Jan J. Piek

Myocardial infarct heterogeneity assessment by late gadolinium enhancement cardiovascular magnetic resonance imaging shows predictive value for ventricular arrhythmia development after acute myocardial infarction

AIMSnThe aim of this study was to assess the association between the proportions of penumbra-visualized by late gadolinium enhanced cardiovascular magnetic resonance imaging (LGE-CMR)-after acute myocardial infarction (AMI) and the prevalence of ventricular tachycardia (VT).nnnMETHODSnOne-hundred and sixty-two AMI patients, successfully, treated by primary percutaneous coronary intervention (PCI) underwent LGE-CMR after a median of 3 days (3-4) and 24-h Holter monitoring after 1 month. With LGE-CMR, the total amount of enhanced myocardium was quantified and divided into an infarct core (>50% of maximal signal intensity) and penumbra (25-50% of maximal signal intensity). With Holter monitoring, the number of VTs (≥4 successive PVCs) per 24 h was measured.nnnRESULTSnThe mean total enhanced myocardium was 31 ± 11% of the left ventricular mass. The % penumbra accounted for 39 ± 11% of the total enhanced area. In 29 (18%) patients, Holter monitoring showed VT, with a median of 1 episode (1-3) in 24 h. A larger proportion of penumbra within the enhanced area increased the risk of VTs [OR: 1.06 (95% CI: 1.02-1.10), P = 0.003]. After multivariate logistic regression analysis, the presence of ventricular fibrillation before primary PCI [OR: 5.60 (95% CI: 1.54-20.29), P = 0.01] and the proportional amount of penumbra within the enhanced myocardium [OR: 1.06 (95% CI: 1.02-1.10), P = 0.04] were independently associated with VT on Holter monitoring.nnnCONCLUSIONnLarger proportions of penumbra in the subacute phase after AMI are associated with increased risk of developing VTs. Quantification of penumbra size may become a useful future tool for risk stratification and ultimately for the prevention of ventricular arrhythmias.

Evaluation of the Occupational Doses of Interventional Radiologists

The aim of the present study was to determine whether there is a linear relation between the doses measured above and those measured under the lead apron of the radiologists performing interventional procedures. To monitor radiation exposure the International Commission of Radiological Protection (ICRP) recommends the use of a single dosimeter under the protective apron. To determine the exposure more accurately an additional dosimeter is recommended above the protective apron. The exposure of eight radiologists was monitored with two personal dosimeters during 3 consecutive years. To measure the doses uniformly the two dosimeters were worn in a special holder attached to the lead apron. The two personal dosimeters were replaced every 4xa0weeks on the same day. The doses above and under the protective aprons of seven radiologists did not differ significantly. A significant lower dose above and under the protective apron was measured for one of the radiologists. During a 4-week period the average dose measured above the lead apron was 3.44xa0mSv (median, 3.05xa0mSv), while that under the 0.25-mm lead apron was 0.12xa0mSv (median, 0.1xa0mSv). The coefficients of the regression line result in the equation Yxa0=xa00.036X − 0.004, with Y as the dose under the lead apron and X as the dose above the lead apron. The statistical analysis of the data established a linear relation between the doses above and those under the lead apron (R2xa0=xa00.59). Before the special holder was introduced it was not possible to derive a relation between the doses above and those under the lead apron, as the doses were measured at varying places above and under the lead apron. There is no evidence that the effective dose can be estimated more accurately when an additional dosimeter is used. The present study revealed a threshold before doses under the lead apron were measured. Due to the threshold it can be concluded that the doses under the lead apron will not be underestimated easily when doses above the lead apron are used to calculate them. This is not the case when the doses above the lead apron are calculated for the doses under the lead apron.

Prognostic value of myocardial perfusion scintigraphy in type 2 diabetic patients with mild, stable angina pectoris

AimTo determine the prognostic value of reversible myocardial perfusion defects on myocardial perfusion scintigraphy (MPS) in patients with type 2 diabetes mellitus and mild anginal complaints.Methods and resultsIn the MERIDIAN trial, patients with diabetes mellitus type 2, stable, mild anginal symptoms (Canadian Cardiovascular Society classification (CCS) I-II/IV) and reversible perfusion defects were randomized to either continued pharmacological treatment or early invasive treatment. In this sub analysis, the severity of the myocardial perfusion defect was related to the occurrence of cardiac death and non-fatal myocardial infarction, in 319 patients (63% male, 65xa0±xa09xa0years). During follow-up (2.2xa0±xa00.6xa0years), 14 patients had a cardiac event: 3 in 171 patients without myocardial ischemia and 11 in 148 patients with myocardial ischemia. Annual event rates rose from 0.8% to 5.8% with increasing severity of myocardial ischemia. Multivariable analysis identified the presence of severe myocardial ischemia (hazard ratio (HR) 5.45, 95%CI 1.89-15.71) and insulin use (HR 4.00, 95%CI 1.25-12.75) as independent predictors of cardiac events.ConclusionsType 2 diabetics with mild anginal symptoms with no or moderate myocardial ischemia have a low annual cardiac event rate. In patients with severe myocardial ischemia event rate increased 3-6 fold.

3.0 T cardiovascular magnetic resonance in patients treated with coronary stenting for myocardial infarction: evaluation of short term safety and image quality

Purpose To evaluate safety and image quality of cardiovascular magnetic resonance (CMR) at 3.0xa0T in patients with coronary stents after myocardial infarction (MI), in comparison to the clinical standard at 1.5xa0T. Methods Twenty-five patients (21 men; 55xa0±xa09xa0years) with first MI treated with primary stenting, underwent 18 scans at 3.0xa0T and 18 scans at 1.5xa0T. Twenty-four scans were performed 4xa0±xa02xa0days and 12 scans 125xa0±xa023xa0days after MI. Cine (steady-state free precession) and late gadolinium-enhanced (LGE, segmented inversion-recovery gradient echo) images were acquired. Patient safety and image artifacts were evaluated, and in 16 patients stent position was assessed during repeat catheterization. Additionally, image quality was scored from 1 (poor quality) to 4 (excellent quality). Results There were no clinical events within 30xa0days of CMR at 3.0xa0T or 1.5xa0T, and no stent migration occurred. At 3.0xa0T, image quality of cine studies was clinically useful in all, but not sufficient for quantitative analysis in 44% of the scans, due to stent (6/18 scans), flow (7/18 scans) and/or dark band artifacts (8/18 scans). Image quality of LGE images at 3.0xa0T was not sufficient for quantitative analysis in 53%, and not clinically useful in 12%. At 1.5 T, all cine and LGE images were quantitatively analyzable. Conclusion 3.0xa0T is safe in the acute and chronic phase after MI treated with primary stenting. Although cine imaging at 3.0xa0T is suitable for clinical use, quantitative analysis and LGE imaging is less reliable than at 1.5xa0T. Further optimization of pulse sequences at 3.0xa0T is essential.

Intracoronary infusion of mononuclear cells after PCI-treated myocardial infarction and arrhythmogenesis: is it safe?

To reduce long-term morbidity after revascularised acute myocardial infarction, different therapeutic strategies have been investigated. Cell therapy with mononuclear cells from bone marrow (BMMC) or peripheral blood (PBMC) has been proposed to attenuate the adverse processes of remodelling and subsequent heart failure. Previous trials have suggested that cell therapy may facilitate arrhythmogenesis. In the present substudy of the HEBE cell therapy trial, we investigated whether intracoronary cell therapy alters the prevalence of ventricular arrhythmias after 1xa0month or the rate of severe arrhythmogenic events (SAE) in the first year. In 164 patients of the trial we measured function and infarct size with cardiovascular magnetic resonance (CMR) imaging. Holter registration was performed after 1xa0month from which the number of triplets (3 successive PVCs) and ventricular tachycardias (VT, ≥4 successive PVCs) was assessed. Thirty-three patients (20%) showed triplets and/or VTs, with similar distribution amongst the groups (triplets: control nu2009=u20098 vs. BMMC nu2009=u20099, pu2009=u20091.00; vs. PBMC nu2009=u200910, pu2009=u20090.67. VT: control nu2009=u20099 vs. BMMC nu2009=u20099, pu2009=u20090.80; vs. PBMC nu2009=u200911, pu2009=u20090.69). SAE occurred in 2 patients in the PBMC group and 1 patient in the control group. In conclusion, intracoronary cell therapy is not associated with an increase in ventricular arrhythmias or SAE.

Early recognition of sudden cardiac arrest in athletes during sports activity

IntroductionSudden cardiac arrest (SCA) in athletes is an unexpected life-threatening event, which is often not recognised early and cardiopulmonary resuscitation (CPR) is not always initiated immediately. We describe key features to rapidly recognise non-traumatic SCA in athletes during sports activity.MethodsWe reviewed videos and images of athletes suffering from non-traumatic SCA during sports activity. We searched Google images, Google videos and YouTube.com using the keywords ‘sudden cardiac death athlete’ and ‘resuscitation athlete’. We analysed (1)xa0the athlete’s performance before syncope, (2)xa0the athlete’s performance at the start of syncope, (3)xa0the position of the body, and (4)xa0the athlete’s facial expressions before CPR. We analysed our data by describing these four features to answer our research question.ResultsWe analysed the sequence of events in six well-known soccer players in whom axa0camera-witnessed non-traumatic SCA occurred during their athletic activity. All six athletes showed no changes before syncope. Four became unstable while standing and unexpectedly collapsed falling on their back. Two suddenly ‘dropped dead’ and fell face down. All six had their eyes wide open with axa0fixed gaze and fixed pupils.ConclusionsSudden unexpected loss of consciousness in an athlete in action and axa0fixed gaze eye position are key features of SCA. Immediate cardiac massage should follow. The described features to immediately recognise SCA in athletes during sports activity should be taught to everyone involved in athletic activity leading to earlier recognition of SCA followed by earlier CPR.

Prevalence of myocardial ischaemia as assessed with myocardial perfusion scintigraphy in patients with diabetes mellitus type 2 and mild anginal symptoms

PurposeTo determine the prevalence and predictors of reversible myocardial perfusion defects, indicative of myocardial ischaemia, in patients with mild, stable anginal complaints [Canadian Cardiovascular Society classification (CCS) I–II/IV] and diabetes mellitus type 2 (T2DM).MethodsA total of 329 patients with T2DM and stable, mild anginal symptoms (CCS I–II/IV) underwent myocardial perfusion scintigraphy. Perfusion images were assessed using a five-point (semi)-quantitative scoring system according to a 17-segment myocardial model.ResultsOne-hundred and fifty-six (47%) patients showed reversible myocardial perfusion defects defined as a summed difference score of ≥3. Male gender [odds ratio (OR) 2.28, 95% CI 1.4–3.71, p=0.001], previous myocardial infarction (MI) without revascularisation (OR 3.04, 95% CI 1.28–7.24, p=0.01), and the use of two or more classes of anti-anginal medication (OR 2.36, 95% CI 1.48–3.76, p<0.001) were independent predictors for the presence of reversible defects. By contrast, lipid-lowering therapy reduced the possibility of reversible perfusion defects (OR 0.56, 95% CI 0.33–0.95, p=0.03).ConclusionApproximately half of the patients with mild, stable angina pectoris and T2DM showed evidence of myocardial ischaemia. Male gender, previous MI and the use of anti-anginal medication were positive predictors and lipid-lowering therapy was a negative predictor for the results of the scintigraphic stress test.

Guideline-defined futility or patient-reported outcomes to assess treatment success after TAVI: what to use? Results from a prospective cohort study with long-term follow-up

Objective Transcatheter aortic valve implantation (TAVI) provides a significant symptom relief and mortality reduction in most patients; however, a substantial group of patients does not experience the same beneficial results according to physician-determined outcomes. Methods Single-centre prospective design; the population comprises all consecutive patients undergoing TAVI in 2012–2017. TAVI futility was defined as the combined endpoint of either no symptomatic improvement or mortality at 1u2009year. We actively gathered telephone follow-up using a predefined questionnaire. Results Guideline defined TAVI futility was present in 212/741 patients. Multivariate regression showed lower albumin and non-transfemoral approach to be predictive for futility. In addition to these, chronic obstructive pulmonary disease, lower estimated glomerular filtration rate, atrial fibrillation, low-flow–low-gradient aortic stenosis and lower Body Mass Index were predictive for 1-year mortality. Patients who showed symptomatic benefit estimated the percentage in which their symptoms were remedied higher than patients who did not (80% vs 60%, p<0.001). Guideline-defined TAVI futility occurs frequently, contrasting with patient-reported outcome measures (PROMs). The vast majority in both groups would again choose for TAVI treatment. Conclusion Lower albumin and non-transfemoral access route were predictors for guideline-defined TAVI futility, defined as mortality within 1u2009year or no objective symptomatic improvement in New York Heart Association class. Futility according to this definition occurred frequently in this study, contrasting with much more positive PROMs. The majority of patients would undergo a TAVI again, underlining the patients’ experienced value of TAVI and putting the definition of TAVI futility further on debate. In the near future, less-strict criteria for TAVI futility, that is, using a shorter warranted life expectancy and incorporating patients’ perceived outcomes, should be used.

Premedication to reduce anxiety in patients undergoing coronary angiography and percutaneous coronary intervention

Aims In this study, we examined the effects of the routinely administration of benzodiazepines on reducing periprocedural anxiety versus no premedication. Methods In this open label study, we enrolled 1683 patients undergoing diagnostic coronary angiograms (CAG) or percutaneous coronary interventions (PCI). Randomisation was simulated by systematically allocating patients in monthly rotational periods to lorazepam 1 u2009mg/sl, oxazepam 10 u2009mg/po, diazepam 5 u2009mg/po, midazolam 7.5 u2009mg/po or no premedication. Anxiety was measured at four different time points using the one-item Visual Analogue Scale for Anxiety (VAS score) ranging from 0 to 10. The primary outcome was the difference in anxiety reduction (ΔVAS, preprocedure to postprocedure), between the different premedication strategies versus no premedication. Results Anxiety reduction was larger in patients premedicated with lorazepam (ΔVAS=−2.0, SE=1.6, P=0.007) or diazepam (ΔVAS=−2.0, SE=1.5, p=0.003) compared with patients without any premedication (ΔVAS=−1.4, SE=1.2). The use of midazolam or oxazepam did not lead to a significant reduction in anxiety compared with patients who did not receive premedication. Additionally, a high number of patients treated with midazolam (N=39, 19.8%) developed side effects. Conclusions In this study, the use of lorazepam or diazepam was associated with a significant, but modest anxiety reduction in patients undergoing CAG or PCI. This study does not support the standard use of oxazepam or midazolam as premedication to reduce anxiety.

Reply to the letter from A. Zorzi and D. Corrado. Rhythm analysis with an AED in an unconscious athlete

We thank our colleagues Zorzi and Corrado for their comments on the problem of delayed on-site cardiopulmonary resuscitation and defibrillation with an AED when the athlete loses his/her consciousness during exercise [1, 2]. Those problems are well illustrated in their video from episodes of sudden cardiac arrest (SCA) in 22 athletes. They correctly stress the confusion created when agonal breathing and limb movements may mistakenly be interpreted that the person is still alive [1]. We agree with Zorzi and Corrado that the immediate use of an AED would allow recognition of a cardiac cause of unconsciousness, i. e. ventricular tachycardia or fibrillation or asystole [1]. Indeed, immediate cardiac massage and rhythm analysis with an AED should be performed as soon as possible in an unexpected unconscious athlete.