Farqad Alamgir

Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction

Objective: To assess the prognostic value of various conventional and novel echocardiographic indices in patients with chronic heart failure (CHF) caused by left ventricular (LV) systolic dysfunction. Methods: 185 patients with a mean (SD) age of 67 (11) years with CHF and LV ejection fraction < 45% despite optimal pharmacological treatment were prospectively enrolled. The patients underwent two dimensional echocardiography with tissue harmonic imaging to assess global LV systolic function and obtain volumetric data. Transmitral flow was assessed with conventional pulse wave Doppler. Systolic (Sm), early, and late diastolic mitral annular velocities were measured with the use of colour coded Doppler tissue imaging. Results: During a median follow up of 32 months (range 24–38 months in survivors), 34 patients died and one underwent heart transplantation. Sm velocity (hazard ratio (HR) 0.648, 95% confidence interval (CI) 0.463 to 0.907, p  =  0.011), diastolic arterial pressure (HR 0.965, 95% CI 0.938 to 0.993, p  =  0.015), serum creatinine (HR 1.006, 95% CI 1.001 to 1.011, p  =  0.023), LV ejection fraction (HR 0.945, 95% CI 0.899 to 0.992, p  =  0.024), age (HR 1.035, 95% CI 1.000 to 1.071, p  =  0.052), LV end systolic volume index (HR 1.009, 95% CI 0.999 to 1.019, p  =  0.067), and restrictive pattern of transmitral flow (HR 0.543, 95% CI 0.278 to 1.061, p  =  0.074) predicted the outcome of death or transplantation on univariate analysis. On multivariate analysis, only Sm velocity (HR 0.648, 95% CI 0.460 to 0.912, p  =  0.013) and diastolic arterial pressure (HR 0.966, 95% CI 0.938 to 0.994, p  =  0.016) emerged as independent predictors of outcome. Conclusions: In patients with CHF and LV systolic dysfunction despite optimal pharmacological treatment, the strongest independent echocardiographic predictor of prognosis was Sm velocity measured with quantitative colour coded Doppler tissue imaging.

The timing of development and subsequent clinical course of heart failure after a myocardial infarction

AIMS Myocardial infarction (MI) is a common cause of heart failure (HF), which may develop early and persist or resolve, or develop late. The cumulative incidence, persistence, and resolution of HF after MI are poorly described. The aim of this study is to describe the natural history and prognosis of HF after an MI. METHODS AND RESULTS Patients with a death or discharge diagnosis of MI in 1998 were identified from records of hospitals providing services to a local community of 600 000 people. Records were scrutinized to identify the development of HF, defined as signs and symptoms consistent with that diagnosis and treated with loop diuretics. HF was considered to have resolved if diuretics could be stopped without recurrent symptoms. Totally, 896 patients were identified of whom 54% had died by December 2005. During the index admission, 199 (22.2%) patients died, many with HF, and a further 182 (20.3%) patients developed HF that persisted until discharge, of whom 121 died subsequent to discharge. Of 74 patients with transient HF that resolved before discharge, 41 had recurrent HF and 38 died during follow-up. After discharge, 145 (33%) patients developed HF for the first time, of whom 76 died during follow-up. Overall, of 281 deaths occurring after discharge, 235 (83.6%) were amongst inpatients who first developed HF. CONCLUSION The development of HF precedes death in most patients who die in the short- or long-term following an MI. Prevention of HF, predominantly by reducing the extent of myocardial damage and recurrent MI, and subsequent management could have a substantial impact on prognosis.

Relationship between right ventricular volumes measured by cardiac magnetic resonance imaging and prognosis in patients with chronic heart failure.

The aim of this study was to investigate the prognostic impact of right ventricular (RV) size in patients with chronic heart failure.

Endeavour zotarolimus-eluting stent reduces stent thrombosis and improves clinical outcomes compared with cypher sirolimus-eluting stent: 4-year results of the PROTECT randomized trial

AIMS To compare the long-term clinical safety between two drug-eluting stents with different healing characteristics in the Patient Related Outcomes with Endeavour (E-ZES) vs. Cypher (C-SES) Stenting Trial (PROTECT). At 3 years, there was no difference in the primary outcome of definite or probable stent thrombosis or in the other main secondary clinical outcomes consisting of the composite of death or myocardial infarction (MI). Prespecified 4-year clinical follow-up was analysed. METHODS AND RESULTS Patient Related OuTcomes with Endeavour vs. Cypher Stenting Trial was a prospective, open-label randomized-controlled superiority trial powered to look at differences in long-term clinical safety, including stent thrombosis. Dual antiplatelet therapy (DAPT) was prescribed for ≥ 3 months and up to 12 months based on current guidelines. Patient Related OuTcomes with Endeavour vs. Cypher Stenting Trial enrolled 8791 patients undergoing elective or emergency PCI to E-ZES or C-SES. There was no difference in DAPT usage between the two groups up to 4 years. At 4-year follow-up, the primary outcome occurred in 1.6% of E-ZES vs. 2.6% of C-SES patients [HR 0.63 (95% CI 0.46-0.85), P = 0.003]. The composite of all-cause death or large MI occurred in 6.7% of E-ZES vs. 8.0% of C-SES-treated patients [HR 0.84 (95% CI 0.71-0.98), P = 0.024]. CONCLUSIONS Drug-eluting coronary stents with different healing characteristics demonstrated different late safety profiles: after 4 years, compared with C-SES, E-ZES reduced the risk of stent thrombosis and the risk of the composite endpoints of death or MI. Appropriately powered large-scale trials with long-term follow-up are critical to determine clinical safety and efficacy of permanently implanted coronary stents. This trial is registered with ClinicalTrials.gov, number NCT00476957.

Fusion of optical coherence tomography and coronary angiography — In vivo assessment of shear stress in plaque rupture

Advancements in cardiovascular imaging [e.g. computed tomo-graphic coronary angiography (CTCA)] and new developments inimage processing [e.g. fusion of intravascular ultrasound (IVUS) withangiographic data, fusion of IVUS with CTCA] permitted complete andcomprehensive three dimensional (3D) reconstruction of coronaryarteries and allowed us to study in-vivo the role of blood flowdynamics in the atherosclerotic process. Over the last years severalstudies used 3D reconstruction techniques to demonstrate that localhemodynamics are involved in the atherosclerotic evolution andaffect the composition of the plaque [1]. However, indigenouslimitations of the implemented imaging techniques (mainly theincreasednoise and the reduced resolution)have not allowed reliableidentification of the vulnerable/ruptured plaques and thus the effectofthebloodflowonplaquedestabilizationandruptureisstillunclear.In this report we fused optical coherence tomography (OCT) withcoronary angiographic data, in order to identify the location of plaquerupture and so to examine the association between flow hemody-namics and plaque rupture.A 55 year old patient with a medical history of hypertension whosustained an acute inferior myocardial infarction and treatedsuccessfully with thrombolysis was subsequently transferred to ourhospital, within 24 h from the event, to undergo coronary angiogra-phy.Thisdemonstratedanormalleftcoronarysystemandahazynon-flow limiting lesion in the distal right coronary artery (RCA) (Fig. 1A).To study in more detail the morphology of the culprit lesion, OCTexamination was performed with a M3CV OCT system (LightLabImaging Inc., Westford, MA, USA). Before OCT interrogation, thesystemwasconnectedwithaviewermixerthatallowedsimultaneousvisualizationof theelectrocardiogramandthe OCTsequence.TheOCTcatheter was advanced in the RCA distal to the culprit lesion, and cineangiographic images from two different views were obtained duringdiluted contrast agent injection. Then, the OCT catheter waswithdrawn, under saline purge through the guiding catheter, withthe use of an automated pull-back device (pull-back speed: 3 mm/s;15 frames/s). Three consecutive pull-backs were performed in orderto examine a 45-mm segment. From the obtained sequences, theframes that corresponded to the end-diastolic phase of the cardiaccircle (peak of R wave on electrocardiogram) were selected and anexpert observer identified the ruptured plaque (Fig. 1B), andextracted manually the luminal borders. At the site of rupture, twotracings of the luminal borders were performed: one along theresidualintimalflaprepresentingthetruelumenwithplaquerupture,and the other by extrapolation along the plaque cavity representingthe lumen before plaque rupture [2]. Fusion of the OCT with theangiographic data was performed to reconstruct the luminal surface(Fig. 1C) by adapting our previously described methodology devel-oped for the fusion of IVUS and angiography [3]. In brief, anatomicalmarkers seen in both angiographic and OCT images were used toidentify the proximal and the distal end of the pull-back. Then, thecatheter path was extracted from two end-diastolic angiographicimages, the OCT borders were placed perpendicularly onto the 3Dpath and their absolute orientationwas determined. A good matchingwas achieved between the projections of the 3D model with theruptured plaque onto the angiographic images and the luminalsilhouette (Fig. 1D and E).Inthe3Dmodelrepresentingthelumenbeforeplaquerupture,thelocal shear stress distribution was calculated by computational fluiddynamics (Fig. 1F) [4]. Plaque rupture was located on the outercurvature of the vessel where the velocity profile was skewed leadingto locally elevated shear stress (Fig. 1G and H).

Clinical Indications for Intravascular Ultrasound Imaging

Intravascular ultrasound (IVUS) is a catheter‐based imaging modality, which provides high resolution cross‐sectional images of the coronary arteries. Unlike angiography, which displays only the opacified luminal silhouette, IVUS permits imaging of both the lumen and vessel wall and allows characterization of the type of the plaque. Although IVUS provides accurate quantitative and qualitative information regarding the lumen and outer vessel wall, it is not routinely used during coronary angiography or in angioplasty procedures because the risk to benefit ratio (additional expense, procedural time, certain degree of risk, and complication versus improvement in the outcome) does not justify routine utilization. Nevertheless, there are situations where IVUS is extremely useful tool both for diagnosis and management so the aim of this review is to summarize the indications for IVUS imaging in the contemporary clinical practice. (Echocardiography 2010;27:1282‐1290)

Renal artery stenosis: an innocent bystander or an independent predictor of worse outcome in patients with chronic heart failure? A magnetic resonance imaging study.

To investigate the prognostic impact of atherosclerotic renovascular disease in patients with chronic heart failure.

Carcinoid syndrome diagnosed by echocardiography

Right heart failure is a common presentation to both general physicians and cardiologists. Echocardiography is a useful investigation, and usually imaging of the liver is confined to helping estimate the right atrial pressure. We report a case of right heart failure where incidental imaging of the liver architecture during transoesophageal echocardiography helped in establishing the final diagnosis.

Catheter-based intervention for symptomatic patient with severe mitral regurgitation and very poor left ventricular systolic function - Safe but no room for complacency.

Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation (MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous MitraClip(®) can be used safely to reduce the severity of MR even in patients with advanced heart failure and is associated with improved symptoms, quality of life and exercise tolerance. However, a few patients with very poor left ventricular systolic function may experience significant haemodynamic disturbance in the peri-procedural period. We present three such patients, highlighting some of the potential problems encountered and discuss their possible pathophysiological mechanisms and safety measures.