Alexander Hirsch

Dobutamine-induced increase of right ventricular contractility without increased stroke volume in adolescent patients with transposition of the great arteries: evaluation with magnetic resonance imaging.

Objective: Prognosis in patients with surgically corrected (Senning or Mustard) transposition of the great arteries (TGA) depends mainly on right ventricular (RV) function and RV functional reserve. We examined the role of dobutamine stress in the early detection of RV dysfunction in asymptomatic or slightly symptomatic patients with TGA using magnetic resonance imaging (MRI). Design and patients: Twelve asymptomatic or slightly symptomatic patients with chronic RV pressure overload, surgically corrected (Mustard or Senning) TGA (age 22.8 (±3.4) years; New York Heart Association (NYHA) class I/II) and nine age matched healthy volunteers (age 27.3 (±4.4) years) were included. MRI was applied both at baseline and during dobutamine stress (start dose 5 μg/kg/min to maximum dose 15 μg/kg/min) to determine RV and left ventricular (LV) stroke volumes (SV) and ejection fraction (EF). Results: At baseline only RVEF was significantly higher in controls than in patients (71 (±9) vs. 57 (±10)%, p < 0.001), other RV parameters were not significantly different between the two examined groups: RVSV (86 (±21) vs. 72 (±27) ml, p = ns), RV end-diastolic volume (EDV) (123 (±37) vs. 123 (±33) ml, p = ns), and heart rate (61 (±10) vs. 69 (±14) bpm, p = ns), respectively. During dobutamine stress RVEF increased significantly both in controls and patients (20 (±16) vs. 17 (±18)%, p < 0.01 and p < 0.02 vs. rest, respectively), but stress RVEF was significantly higher in controls than in patients (85 (±3) vs. 66 (±7)%, p < 0.0001). RVSV increased significantly in controls (22 (±19)%, p < 0.02), and there was no significant increase in RVSV in patients (−10 (±28)%, p = ns). The controls showed no change in RVEDV (2 (±17)%, p = ns), but in patients a significant decrease in RVEDV (−24 (±15)%, p < 0.001) was observed. Maximal heart rate was significantly higher in patients than in controls (122 (±20) vs. 101 (±14) bpm, p < 0.02). Conclusion: In asymptomatic or slightly symptomatic patients with surgically corrected TGA dobutamine had a positive inotropic effect on RV, but the increased contractility was not accompanied by an appropriate increase in SV. Our data suggest inadequate RV filling in this category of patients, possibly due to rigid atrial baffles and compromised atrial function or decreased compliance due to RV hypertrophy.

Improved recovery of regional left ventricular function after PCI of chronic total occlusion in STEMI patients: A cardiovascular magnetic resonance study of the randomized controlled EXPLORE trial

BackgroundThe Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) trial did not show a significant benefit of percutaneous coronary intervention (PCI) of the concurrent chronic total occlusion (CTO) in ST-segment elevation myocardial infarction (STEMI) patients on global left ventricular (LV) systolic function. However a possible treatment effect will be most pronounced in the CTO territory. Therefore, we aimed to study the effect of CTO PCI compared to no-CTO PCI on the recovery of regional LV function, particularly in the CTO territory.MethodsUsing cardiovascular magnetic resonance (CMR) we studied 180 of the 302 EXPLORE patients with serial CMR (baseline and 4xa0months follow-up). Segmental wall thickening (SWT) was quantified on cine images by an independent core laboratory. Dysfunctional segments were defined as SWTxa0<xa045%. Dysfunctional segments were further analyzed by viability (transmural extent of infarction (TEI) ≤50%.). All outcomes were stratified for randomization treatment.ResultsIn the dysfunctional segments in the CTO territory recovery of SWT was better after CTO PCI compared to no-CTO PCI (ΔSWT 17xa0±xa027% vs 11xa0±xa023%, pxa0=xa00.03). This recovery was most pronounced in the dysfunctional but viable segments(TEIxa0<xa050%) (ΔSWT 17xa0±xa027% vs 11xa0±xa022%, pxa0=xa00.02). Furthermore in the CTO territory, recovery of SWT was significantly better in the dysfunctional segments in patients with Rentrop grade 2–3 collaterals compared to grade 0–1 collaterals to the CTO (16xa0±xa026% versus 11xa0±xa024%, pxa0=xa00.04).ConclusionCTO PCI compared with no-CTO PCI is associated with a greater recovery of regional systolic function in the CTO territory, especially in the dysfunctional but viable segments. Further research is needed to evaluate the use of CMR in selecting post-STEMI patients for CTO PCI and the effect of regional LV function recovery on clinical outcome.Trial registrationTrialregister.nl NTR1108, Date registered NTR: 30-okt-2007.

Long-term impact of chronic total occlusion recanalisation in patients with ST-elevation myocardial infarction

Background During primary percutaneous coronary intervention (PCI), a concurrent chronic total occlusion (CTO) is found in 10% of patients with ST-elevation myocardial infarction (STEMI). Long-term benefits of CTO-PCI have been suggested; however, randomised data are lacking. Our aim was to determine mid-term and long-term clinical outcome of CTO-PCI versus CTO-No PCI in patients with STEMI with a concurrent CTO. Methods The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) was a multicentre randomised trial that included 302 patients with STEMI after successful primary PCI with a concurrent CTO. Patients were randomised to either CTO-PCI or CTO-No PCI. The primary end point of the current study was occurrence of major adverse cardiac events (MACE): cardiac death, coronary artery bypass grafting and MI. Other end points were 1-year left ventricular function (LVF); LV-ejection fraction and LV end-diastolic volume and angina status. Results The median long-term follow-up was 3.9 (2.1–5.0) years. MACE was not significantly different between both arms (13.5% vs 12.3%, HR 1.03, 95%u2009CI 0.54 to 1.98; P=0.93). Cardiac death was more frequent in the CTO-PCI arm (6.0% vs 1.0%, P=0.02) with no difference in all-cause mortality (12.9% vs 6.2%, HR 2.07, 95%u2009CI 0.84 to 5.14; P=0.11). One-year LVF did not differ between both arms. However, there were more patients with freedom of angina in the CTO-PCI arm at 1u2009year (94% vs 87%, P=0.03). Conclusions In this randomised trial involving patients with STEMI with a concurrent CTO, CTO-PCI was not associated with a reduction in long-term MACE compared to CTO-No PCI. One-year LVF was comparable between both treatment arms. The finding that there were more patients with freedom of angina after CTO-PCI at 1-year follow-up needs further investigation. Clinical trial registration EXPLORE trial number NTR1108 www.trialregister.nl.

Decreased plasma neurohormones and improved cardiac performance after surgical treatment of chronic pulmonary embolism

The findings of this case report suggest that quantitative assessment of plasma neurohormones and magnetic resonance imaging functional parameters in patients with right ventricular pressure overload due to chronic pulmonary embolism might be used as indicators for right ventricular function before and after intervention. Monitoring of changes in these parameters may provide quantitative follow-up of right ventricular function in these patients.

Atrial septal defect in adults is associated with airway hyperresponsiveness

OBJECTIVEnThe association between secundum atrial septal defects (ASD) and asthma-like dyspnea with consequent long-term pulmonary inhalant use, is poorly understood in adult ASD patients. Airway hyperresponsiveness is suggested to be the underlying mechanism of cardiac asthma from mitral valve disease and ischemic cardiomyopathy. We hypothesized that airway hyperresponsiveness may also be found in adult ASD patients. Our aim was to study airway responsiveness in adult ASD patients before percutaneous closure and at short-and long-term postprocedural follow-up.nnnMETHODSnThis prospective study included 31 ASD patients (65% female, mean age 49xa0±xa015y) who underwent spirometry and bronchoprovocation testing pre-and six-month postprocedurally, with additional bronchoprovocation at 2-year follow-up. Airway hyperresponsiveness was defined as ≥20% fall of forced expiratory volume in 1-second (FEV1 ) following <8.0xa0mg/mL of inhaled methacholine.nnnRESULTSnAirway hyperresponsiveness was found in 19/30 patients (63%[95%CI 45%-81%]; post hoc statistical power = 89%). Asthma-like symptoms wheezing, chest tightness, and cough were more frequently reported in airway hyperresponsive patients. Airway responsiveness was not influenced by successful percutaneous ASD closure, corresponding to persistence of asthma-like symptoms postclosure. Regardless of airway responsiveness, postprocedural right-sided reverse remodeling significantly improved dyspnea and pulmonary function.nnnCONCLUSIONSnThis study is the first to report a high prevalence of airway hyperresponsiveness in a cohort of unrepaired adult ASD patients, and confirms the association between asthma-like symptoms and ASD in adults. Attention to symptoms and pulmonary function should be given during clinical follow-up of adult ASD patients, both before and long after repair.

Intermodality variation of aortic dimensions: How, where and when to measure the ascending aorta

BACKGROUNDnNo established reference-standard technique is available for ascending aortic diameter measurements. The aim of this study was to determine agreement between modalities and techniques.nnnMETHODSnIn patients with aortic pathology transthoracic echocardiography, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) were performed. Aortic diameters were measured at the sinus of Valsalva (SoV), sinotubular junction (STJ) and tubular ascending aorta (TAA) during mid-systole and end-diastole. In echocardiography both the inner edge-to-inner edge (I-I edge) and leading edge-to‑leading edge (L-L edge) methods were applied, and the length of the aortic annulus to the most cranial visible part of the ascending aorta was measured. In CTA and MRA the I-I method was used.nnnRESULTSnFifty patients with bicuspid aortic valve (36u202f±u202f13u202fyears, 26% female) and 50 Turner patients (35u202f±u202f13u202fyears) were included. Comparison of all aortic measurements showed a mean difference of 5.4u202f±u202f2.7u202fmm for the SoV, 5.1u202f±u202f2.0u202fmm for the STJ and 4.8u202f±u202f2.1u202fmm for the TAA. The maximum difference was 18u202fmm. The best agreement was found between echocardiography L-L edge and CTA during mid-systole. CTA and MRA showed good agreement. A mean difference of 1.5u202f±u202f1.3u202fmm and 1.8u202f±u202f1.5u202fmm was demonstrated at the level of the STJ and TAA comparing mid-systolic with end-diastolic diameters. The visible length of the aorta increased on average 5.3u202f±u202f5.1u202fmmW during mid-systole.nnnCONCLUSIONSnMRA and CTA showed best agreement with L-L edge method by echocardiography. In individual patients large differences in ascending aortic diameter were demonstrated, warranting measurement standardization. The use of CTA or MRA is advised at least once.

Strain analysis is superior to wall thickening in discriminating between infarcted myocardium with and without microvascular obstruction

ObjectivesThe aim of the present study was to evaluate the diagnostic performances of strain and wall thickening analysis in discriminating among three types of myocardium after acute myocardial infarction: non-infarcted myocardium, infarcted myocardium without microvascular obstruction (MVO) and infarcted myocardium with MVO.MethodsSeventy-one patients with a successfully treated ST-segment elevation myocardial infarction underwent cardiovascular magnetic resonance imaging at 2-6 days after reperfusion. The imaging protocol included conventional cine imaging, myocardial tissue tagging and late gadolinium enhancement. Regional circumferential and radial strain and associated strain rates were analyzed in a 16-segment model as were the absolute and relative wall thickening.ResultsHyperenhancement was detected in 418 (38%) of 1096 segments and was accompanied by MVO in 145 (35%) of hyperenhanced segments. Wall thickening, circumferential and radial strain were all significantly diminished in segments with hyperenhancement and decreased even further if MVO was also present (all p < 0.001). Peak circumferential strain (CS) surpassed all other strain and wall thickening parameters in its ability to discriminate between hyperenhanced and non-enhanced myocardium (all p < 0.05). Furthermore, CS was superior to both absolute and relative wall thickening in differentiating infarcted segments with MVO from infarcted segments without MVO (p = 0.02 and p = 0.001, respectively).ConclusionsStrain analysis is superior to wall thickening in differentiating between non-infarcted myocardium, infarcted myocardium without MVO and infarcted myocardium with MVO. Peak circumferential strain is the most accurate marker of regional function.Key Points• CMR can quantify regional myocardial function by analysis of wall thickening on cine images and strain analysis of tissue tagged images.• Strain analysis is superior to wall thickening in differentiating between different degrees of myocardial injury after acute myocardial infarction.• Peak circumferential strain is the most accurate marker of regional function.