correlated with improved functional parameters and MR reduction. CONCLUSION: In conclusion, a successful MitraClip procedure can reverse the process of LA remodeling within 12 months, and this can be detected by 2DSTE and RT3DE. Also, patients with preprocedural lower LA-Res and higher 3D-LAV min had the worst prognoses at the 1-year follow-up.

Comparison of Right Ventricle Systolic Function between Long-Term Anabolic-Androgenic Steroid User and Nonuser Bodybuilder Athletes: A Study of Two-Dimensional Speckle Tracking Echocardiography.

BACKGROUND: Right ventricular (RV) effects of long-term use of anabolic-androgenic steroids (AAS) are not clearly known. The aim of this study was to assess RV systolic functions by two-dimensional speckle tracking echocardiography (2DSTE) in AAS user and nonuser bodybuilders. METHODS: A total of 33 competitive male bodybuilders (15 AAS users, 18 AAS nonusers) were assessed. To assess RV systolic functions, all participants underwent standard two-dimensional and Doppler echocardiography, and 2DSTE. RESULTS: Interventricular septal thickness, left ventricle posterior wall thickness, relative wall thickness, and left ventricle mass index were significantly higher in AAS users than nonusers. While standard diastolic parameters were not statistically different between the groups, tissue Doppler parameters including RV E' and E'/A' were lower in AAS users than nonusers (10.1 ± 2.0 vs. 12.7 ± 2.1; P = 0.001, 1.1 ± 0.1 vs. 1.5 ± 0.4; P = 0.009, respectively). Tricuspid annular plane systolic excursion, RV fractional area change, and RV S' were in normal ranges. However, RV S' was found to be lower in users than nonusers (12.2 ± 2.2 vs. 14.6 ± 2.8, P = 0.011). RV free wall longitudinal strain and strain rate were decreased in AAS users in comparison with nonusers (-20.2 ± 3.1 vs. -23.3 ± 3.5; P = 0.012, -3.2 ± 0.1 vs. -3.4 ± 0.1; P = 0.022, respectively). In addition, there were good correlations between 2DSTE parameters and RV S', E', and E'/A'. CONCLUSION: Despite normal standard systolic echo parameters, peak systolic RV free wall strain and strain rate were reduced in AAS user bodybuilders in comparison with nonusers. Strain and strain rate by 2DSTE may be useful for early determination of subclinical RV dysfunction in AAS user bodybuilders.

Utility of speckle tracking echocardiography imaging in patients with asymptomatic and symptomatic arrhythmogenic right ventricular cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by the progressive replacement of ventricular myocytes with variable amounts of fibrous and adipose tissue. Several studies have suggested that speckle tracking echocardiographic (STE) parameters such as strain (S) and strain rate (SR) may prove useful in the early detection of right ventricular (RV) dysfunction. Therefore, the aim of this study was to evaluate RV myocardial function using the STE method in both asymptomatic and symptomatic patients with ARVD and to assess its potential role in the differential diagnosis of these two presentations. METHODS: We recruited 34 patients with ARVD. Seventeen patients were symptomatic, and seventeen were asymptomatic. RESULTS: The RV free wall global longitudinal S and SR were significantly lower in symptomatic patients with ARVD than in asymptomatic patients. According to a cutoff value of 1.35 per seconds for RV global SR, the sensitivity and specificity for predicting ARVD were 88% and 77%, respectively. According to a cutoff value of 17.3% for RV S, the sensitivity and specificity for predicting ARVD were 82% and 77%, respectively. CONCLUSION: In conclusion, we present strong evidence that STE-derived global S and SR in the RV free wall are decreased in symptomatic patients with ARVD compared with asymptomatic patients.

Fast track occlusion of aorta with atrial septal defect sizing balloon.

We describe the case of a 57-year-old woman referred to our emergency service with ruptured abdominal aneurysm. We placed a 34-mm Amplatzer sizing balloon II into the suprarenal level of aorta to immediately control the active massive bleeding and to get the patient out of hemorrhage shock into the stable condition. After the bleeding control, endovascular repair was successfully performed. This is the first case report, to our knowledge, of atrial septal defect (ASD) sizing balloon use for blocking the blood flow through aorta to control the bleeding. ASD sizing balloon has some different properties compared to aortic occlusion balloon catheter (AOBC). Due to availability of sheathless usage, ASD sizing balloon may be preferred over AOBC for some of patient groups with peripheral artery diseases and small femoral artery diameters.

The value of plasma D-dimer level on admission in predicting no-reflow after primary percutaneous coronary intervention and long-term prognosis in patients with acute ST segment elevation myocardial infarction.

D-dimer is a final product of fibrin degradation and gives an indirect estimation of the thrombotic burden. We aimed to investigate the value of plasma D-dimer levels on admission in predicting no-reflow after primary percutaneous coronary intervention (p-PCI) and long-term prognosis in patients with ST segment elevation myocardial infarction (STEMI). We retrospectively involved 569 patients treated with p-PCI for acute STEMIs. We prospectively followed up the patients for a median duration of 38 months. Angiographic no-reflow was defined as postprocedural thrombolysis in myocardial infarction (TIMI) flow grade <3 or TIMI 3 with a myocardial blush grade <2. Electrocardiographic no-reflow was defined as ST-segment resolution <70%. The primary clinical end points were mortality and major adverse cardiovascular events (MACE). The incidences of angiographic and electrocardiographic no-reflow were 31 and 39% respectively. At multivariable analysis, D-dimer was found to be an independent predictor of both angiographic (p < 0.001), and electrocardiographic (p < 0.001) no-reflow. Both mortality (from Q1 to Q4, 5.7, 6.4, 11.3 and 34.1%, respectively, p < 0.001) and MACE (from Q1 to Q4, 17.9, 29.3, 36.9 and 52.2%, respectively, p < 0.001) rates at long-term follow-up were highest in patients with admission D-dimer levels in the highest quartile (Q4), compared to the rates in other quartiles. However, Cox proportional hazard model revealed that high D-dimer on admission (Q4) was not an independent predictor of mortality or MACE. In contrast, electrocardiographic no-reflow was independently predictive of both mortality [Hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.04-8.58, p = 0.041] and MACE [HR 1.90, 95% CI 1.32-4.71, p = 0.042]. In conclusion, plasma D-dimer level on admission independently predicts no-reflow after p-PCI. However, D-dimer has no independent prognostic value in patients with STEMI.

Effect of increased severity of mitral regurgitation and preprocedural right ventricular systolic dysfunction on biventricular and left atrial mechanical functions following percutaneous mitral balloon valvuloplasty.

BACKGROUND: Severe mitral stenosis (MS) may impair left atrial (LA) pump function, and increase LA and pulmonary venous pressure resulting in right ventricular (RV) systolic dysfunction. The aim of this study was to evaluate biventricular and LA function after percutaneous mitral balloon valvuloplasty (PMBV) by tissue Doppler (TDI) and speckle tracking echocardiography (STE). METHODS: Twenty-eight consecutive patients with severe symptomatic rheumatic MS (11 men, mean age: 39 ± 7 years) who were referred for PMBV were included in the study. In addition to conventional echocardiography, all patients underwent TDI and two-dimensional (2D) (STE) to assess left ventricular (LV), LA, and RV function before and 3 months after PMBV. Severity of mitral regurgitation (MR) was graded by the ratio of MR jet area to LA area (JA/LAA) method and any postprocedural progression of the JA/LAA ratio was defined as worsening of MR. Peak systolic velocity of tricuspid lateral annulus (RVs) <11.5 cm/sec was accepted as RV dysfunction. RESULTS: Left atrial diameter and area were decreased, while LV dimensions were unchanged following the valvuloplasty. PMBV improved STE-based LV mechanical indices, LA reservoir and conduit function, and RV free wall basal longitudinal strain (LS) and displacement. Increased severity of MR was detected in 6 patients, and PMBV did not improve the STE-based RV or LV function in these patients, while LA reservoir and conduit function were both improved independent of MR worsening. There was significant improvement in RVs and RV basal LS in the 15 patients with preprocedural RV systolic dysfunction, while the improvement in patients with normal preprocedural RV function was not significant. CONCLUSION: Percutaneous mitral balloon valvuloplasty may improve both LA and biventricular function in patients with severe symptomatic MS. Both TDI and STE are useful to determine biventricular and LA function after PMBV. Although the number of patients was insufficient, worsening of MR after PMBV may limit the improvement in RV and LV function, while preprocedural RV dysfunction does not seem to limit the improvement in RV function and pulmonary artery systolic pressure. Large scale follow-up studies are required to see whether the changes observed in cardiac mechanics are persistent.

Learning electrocardiogram on YouTube: how useful is it?

BACKGROUND: YouTube has become a useful resource for knowledge and is widely used by medical students as an e-learning source. The purpose of this study was to assess the videos relating electrocardiogram (ECG) on YouTube. METHODS: YouTube was searched on May 28, 2013 for the search terms "AF ecg" for atrial fibrillation, "AVNRT" for atrioventricular nodal reentrant tachycardia, "AVRT" for atrioventricular reentrant tachycardia, "AV block or heart block" for atrioventricular block, "LBBB, RBBB" for bundle branch block, "left anterior fascicular block or left posterior fascicular block" for fascicular blocks, "VT ecg" for ventricular tachycardia, "long QT" and "Brugada ecg". Non-English language, unrelated and non-educational videos were excluded. Remaining videos were assessed for usefulness, source and characteristics. Usefulness was assessed with using a checklist developed by the authors. RESULTS: One hundred nineteen videos were included in the analysis. Sources of the videos were as follows: individuals n=70, 58.8%, universities/hospitals n=10, 8.4% and medical organizations n=3, 2.5%, health ads n=10 8.4%, health websites n=26, 21.8%. Fifty-six (47.1%) videos were classified as very useful and 16 (13.4%) videos were misleading. 90% of the videos uploaded by universities/hospitals were grouped as very useful videos, the same ratio was 45% for the individual uploads. There were statistically significant differences in ECG diagnosis among the groups (for very useful, useful and misleading, p<0.001, 0.02 and 0.008, respectively). The ratio of the misleading information in ventricular tachycardia videos was found to be 42.9%. CONCLUSIONS: YouTube has a substantial amount of videos on ECG with a wide diversity from useful to misleading content. The lack of quality content relating to ECG on YouTube necessitates that videos should be selected with utmost care.

Soluble CD40 ligand release in patients with stable coronary artery disease during elective stent implantation: effect of drug-eluting stent over bare metal stent.

OBJECTIVES: We aimed to determine the effect of drug-eluting stent (DES) implantation on soluble CD40 ligand (sCD40L) levels in patients with stable coronary artery disease undergoing stent replacement. STUDY DESIGN: Eighty-nine consecutive patients (33 women, 56 men; mean age 61±10 years) with stable coronary artery disease undergoing stent replacement were recruited. Pre- and post-procedural blood samples were collected for sCD40L analysis, and differences in plasma levels were calculated and expressed as delta sCD40L. Total size and length of implanted stents and pre- and post-dilatation procedures were recorded for each patient, for possible impact on sCD40L release. Patients were followed for one year following procedures for possible adverse cardiac events such as death, myocardial infarction and revascularization. RESULTS: Forty-nine patients received bare metal stent (BMS) and 40 patients received DES. There were no differences between BMS- and DES-implanted patients in terms of age, stent size and length, and delta sCD40L plasma levels. Delta sCD40L was correlated only with total implanted stent length (r=0.374, p<0.001). Delta sCD40L levels were divided into quartiles for better determination of the procedural parameters that are effective on biomarker release. Total stent length (p=0.008), stent size (p=0.038) and pre-dilatation procedure (p=0.034) were the statistically differing parameters between delta sCD40L quartiles. Although statistically non-significant, all three adverse events were observed in patients with the highest quartile (p=0.179). CONCLUSION: Procedural sCD40L release did not differ between DES- and BMS-implanted stable coronary artery disease patients. Total implanted stent length, stent size and pre-dilatation procedure were the influential parameters on procedural sCD40L release.

Comparison of early and late clinical outcomes in patients >= 80 versus <80 years of age after successful primary angioplasty for ST segment elevation myocardial infarction.

OBJECTIVES: We aimed to compare the efficacy of primary percutaneous coronary intervention (p-PCI) in patients >=80 versus <80 years of age with ST-segment elevation myocardial infarction (STEMI). STUDY DESIGN: We retrospectively enrolled 2213 patients with acute STEMI. The patients were prospectively followed up for a median of 42 months. Early and late clinical outcomes were compared according to age. RESULTS: One-hundred and seventy-nine (8.1%) of the 2213 patients were aged >=80 years. Post-procedural TIMI grade 3 flow was significantly less frequent in the age >=80 years patients (82.1% vs. 91.1%, p<0.001). Rates of mortality (14.5% vs. 3.4%, p<0.001), heart failure (20.7% vs. 10.5%, p<0.001), major hemorrhage (9.5% vs. 3.3%, p<0.001), secondary VT/VF (10.1% vs. 4.2%, p=0.002) and atrial fibrillation (12.8% vs. 4.3%, p<0.001) during the early hospitalization period were significantly higher in the age >=80 years patient group. Overall rates of mortality (40% vs. 9.7%, p<0.001) and total stroke (5.6% vs. 1.1%, p=0.005) at long-term follow-up were also higher in the age >=80 years patient group. However, there was no difference between the two groups with respect to the reinfarction/revascularization rates. Analysis, using the Cox proportional hazards model, revealed that age >=80 to was an independent predictor of long-term mortality (hazard ratio 2.17, 95% CI 1.23-4.17, p=0.02). CONCLUSION: Age is an independent predictor of mortality after p-PCI for STEMI. Although it seems to improve early outcomes, the efficacy of p-PCI at long-term follow-up is limited in elderly patients.

Predictors and long-term prognostic significance of angiographically visible distal embolization during primary percutaneous coronary intervention.

OBJECTIVES: We aimed to identify the predictors of angiographically visible distal embolization (AVDE) during primary percutaneous coronary intervention (p-PCI) as well as to assess its impact on short- and long-term clinical outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI). STUDY DESIGN: We retrospectively enrolled 2007 patients with STEMI who underwent p-PCI. We assessed the clinical and angiographic characteristics of patients in order to identify the predictors of AVDE and compared the outcomes of patients with and without AVDE during p-PCI. RESULTS: Distal embolization developed in 135 (6.7%) patients. Age (for each 10- year increase, Odds Ratio (OR) 1.34, 95% Confidence Interval (CI) 1.16-1.52, p<0.001), treatment of right coronary artery (OR 2.52, 95% CI 1.30-4.87, p=0.034), repeated balloon dilatation (OR 1.84, 95% CI 1.16-2.94, p=0.009), cut-off occlusion pattern (OR 2.17, 95% CI 1.38-3.42, p=0.001), lesion length >15 mm (OR 1.67, 95% CI 1.09-2.58, p=0.019), and reference vessel diameter >3.5 mm (OR 5.08, 95% CI 3.32-7.65, p<0.001) were independent predictors of AVDE. In-hospital (8.1% vs. 3.8%, p=0.014) and one-month (10.8% vs. 4.9%, p=0.004) all-cause mortality rates were higher in patients with AVDE. At the long-term follow-up (median: 42 months), both all-cause (21.5% vs. 10.4%, p<0.001) and cardiac mortality rates (18.4% vs. 8.0%, p<0.001) were higher in patients with AVDE. CONCLUSION: AVDE is associated with worse clinical outcome at both the short- and long-term follow-up of STEMI patients treated early with p-PCI.

Relation of plasma matrix metalloproteinase-8 levels late after myocardial infarction with left ventricular volumes and ejection fraction.

OBJECTIVES: Enhanced matrix metalloproteinase-8 (MMP-8) activity in the early post-myocardial infarction (MI) period has been related to early remodeling. However, it has been demonstrated that plasma MMP-8 level has a biphasic profile, and the relation between the late plasma levels and remodeling is unclear. We evaluated the plasma MMP-8 levels and its correlates 20±3 months after acute MI. STUDY DESIGN: 58 post-MI patients and 26 control subjects underwent quantitative single-photon emission computed tomography (SPECT) and echocardiography. The plasma MMP-8 levels were measured and its correlates were investigated. RESULTS: The MMP-8 levels were significantly higher in post-MI patients [median 3.88 ng/ml, interquartile range (1.88-6.43) vs. 0.67 ng/ml (0.34-2.47); p<0.001]. Plasma MMP-8 levels were significantly correlated with left ventricular ejection fraction (LVEF) (ρ=0.34, p=0.009), end diastolic volume index (EDVi) (ρ=-0.39, p=0.002) and end systolic volume index (ESVi) (ρ=-0.40, p=0.002). CONCLUSION: Plasma MMP-8 levels were found to still be high in post-MI patients 20±3 months after the index event. The levels were significantly correlated with left ventricular volume indices and LVEF. We speculate that, in contrast to the relation between the higher early MMP-8 activity and the extent of cardiac remodeling, higher late levels may be associated with relative preservation of left ventricular systolic function.

Carotid artery stenting without embolic protection: A randomized multicenter trial (the CASWEP trial).

BACKGROUND: Carotid artery stenting (CAS) with a carotid protection device (CPD) has become the standard practice in patients with severe carotid stenosis and high surgical risk. However, the clinical efficacy and safety of CPDs are still controversial issues. We aimed to compare the clinical outcomes of the CAS without CPD with CAS combined with CPD. METHODS: This is a multicenter randomized prospective study registered with http://clinicaltrials.gov (NCT02781181). After the exclusion, 279 patients were enrolled (139 patients in the CAS with CPD group and 140 patients in the CAS without CPD group). The primary outcome was a combination of peri-procedural in-hospital transient ischemic attack (TIA), ipsilateral stroke, or death. The secondary outcome was new ischemic brain lesions on post-procedural diffusion-weighted magnetic resonance imaging (DW-MRI). RESULTS: Two patients died in CAS without CPD group, one patient died in CAS with CPD group. TIA was only seen in patients who underwent CAS under protection (n = 5). The combined primary outcome of TIA, ipsilateral stroke, and death rate was not different between groups (5.7% vs. 2.8%; p = 0.254). New defects were noted on the post-procedural DW-MRI in 28% of patients in the CPD group and 27% of patients in the no CPD group (p = 0.881). CONCLUSIONS: This study suggests that CAS without CPD is not associated with higher rates of peri-procedural TIA, stroke, and death or new ischemic brain lesions on post-procedural DW-MRI compared to CAS with CPD in selected symptomatic and asymptomatic patients with significant carotid artery stenosis provided that there is no visible thrombus.

Intracoronary bolus-only compared with intravenous bolus plus infusion of tirofiban application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: The aim of this pilot study was to compare intracoronary bolus-only with standard intravenous bolus plus maintenance infusion of tirofiban with respect to improvement in myocardial reperfusion after primary percutaneous coronary intervention (p-PCI). BACKGROUND: Changes in clinical practice may obviate the need for a maintenance infusion of small molecule glycoprotein IIb/IIIa inhibitors in current practice. METHODS: Forty-nine patients undergoing p-PCI were randomized to either intracoronary bolus-only (n = 25) or intravenous bolus plus infusion (n = 24) of tirofiban. The primary end point was coronary hemodynamic indices of microvascular perfusion measured 4-5 days after p-PCI. The secondary end points were ST segment resolution at 90 min, the corrected TIMI frame count and myocardial blush grade. At 6 months, echocardiography and technetium-99m single-photon-emission computed tomography were performed. RESULTS: Microvascular perfusion did not differ significantly between the two treatment groups: index of microvascular resistance (27 ± 13 vs. 35 ± 15 U, P = 0.08) and coronary flow reserve (2.2 ± 0.7 vs. 1.9 ± 0.6, P = 0.25). The corrected TIMI frame counts assessed in the first (P = 0.13) and the second (P = 0.09) catheterization or the myocardial blush grades evaluated immediately (P = 0.23) and 4-5 days after MI (P = 1.00) were not significantly different between the two groups. At 6 months, there was no difference between the two groups in infarct size, left ventricular volumes, or ejection fraction. CONCLUSIONS: The standard intravenous bolus plus maintenance infusion of tirofiban in p-PCI is not superior to intracoronary bolus-only administration with respect to microvascular perfusion. Further, adequately powered randomized trials are warranted to evaluate the clinical outcomes associated with this strategy.