Edouard Gerbaud

Effect of ivabradine on left ventricular remodelling after reperfused myocardial infarction: A pilot study

BACKGROUND Heart rate is a major determinant of myocardial oxygen demand; in ST-segment elevation myocardial infarction (STEMI), patients treated with primary percutaneous intervention (PPCI), heart rate at discharge correlates with mortality. Ivabradine is a pure heart rate-reducing agent that has no effect on blood pressure and contractility, and can reverse left ventricular (LV) remodelling in patients with heart failure. AIMS To evaluate whether ivabradine, when added to current guideline-based therapy, improves LV remodelling in STEMI patients treated with PPCI. METHODS This paired-cohort study included 124 patients between June 2011 and July 2012. Ivabradine (5mg twice daily) was given promptly after PPCI, along with beta-blockers, to obtain a heart rate<60 beats per minute (ivabradine group). This group was matched with STEMI patients treated in line with current guidelines, including beta-blockers (bisoprolol), according to age, sex, infarct-related coronary artery, ischaemia time and infarct size determined by initial cardiac magnetic resonance imaging (CMR) (control group). Statistical analyses were performed according to an intention-to-continue treatment principle. CMR data at 3 months were available for 122 patients. RESULTS Heart rate was lower in the ivabradine group than in the control group during the initial CMR (P=0.02) and the follow-up CMR (P=0.006). At the follow-up CMR, there was a smaller increase in LV end-diastolic volume index in the ivabradine group than in the control group (P=0.04). LV end-systolic volume index remained unchanged in the ivabradine group, but increased in the control group (P=0.01). There was a significant improvement in LV ejection fraction in the ivabradine group compared with in the control group (P=0.04). CONCLUSIONS In successfully reperfused STEMI patients, ivabradine may improve LV remodelling when added to current guideline-based therapy.

Cardiac magnetic resonance demonstrates myocardial oedema in remote tissue early after reperfused myocardial infarction

BACKGROUND Cardiac magnetic resonance can detect myocardial oedema using myocardial transverse relaxation time (T2)-weighted sequences but quantitative data are lacking in patients evaluated early after acute myocardial infarction. AIM To assess the spatial distribution of T2 in patients with recent acute myocardial infarction. METHODS Twenty-four consecutive patients (mean age 60+/-11 years) with acute myocardial infarction (anterior, n=12; inferior, n=12) were evaluated prospectively. T2 was determined using a series of breath-hold T2-weighted segmented half-Fourier turbo-spin echo sequences. No-reflow was defined as the association of early hypoenhancement and delayed enhancement in an akinetic region after a bolus injection of DOTA-Gd (0.2 mmol/kg). RESULTS No-reflow was present in 13 (54%) patients and absent in 11 (46%) patients. Mean T2 was increased in the infarct region (84.9+/-23.7 ms) compared with in the remote myocardium (62.8+/-10.3 ms, p=0.0001) and in control subjects (55.7+/-4.6 ms, p<0.0001), but also in the remote myocardium compared with control subjects (p<0.02). In patients with no-reflow, T2 was further increased within the infarcted subendocardium compared with in patients without no-reflow (97.9+/-24.8 ms vs 76.3+/-24.7 ms, p<0.03). Peak troponin correlated with T2 (r=0.47, p<0.02) and was higher in patients with no-reflow (297.9+/-249.7 microg/L) than in patients without no-reflow (42.4+/-43.1 microg/L, p=0.003). CONCLUSION T2 was lengthened in both infarcted and remote myocardium and was influenced by the occurrence of no-reflow.

Multi-laboratory inter-institute reproducibility study of IVOCT and IVUS assessments using published consensus document definitions.

AIMS The aim of this study was to investigate the reproducibility of intravascular optical coherence tomography (IVOCT) assessments, including a comparison to intravascular ultrasound (IVUS). Intra-observer and inter-observer variabilities of IVOCT have been previously described, whereas inter-institute reliability in multiple laboratories has never been systematically studied. METHODS AND RESULTS In 2 independent laboratories with intravascular imaging expertise, 100 randomized matched data sets of IVOCT and IVUS images were analysed by 4 independent observers according to published consensus document definitions. Intra-observer, inter-observer, and inter-institute variabilities of IVOCT qualitative and quantitative measurements vs. IVUS measurements were assessed. Minor inter- and intra-observer variability of both imaging techniques was observed for detailed qualitative and geometric analysis, except for inter-observer mixed plaque identification on IVUS (κ = 0.70) and for inter-observer fibrous cap thickness measurement reproducibility on IVOCT (ICC = 0.48). The magnitude of inter-institute measurement differences for IVOCT was statistically significantly less than that for IVUS concerning lumen cross-sectional area (CSA), maximum and minimum lumen diameters, stent CSA, and maximum and minimum stent diameters (P < 0.001, P < 0.001, P < 0.001, P = 0.02, P < 0.001, and P = 0.01, respectively). Minor inter-institute measurement variabilities using both techniques were also found for plaque identification. CONCLUSION In the measurement of lumen CSA, maximum and minimum lumen diameters, stent CSA, and maximum and minimum stent diameters by analysts from two different laboratories, reproducibility of IVOCT was more consistent than that of IVUS.

Comparative Analysis of Cardiac Magnetic Resonance Viability Indexes to Predict Functional Recovery After Successful Percutaneous Coronary Intervention in Acute Myocardial Infarction

The aim of this study was to examine the relative value and the influence of the association of 4 cardiac magnetic resonance (CMR) viability indexes for predicting segmental functional recovery after optimal pharmacologic therapies and early percutaneous coronary intervention in acute myocardial infarction (AMI). CMR has been shown to predict functional recovery after AMI. The relative predictive value of CMR viability indexes remains disputed and has not been described in AMI reperfused within the first 12 hours. Sixty-nine patients with a first reperfused (<12 hours) Thrombolysis In Myocardial Infarction grade 3 AMI (61 men, 57.6 +/- 12.6 years) were studied on day 5 +/- 2. Low-dose (10 microg/kg/min) dobutamine response (DOB), microvascular obstruction (MVO), relative delayed enhancement extent (DE), and transmural DE pattern (TMDE) were assessed in each of the 17 left ventricular segments. Segmental functional outcome was assessed by CMR at 3 months. Logistic regression and Bayesian probabilities evaluated the association between viability indexes and functional segmental outcome. At rest, 27% of segments (314 of 1,173) were dysfunctional of which 53% (165 of 314) recovered at follow-up. Odd ratios for dobutamine response, MVO, DE, and TMDE were 15.8, 5.9, 2.6, and 2.5 respectively. The probability of segmental recovery was 0.84 when dobutamine response was positive and increased successively to 0.91 when adding MVO absence, 0.94 when adding TMDE absence, and 0.97 when adding DE absence. In conclusion, contractile response to low-dose dobutamine is the best predictive factor of segmental recovery after Thrombolysis In Myocardial Infarction grade 3 early reperfused AMI. Its value is further increased by other CMR viability indexes.

Transient left ventricular non-apical ballooning syndrome: Diagnosis with multiple imaging modalities

a Service des soins intensifs cardiologiques, hopital cardiologique du Haut-Leveque, CHU de Bordeaux, Pessac, France b Service de cardiologie, hopital cardiologique du Haut-Leveque, universite Victor-Segalen Bordeaux-2, CHU de Bordeaux, Pessac, France c Unite d’imagerie thoracique et cardiovasculaire, service des soins intensifs cardiologiques, hopital cardiologique du Haut-Leveque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France

Peri-infarct ischaemia assessed by cardiovascular MRI: comparison with quantitative perfusion single photon emission CT imaging

OBJECTIVE To develop a new method for the cardiac MR (CMR) quantification of peri-infarct ischaemia using fused perfusion and delayed-enhanced images and to evaluate this method using quantitative single photon emission CT (SPECT) imaging as a reference. METHODS 40 patients presenting with peri-infarct ischaemia on a routine stress (99m)Tc-SPECT imaging were recruited. Within 8 days of the SPECT study, myocardial perfusion was evaluated using stress adenosine CMR. Using fused perfusion and delayed-enhanced images, peri-infarct ischaemia was quantified as the percentage of myocardium with stress-induced perfusion defect that was adjacent to and larger than a scar. This parameter was compared with both the percent myocardium ischaemia (SD%) and the ischaemic total perfusion deficit (TPD). The diagnostic performance of CMR in detection of significant coronary artery stenosis (of ≥70%) was also determined. RESULTS On SPECT imaging, in addition to peri-infarct ischaemia, reversible perfusion abnormalities were detected in a remote zone in seven patients. In the 33 patients presenting with only peri-infarct ischaemia, the agreement between CMR peri-infarct ischaemia and both SD% and ischaemic TPD was excellent [intraclass coefficient of correlation (ICC) = 0.969 and ICC = 0.877, respectively]. CMR-defined peri-infarct ischaemia for the detection of a significant coronary artery stenosis showed an areas under receiver-operating characteristic curve of 0.856 (95% confidence interval, 0.680-0.939). The best cut-off value was 8.1% and allowed a 72% sensitivity, 96% specificity, 60% negative predictive value and 97% positive predictive value. CONCLUSION This proof-of-concept study shows that CMR imaging has the potential as a test for quantification of peri-infarct ischaemia. ADVANCES IN KNOWLEDGE This study demonstrates the proof of concept of a commonly known intuitive idea, that is, evaluating the peri-infarct ischaemic burden by subtracting delayed enhancement from first-pass perfusion imaging on CMR.

Pericardial cystic lymphangioma

A 43-year-old woman was referred for acute chest pain. She had no relevant past medical history. Her electrocardiogram was normal. However, transthoracic echocardiography revealed an uncommon cystic pericardial effusion. Septations of variable thickness were observed in this multilocular mass ( Panel A , see Supplementary data online, Video S1 ). C-reactive protein raised to 82 mg/L. The patient was treated efficiently with aspirin and colchicine. Serological …

Unexpected Coexisting Myocardial Infarction Detected by Delayed Enhancement MRI

We report a case of an unexpected coexisting anterior myocardial infarction detected by delayed enhancement MRI in a 41-year-old man following a presentation with a first episode of chest pain during inferior acute myocardial infarction. This second necrotic area was not initially suspected because there were no ECG changes in the anterior leads and the left descending coronary artery did not present any significant stenoses on emergency coronary angiography. Unrecognised myocardial infarction may carry important prognostic implications. CMR is currently the best imaging technique to detect unexpected infarcts.

Value of phase-sensitive inversion recovery sequence to perform and analyse late gadolinium enhancement in cardiac amyloidosis.

MOTS CLÉS Amylose ; A 62-year-old man was referred with new onset right heart failure and polyneuropathy. Echocardiography demonstrated severe left ventricular (LV) hypertrophy, with an ejection fraction of 76%. The interventricular septal thickness was 20 mm. On cardiovascular magnetic resonance (CMR), short-axis dark-blood T2-weighted (Fig. 1A) and four chamber steady-state free precession (SSFP) cine (Fig. 1B) sequences showed concentric thickening of the left ventricle and bilateral pleural effusions (Supplemental material). Multi-TI inversion recovery sequence performed 8 min after gadolinium (Gd) injection showed nulling of the myocardium at TI = 160 ms, whereas nulling of the blood pool was observed at TI = 240 ms. Delayed enhancement CMR (DE-CMR) using

0430 : Predictors of long-term clinical outcomes in acute coronary syndrome treated with everolimus-eluting stent

Background Everolimus-eluting stent (EES) improves long-term prognosis in patients with acute coronary syndrome (ACS) and is currently recommended over bare metal stent (BMS) in this population. Nevertheless, predictors of long-term outcomes in ACS patients treated with EES have not been evaluated in routine practice. Methods We retrospectively included patients treated with EES for ACS between June 2012 and December 2013 in our institution. Baseline clinical, biological and procedural characteristics were collected and all patients completed at least one-year follow-up. The primary endpoint was defined as the composite of target-vessel revascularization (TVR), target-vessel myocardial infarction (MI), or cardiac death at one year. Results of 447 patients included, 67 patients (15.1%) reached the primary endpoint at one year. In a multivariate analysis using Cox regression model, cardiogenic shock (HR 6.74; 95% CI [5-18.6]; p Conclusion in ACS patients treated with EES, cardiogenic shock and baseline anemia were the most robust predictors of long-term adverse clinical outcomes. The author hereby declares no conflict of interest