Alessio Lilli

ST-Segment Elevation Myocardial Infarction Due to Early and Late Stent Thrombosis. A New Group of High-Risk Patients

OBJECTIVES The aim of this retrospective study was to compare clinical and angiographic outcomes between patients presenting with ST-segment elevation myocardial infarction (STEMI) due to stent thrombosis (ST) and de novo coronary thrombosis. BACKGROUND There are limited data for procedural and mid-term outcomes of patients with ST presenting with STEMI. METHODS From January 2004 to March 2007, 115 definite ST patients were observed: 92 (80%) of them presented as STEMI and were compared with a consecutive group of 98 patients with de novo STEMI. All patients underwent primary percutaneous coronary intervention. Primary end points were successful angiographic reperfusion and distal embolization. Major adverse cardiovascular and cerebrovascular events (MACCE), evaluated at 6-month follow-up, were defined as death, nonfatal myocardial reinfarction, target vessel revascularization, and cerebrovascular accident. RESULTS Successful reperfusion rate was lower in patients with ST (p < 0.0001), whereas distal embolization rate was higher (p = 0.01) in comparison with patients with de novo STEMI. Stent thrombosis proved to be an independent predictor of unsuccessful reperfusion at propensity-adjusted binary logistic regression (odds ratio 6.8, p = 0.004). In-hospital MACCE rate was higher in patients with ST (p = 0.003), whereas no differences were observed at 6-month follow-up among hospital survivors between the 2 groups (p = 0.7). CONCLUSIONS Stent thrombosis identifies a subgroup of patients with STEMI with poor angiographic and early clinical outcomes, suggesting that the management of these patients should be improved.

Cardiac resynchronization therapy : Gender related differences in left ventricular reverse remodeling

Cardiac resynchronization refers to pacing techniques that change the degree of atrial and ventricular electromechanical asynchrony in patients with major atrial and ventricular conduction disorders. Atrial and ventricular resynchronization is usually accomplished by pacing from more than one site in an electrical chamber--atrium or ventricle--and occasionally by stimulation at a single unconventional site. Resynchronization produces beneficial hemodynamic and antiarrhythmic effects by providing a more physiologic pattern of depolarization. Atrial resynchronization may prevent atrial fibrillation in selected patients with underlying bradycardia or interatrial block. Its antiarrhythmic effect in the absence of bradycardia is unclear. Ventricular resynchronization is of far greater clinical value than atrial resynchronization. Biventricular (or single-chamber left ventricular) pacing is beneficial for patients with congestive heart failure, severe left ventricular systolic dysfunction, dilated cardiomyopathy (either ischemic or idiopathic), and a major left-sided intraventricular conduction disorder, such as left bundle branch block. The change in electrical activation from resynchronization, which has no positive inotropic effect as such, is translated into mechanical improvement with a more coordinated left ventricular contraction. Several recent randomized trials and a number of observational studies have demonstrated the long-term effectiveness of ventricular resynchronization in the above group of patients. The high incidence of sudden death among these patients has encouraged ongoing clinical trials to evaluate the benefit of a system that combines biventricular pacing and cardioversion-defibrillation into a single implantable device.Aim: Gender related differences in epidemiology, treatment, and prognosis of heart failure (HF) have been reported. We examined the sex influence in patients treated with cardiac resynchronization therapy (CRT).

Tissue Doppler and strain imaging: a new tool for early detection of cardiac amyloidosis.

Using traditional echocardiography, the diagnosis of cardiac amyloidosis (CA) is often only possible in advanced stage when recommended therapies may have adverse effects. The aim of our study was to evaluate whether additional information can be derived from Tissue and strain Doppler imaging (TDI and SDI). Forty patients with systemic amyloidosis and 24 healthy subjects underwent traditional, tissue and strain Doppler echocardiography. Patients were classified having CA if mean wall thickness (mT), was half of the sum septum and posterior wall thickness, was ≥12 mm. The following parameters were evaluated: peak early diastolic velocity (Em) as index of ventricular relaxation, mitral E-wave to Em ratio (E/Em) as index of left ventricular (LV) filling pressure and mean LV strain peak curves (mSt) as global long-axis contraction index. In non cardiac amyloidosis (NCA), both Em and mSt were lower than in age matched controls (p < 0.01, p < 0.05, respectively) and higher than in CA (p < 0.01 and p < 0.01, respectively). Both Em and mSt were related to mT (p < 0.001). A significant (p < 0.01) nonlinear relation was observed between plasma terminal of pro B-natriuretic peptide and mT, Em, E/Em and mSt. TDI and SDI are able to detect amyloid myocardial involvement in such an early stage that cannot be evidenced by using traditional echocardiography.

A real-time three-dimensional echocardiographic validation of an intracardiac electrogram-based method for optimizing cardiac resynchronization therapy

Introduction: Although optimization of atrioventricular and interventricular delays has been demonstrated to improve hemodynamics in patients with cardiac resynchronization therapy (CRT), the required time‐consuming procedure discourages its use in clinical practice. Recently, a new method for CRT optimization based on the intracardiac electrogram (IEGM) detected by the implanted leads, has been developed. We evaluated the effectiveness of this method in improving left ventricular (LV) asynchrony and performance using real‐time 3D echocardiography (RT3DE).

Three-dimensional simultaneous strain-volume analysis describes left ventricular remodelling and its progression: a pilot study.

Aims Three-dimensional (3D)-echocardiography speckle imaging allows the evaluation of frame-by-frame strain and volume changes simultaneously. The aim of the present investigation was to describe the strain–volume combined assessment in different patterns of cardiac remodelling. Methods and results Fifty patients received a 3D acquisition. Patients were classified as follows: healthy subjects (CNT), previous AMI, and normal ejection fraction (EF; group A); ischaemic cardiomyopathy with reduced EF (group B); hypertrophic/infiltrative cardiomyopathy (group C). Values of 3D strain were plotted vs. volume for each frame to build a strain–volume curve for each case. Peak of radial, longitudinal, and circumferential systolic strain (Rɛp, Lɛp, and Cɛp, respectively), slopes of the curves (RɛSl, LɛSl, CɛSl), and strain to end-diastolic volume (EDV) ratio (Rɛ/V, Lɛ/V, Cɛ/V) were computed for the analysis. Strain–volume curves of the CNT group were steep and clustered, whereas, due to progressive dilatation and reduction of strains, progressive flattening could be demonstrated in groups A and B. Quantitative data supported visual assessment with progressive lower slopes (P< 0.05 for RɛSl, CɛSl, P= 0.06 for LɛSl) and significantly lower ratios (P< 0.01 for Rɛ/V, Lɛ/V, and Cɛ/V). Group C showed an opposite behaviour with slopes and ratios close to those of normal subjects. Correlation coefficients between EDV and slopes of the curves were significant for all the directions of strain (CɛSl: r = 0.891; RєSl: r = 0.704; LєSl: r = 0.833; P< 0.0001 for all). Conclusion We measured left ventricular volumes and strain by 3D-echo and obtained strain–volume curve to evaluate their behaviour in remodelling. A distinctive and progressive pattern consistent with pathophysiology was observed. The analysis here shown could represent a new non-invasive method to assess myocardial mechanics and its relationship with volumes.

Real-time 3-dimensional transthoracic echocardiography improves the diagnosis of isolated ventricular noncompaction.

In a 26-year-old man, an echocardiographic examination was performed for recurrent episodes of syncope. He had no familial history of cardiovascular diseases or sudden cardiac death. Traditional standard 2-dimensional (2D) echocardiography showed left ventricular (LV) dilatation with prominent trabeculations and diffuse contractility impairment (ejection fraction, 0.35) (Figure 1). Although the presence of isolated ventricular noncompaction of the myocardium (IVNC) was suspected, such findings did not fulfill the established criteria for the diagnosis as proposed by Jenni et al. 1 When transthoracic real-time 3-dimensional echocardiography (RT3DE) was performed with a model sonography system (IE33RD; Philips Medical Systems, Bothell, WA), a thickened myocardium with extensive trabeculations of both ventricles, especially in the LV apical and midventricular areas of both the inferior and lateral segments, clearly appeared, and the typical 2-layered structure of the myocardium was disclosed, with a thin, compacted outer band and a much thicker, noncompacted inner layer. The maximal end-systolic ratio of the noncompacted endocardial layer to the compacted myocardium was greater than 2 (Figure 2A). The 3-dimensional (3D) color images were able to denote the deep intertrabecular recess flow (Figure 2B). Thus, all the proposed diagnostic criteria for IVNC were fulfilled. Cardiac nuclear magnetic resonance (NMR) imaging subsequently performed confirmed the findings with the presence of extensive trabeculations and deep intratrabecular recesses involving the right ventricular apex and LV lateral and posterior walls, as shown on RT3DE (Figure 3).

Left Ventricular Rotation and Twist Assessed by Four‐Dimensional Speckle Tracking Echocardiography in Healthy Subjects and Pathological Remodeling: a Single Center Experience

Background: Left ventricular (LV) twist represents a main aspect of ejection. It is defined as the difference between the apical and basal rotation and can be assessed by speckle tracking echocardiography (STE). Twist may be underestimated when assessed by two‐dimensional‐echocardiography due to the difficulty of identifying the real apex. Aim of this study was to evaluate the LV twist by means of three‐dimensional (3D)‐STE and verify if the inclusion of the apex can modify the assessment of the global twist. Methods: LV volume acquisition with a fully sampled matrix array transducer was performed in 30 healthy subjects and 79 patients with cardiomyopathy secondary to different etiologies. Thirty‐nine patients had a LV ejection fraction (EF) ≥50% (Group A), 16 showed an EF between 40 and 50% (Group B), and 24 patients had an EF ≤40%(Group C). LV rotation was assessed by 3D‐STE at basal, medium, apical, and apical‐cap levels. Twist was computed considering the apex either at the apical level (TwistApi) or at the apical‐cap level (TwistAC). Results: LV rotation resulted to be progressively higher from base to apical‐cap (P < 0.0001) with a significant difference between the apex and the apical‐cap level (6.20 ± 3.90° vs. 10.23 ± 7.52°; P < 0.001). Such a difference was constantly found in all Groups (P < 0.01 for Group A, P < 0.05 for Group B and C). TwistApi was also significantly lower than TwistAC both in the overall population (6.2 ± 3.89° vs. 10.23 ± 7.51°; P < 0.001) and in the different subgroups (Controls: 9.61 ± 3.39° vs. 13.75 ± 6.51°; Group A: 10.49 ± 4.77° vs. 16.37 ± 8.49°; Group B: 6.67 ± 3.44° vs. 9.14 ± 5.55°; Group C: 33 ± 2.62° vs. 5.26 ± 3.74°; P < 0.05 for all the comparisons). Conclusions: Identification and inclusion of apical‐cap is relevant for twist assessment and can be carried out efficiently by 3D‐STE. The inclusion of the true apex in the calculation significantly affects the analysis of twist both in normal individuals and patients with different myocardial diseases.

Echo/Doppler-derived time intervals are able to predict left ventricular reverse remodeling after cardiac resynchronization therapy.

Aim We evaluated the predictive value of echo/Doppler derived indices, which reflect the duration of the isovolumic phases of the cardiac cycle, in identifying cardiac resynchronization therapy (CRT) responders. Methods and results In 105 patients before and 6 months after CRT the following echo/Doppler parameters were evaluated: myocardial performance index (MPI) as the sum of isovolumic contraction time (IVCT) and isovolumic relaxation time (IVRT) divided by ejection time; total isovolumic time (t-IVT) as the sum of IVCT and IVRT divided by the RR interval; and standard deviation of the time to systolic peak velocity (Ts-SD) as asynchrony index. After 6 months, patients were defined responders according to 15% left ventricle (LV) end-systolic volume reduction or more. At baseline, responders (53.3%) had higher t-IVT and MPI than nonresponders (0.30 ± 0.06 versus 0.22 ± 0.05, P < 0.0001 and 1.01 ± 0.27 versus 0.73 ± 0.19, P < 0.0001, respectively). Receiving operating characteristic curve analysis showed that both t-IVT (80.3% sensitivity and 83.7% specificity, cut-off = 0.263) and MPI (78.6% sensitivity and 81.6% specificity, cut-off = 0.84) could predict CRT response. Baseline t-IVT correlated well to end-systolic volume reduction (r = −0.56, P < 0.00001). Conclusion Echo/Doppler derived indices, describing physiologic abnormalities of the isovolumic contraction and relaxation phase, are able to predict CRT-induced reverse remodeling.

Short-term extraction profile of cardiac pacing leads with hybrid silicone–polyurethane insulator: A pilot study

[8]. There are no other studies which were designed to compare vernakalant versus EC. Our study is the first clinical investigation which compared these two protocols and showed that the conversion rate and hospital stay length were similar in both groups without statistical differences with the same safety. With these results with a protocol for EC which needs sedation and fasting for a minimum of 3 to 6 h depending on the different recommendations, we think that vernakalant is a safe and effective drug for conversion recent-onset atrial fibrillation instead of EC in this population, althoughwe believe thatwe need clinical randomized trials withmore patients to be able to reach the certainty that these results are able to extrapolate to the daily practice. Study limitations: Not to be a randomized trial is the most important limitation of this study. The sample size may underestimate the differences between the groups. A larger sample size could produce statistically significant differences in conversion rate and hospital stay length between both groups. Conclusions: The conversion rate of recent-onset AF and hospital stay length was similar in vernakalant and EC group without statistical differences. No adverse events were reported in both groups. References

Coronary microfistulae associated with non compacted myocardium: A rare cause of myocardial ischemia unraveled by a multimodality imaging approach

Left Ventricular Non Compaction (LVNC) is a rare cause of cardiomyopathy due to a developmental abnormality related to the lack ofmyocardial compaction during the early phases of embryogenesis [1]. Initially described as a cause of severe heart failure, LV dilatation and dysfunction, it has been recently observed also in patients with minor manifestations thus indicating a wide spectrum of phenotypic expression. [1,2]. We hereby report a very rare case of LVNC associated with an anomaly of the coronary vessels. A 61-year-oldmanwithout history of diseasewas referred to anearby hospital for typical chest pain and palpitations. The initial assessment, ECG and laboratory tests, including high sensitivity Troponin-I, did not show abnormalities. Two-dimensional echocardiography showed a postero-lateral apical hypertrophywith hypokinesiawith normal global ejection fraction. The patient was then scheduled for a dobutamine stress-echo in the same center which did not show reversible wall motion abnormalities although he experienced chest pain and transient Twave diphasic change in lateral leads (V4–V6) during the examination. He was then referred to our center for further evaluation.