Ivan Ilic

Myocardial fibrosis severity on cardiac magnetic resonance imaging predicts sustained arrhythmic events in hypertrophic cardiomyopathy.

BACKGROUND The purpose of our study was to correlate the incidence of adequate implantable cardioverter-defibrillator (ICD) interventions in hypertrophic cardiomyopathy (HCM) patients with risk markers (RMs) for sudden cardiac death (SCD) plus myocardial fibrosis as detected by late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) imaging. METHODS In all, 87 patients with HCM underwent LGE-CMR imaging prior to ICD implantation, performed for secondary (n = 2; 2%) or primary SCD prophylaxis (n = 85; 98%). Fibrosis was graded with a 17-segment left ventricular model (0 = absent, 1 = point-shaped, 2 = limited to 1 left ventricular segment, 3 = involving ≥ 2 segments). During follow-up, ICD memories were read out by a physician blinded to the individual patient data. RESULTS The number of RMs per patient was 1.9 ± 0.8. Myocardial fibrosis was present in 78 patients (90%); 26 (30%) had a fibrosis score of 3. During follow-up (3.5 ± 2.6 [range, 0.2-11.4 years]), 15 patients had 50 appropriate ICD interventions. Episodes of atrial fibrillation were found in 28 patients. Fibrosis severity correlated with occurrence of ventricular tachycardia (Cramérs V, or φc = 0.4, P < 0.001) and atrial fibrillation (φc = 0.6, P < 0.001). On multivariate regression analysis, an independent association between myocardial fibrosis (ß = 0.6, P < 0.01) and sustained ventricular tachycardia was found. CONCLUSIONS In HCM patients treated with ICD implantation because of a high SCD risk by traditional RM assessment, a high rate of arrhythmic events was observed during long-term follow-up. In a cohort of patients with clinical markers for high risk of SCD, severity of myocardial fibrosis as detected by an easy LGE-CMR scoring system was associated with future arrhythmic events and appropriate ICD therapies.

Myocardial mechanical and QTc dispersion for the detection of significant coronary artery disease

AIMS Ischaemic but viable myocardium may exhibit prolongation of contraction and QT interval duration, but it is largely unknown whether non-invasive assessment of regional heterogeneities of myocardial deformation and QT interval duration could identify patients with significant coronary artery disease (CAD). METHODS AND RESULTS We retrospectively studied 205 patients with suspected CAD who underwent coronary angiography. QTc dispersion was assessed from a 12-lead electrocardiogram (ECG) as the difference between the longest and shortest QTc intervals. Contraction duration was assessed as time from the ECG R-(Q-)wave to peak longitudinal strain in each of 18 left ventricular segments. Mechanical dispersion was defined as either the standard deviation of 18 time intervals (dispersionSD18) or as the difference between the longest and shortest time intervals (dispersiondelta). Longitudinal strain was measured by speckle tracking echocardiography. Mean contraction duration was longer in patients with significant CAD compared with control subjects (428 ± 51 vs. 410 ± 40 ms; P = 0.032), and it was correlated to QTc interval duration (r = 0.47; P < 0.001). In contrast to QTc interval duration and dispersion, both parameters of mechanical dispersion were independently associated with CAD (P < 0.001) and had incremental value over traditional risk factors, wall motion abnormalities, and global longitudinal strain (GLS) for the detection of significant CAD. CONCLUSION The QTc interval and myocardial contraction duration are related to the presence of significant CAD in patients without a history of previous myocardial infarction. Myocardial mechanical dispersion has an incremental value to GLS for identifying patients with significant CAD.

Effect of myocardial revascularisation on left ventricular systolic function in patients with and without viable myocardium: should non-viable segments be revascularised?

Objective To assess the effect of surgical revascularisation on left ventricular (LV) systolic function in patients with viable and non-viable dysfunctional LV segments determined by low dose dobutamine stress echocardiography (DSE). Design Prospective observational cohort study. Setting Single tertiary care centre. Patients Consecutive patients referred to surgical revascularisation (n=115). Interventions DSE and surgical revascularisation. Main outcome measures Functional recovery defined as increase in ejection fraction ≥5% 1 year after revascularisation in patients with and without viable myocardium (viability defined as improvement of contractility in ≥4 LV segments on DSE). Results The mean age, ejection fraction and wall motion score index (WMSi) of patients were 59±9 years, 44±9% and 1.82±0.31, respectively. There was no difference between DSE positive and DSE negative patients for any of those parameters at baseline study (p>0.05 for all). After 12 months, the ejection fraction increased 11±1% in patients with viable myocardium vs 7±1% in patients without viable myocardium (p=0.002). Moreover, in patients with viable myocardium, the greatest increase of ejection fraction occurred 1 month after surgery (9±1%), whereas in those patients with negative DSE the ejection fraction increased more gradually (2±1% after 1 month, p=0.002 between groups for 1 month vs preoperative value), but still improved after 12 months follow-up (p<0.0001 in time for both groups). Conclusions It appears that patients with LV dysfunction, but without viable myocardium, may also benefit from myocardial revascularisation. Functional recovery continuously occurs throughout the first year after surgical treatment.

Aborted Myocardial Infarction in a Patient with Rapid Progression of Wellens Syndrome

BACKGROUND Wellens syndrome refers to a distinct electrocardiographic pattern of deeply inverted or biphasic T waves in the anterior precordial leads, in the presence of critical proximal stenosis of the left anterior descending coronary artery (LAD). The natural history of the syndrome is an extensive myocardial infarction within weeks of hospital admission. CASE REPORT This report describes a 63-year-old man in whom typical electrocardiographic signs of Wellens syndrome advanced to persistent ST-segment elevation within 7min of presentation. Extensive anterior myocardial infarction (AMI) was aborted by primary percutaneous coronary intervention of a sub-occluded proximal LAD. CONCLUSION Given the large area of the left ventricle supplied by a sub-occluded LAD, devastating AMI could have been expected and may have resulted in serious ventricular dysfunction and death. Therefore, early recognition of Wellens syndrome is essential and can be lifesaving.

Reduced sirolimus systemic exposure and improved bioresorbable polymer properties: new allies for the treatment of patients with coronary artery disease.

This prospective, first‐in‐man, open‐label multicenter study sought to assess the pharmacokinetics of sirolimus after Ultimaster drug‐eluting stent implantation (coated with sirolimus and bioabsorbable co‐polymer) in patients with de novo coronary artery disease (the TCD‐10023 PK study). The primary endpoint was sirolimus concentration in peripheral whole blood at 28 days after stent implantation. In addition, safety, tolerability, therapeutic outcome and vasomotor response after stent implantation were studied. Twenty patients were enrolled in the study. Blood samples for the measurements of sirolimus concentration were collected at eight time points during first 48 h, at 7 days and 28 days after stent implantation. Patients underwent 6‐month angiographic and up to 12 months clinical follow‐up. At 28 days, only two of 20 patients had sirolimus concentrations above lower limit of quantification (20.0 pg/mL). The highest sirolimus blood concentration was 105 pg/mL. The median maximum concentration was 36.8 pg/mL (range 22.9–41.5 pg/mL) for stent 3.0 × 15 mm and 87.2 pg/mL (range 60.0–105.0 pg/mL) for 3 × 28 mm stent. The median systemic exposure, as measured by the area under the time–concentration curve, was 8.3 ng h/mL (range 6.47–28.0 ng h/mL). At 6 months, endothelial function was well preserved, and up to 12 months, there were no signs of sirolimus toxicity nor any other safety concerns. Our results demonstrate that implantation of Ultimaster stent resulted in almost nondetectable sirolimus in blood after 28 days. These findings were translated into exceptional safety profile, without any sign of systemic toxicity.

Echocardiographic predictors of outcome in patients with chronic obstructive pulmonary disease

We aimed to assess the relationship between echocardiographic characteristics and mortality in patients with chronic obstructive pulmonary disease (COPD).

T-wave changes in patients with Wellens syndrome are associated with increased myocardial mechanical and electrical dispersion

Some patients with unstable angina and critical stenosis of the left anterior descending coronary artery (LAD) present with Wellens syndrome (WS), i.e., inverted or biphasic T-waves in the anterior precordial leads. We assessed clinical, angiographic, electro- and echocardiographic characteristic of patients with WS. In this retrospective study, clinical, angiographic, electro- and echocardiographic characteristic of 35 patients with WS were compared to 57 patients with critical LAD stenosis and normal resting electrocardiogram (ECG), and 45 subjects with normal coronary angiogram. QTc dispersion was measured from the 12-lead ECG as the difference between longest and shortest QTc intervals. Mechanical dispersion was defined as the time difference between the longest and shortest contraction durations which were measured as the time from the first deflection of the QRS complex to maximum myocardial shortening of each 18 segmental longitudinal strain curves derived by speckle tracking echocardiography. There were no significant differences in the complexity and location of the LAD lesion, anterograde and collateral flow in LAD and coronary artery dominance between patients with WS and normal ECG (P > 0.05, for all). Patients with WS had lower global longitudinal strain (GLS) and more pronounced both QTc and myocardial mechanical dispersion than patients with critical LAD stenosis and normal ECG, and control subjects (P < 0.05). T-wave changes in patients with WS are associated with more profound regional myocardial dysfunction and increased QTc and myocardial mechanical dispersion. Similar angiographic characteristics of the LAD lesion were seen in patients with WS and normal ECG.

Favorable outcomes in octogenarians treated with bioresorbable polymer drug‐eluting stent

As a result of a higher prevalence of comorbidities, elderly adults are often underrepresented in clinical trials, and more often experience complications during percutaneous coronary intervention. Our aim was to evaluate clinical outcomes of patients older than 80 years, compared with their younger counterparts, when bioresorbable polymer biolimus A9 drug‐eluting stent is used for their treatment.