Jean Marc Weinstein

Left anterior descending artery length in left and right coronary artery dominance

BackgroundCoronary stenosis of the left anterior descending artery (LAD) is respected by cardiologists because of its negative influence on morbidity and mortality. An important anatomical consideration is the length of the LAD. ObjectiveTo investigate the relationship between length of LAD and coronary dominance. DesignRetrospective comparison of 100 consecutive angiograms with left coronary dominance with 100 consecutive angiograms with right coronary dominance. The relationship between the length of the LAD and coronary dominance was analyzed. MethodsWe retrospectively compared 100 consecutive angiograms with left coronary dominance (the posterior descending artery being supplied by the circumflex artery) with 100 consecutive angiograms with right coronary dominance (the posterior descending artery being supplied by the right coronary artery). LADs were categorized into three types: type A, LAD terminating before the cardiac apex; type B, LAD reaching the apex but not supplying the inferoapical segment of the left ventricle; and type C, LAD wrapping around the apex and supplying the inferoapical segment. LAD typing was also analyzed in relation to gender. ResultsIt was found that the LAD wrapped around the apex in 87% of cases of left coronary dominance but only in 47% of patients with right coronary dominance, and that the long LADs were more frequently seen in women than in men, irrespective of coronary dominance. ConclusionsWe found that the LAD in left coronary dominance is usually long and wraps around the apex, and believe that angiographic interventions in such cases have important clinical significance.

Non-Invasive Lung IMPEDANCE-Guided Preemptive Treatment in Chronic Heart Failure Patients: A Randomized Controlled Trial (IMPEDANCE-HF Trial)

BACKGROUND Previous investigations have suggested that lung impedance (LI)-guided treatment reduces hospitalizations for acute heart failure (AHF). A single-blind 2-center trial was performed to evaluate this hypothesis (ClinicalTrials.gov-NCT01315223). METHODS The study population included 256 patients from 2 medical centers with chronic heart failure and left ventricular ejection fraction ≤35% in New York Heart Association class II-IV, who were admitted for AHF within 12 months before recruitment. Patients were randomized to a control group treated by clinical assessment and a monitored group whose therapy was also assisted by LI, and followed for at least 12 months. Noninvasive LI measurements were performed with a new high-sensitivity device. Patients, blinded to their assignment group, were scheduled for monthly visits in the outpatient clinics. The primary efficacy endpoint was AHF hospitalizations; the secondary endpoints were all-cause hospitalizations and mortality. RESULTS There were 67 vs 158 AHF hospitalizations during the first year (P < .001) and 211 vs 386 AHF hospitalizations (P < .001) during the entire follow-up among the monitored patients (48 ± 32 months) and control patients (39 ± 26 months, P = .01), respectively. During the follow-up, there were 42 and 59 deaths (hazard ratio 0.52, 95% confidence interval 0.35-0.78, P = .002) with 13 and 31 of them resulting from heart failure (hazard ratio 0.30, 95% confidence interval 0.15-0.58 P < .001) in the monitored and control groups, respectively. The incidence of noncardiovascular death was similar. CONCLUSION Our results seem to validate the concept that LI-guided preemptive treatment of chronic heart failure patients reduces hospitalizations for AHF as well as the incidence of heart failure, cardiovascular, and all-cause mortality.

ST Elevation in the Anterior Precordial Leads During Right Ventricular Infarction: Lessons Learned During Primary Coronary Angioplasty A Case Report

ST elevation in the anterior leads may be due to isolated right ventricular infarction associated with occlusion of a nondominant or codominant right coronary artery. The authors report a case of isolated right ventricular infarction from a dominant right coronary arterys proximal occlusion in the presence of collateral circulation provided by the left coronary artery. Extensive damage occurred owing to compromise of the collateral circulation during primary coronary angioplasty. This is an unusual angiographic pattern for isolated right ventricular infarction. The potential consequences of percutaneous interventions to collateral vessels is discussed.

Angiogenic Imbalance and Residual Myocardial Injury in Recovered Peripartum Cardiomyopathy PatientsCLINICAL PERSPECTIVE

Background—Recent studies suggest that angiogenic imbalance during pregnancy may lead to acute peripartum cardiomyopathy (PPCM). We propose that angiogenic imbalance and residual cardiac dysfunction may exist even after recovery from PPCM. Methods and Results—Twenty-nine women at least 12 months after presentation with PPCM, who exhibited recovery of left ventricular (LV) ejection fraction (≥50%), were included in the study (mean age 35±6 years, LV ejection fraction 61.0±3.9%). The number of circulating endothelial progenitor cells (EPCs) and plasma levels of proangiogenic vascular endothelial growth factor and of soluble vascular endothelial growth factor receptor Flt1 (sFlt1) were measured. All patients underwent comprehensive cardiac function assessment, including tissue Doppler imaging and 2-dimensional (2D) strain echocardiography. All measurements were compared with healthy controls. Patients with a history of PPCM have significantly higher sFlt1 concentrations (median [25th–75th percentile]; 149.57, [63.14–177.89] versus 20.29, [15.00–53.89] pg/mL, P<0.001) and significantly decreased vascular endothelial growth factor/sFlt1 ratio (P=0.012) compared with controls, with a trend toward lower concentration of circulating CD34+/KDR+ levels. In addition, patients with PPCM had lower early velocities E′ septal (9.9±2.1 versus 11.0±1.5 cm/s, P=0.02), with a significantly lower systolic velocity S′ septal (7.6±1.2 versus 8.5±1.2 cm/s, P=0.003) by tissue Doppler imaging. Significantly lower LV global longitudinal (−19.1±3.3 versus −22.7±2.2%, P<0.001) and apical circumferential 2D strain (−16.6±4.9 versus −21.2±7.9, P=0.02) were present in patients with PPCM compared with controls. Conclusions—Higher concentration of sFlt1 with concomitant decreased circulating endothelial progenitor cell levels along with inappropriate attenuated vascular endothelial growth factor levels may imply an angiogenic imbalance that exists even after recovery and may thus predispose to PPCM. In addition, tissue Doppler imaging and 2D strain were able to identify residual myocardial injury in post-PPCM women with apparent recovery of LV systolic function. Both angiogenic imbalance and residual myocardial injury may play an important role in the recurrence of LV dysfunction during subsequent pregnancies.

Evaluation of remote dielectric sensing (ReDS) technology-guided therapy for decreasing heart failure re-hospitalizations

OBJECTIVE We tested whether remote dielectric sensing (ReDS)-directed fluid management reduces readmissions in patients recently hospitalized for heart failure (HF). BACKGROUND Pulmonary congestion is the most common cause of worsening HF leading to hospitalization. Accurate remote monitoring of lung fluid volume may guide optimal treatment and prevent re-hospitalization. ReDS technology is a quantitative non-invasive method for measuring absolute lung fluid volume. METHODS Patients hospitalized for acute decompensated HF were enrolled during their index admission and followed at home for 90days post-discharge. Daily ReDS readings were obtained using a wearable vest, and were used as a guide to optimizing HF therapy, with a goal of maintaining normal lung fluid content. Comparisons of the number of HF hospitalizations during ReDS-guided HF therapy were made, both to the 90days prior to enrollment and to the 90days following discontinuation of ReDS monitoring. RESULTS Fifty patients were enrolled, discharged, and followed at home for 76.9±26.2days. Patients were 73.8±10.3years old, 40% had LVEF above 40%, and 38% were women. Compared to the pre- and post-ReDS periods, there were 87% and 79% reductions in the rate of HF hospitalizations, respectively, during ReDS-guided HF therapy. The hazard ratio between the ReDS and the pre-ReDS period was 0.07 (95% CI [0.01-0.54] p=0.01), and between the ReDS and the post-ReDS period was 0.11 (95% CI [0.014-0.88] p=0.037). CONCLUSIONS These findings suggest that ReDS-guided management has the potential to reduce HF readmissions in acute decompensated HF patients recently discharged from the hospital.

Low-pressure deployment of stents: short- and long-term outcome.

This study investigates a strategy of low‐pressure stenting with concomitant anti‐platelet treatment designed to prevent short‐ and long‐term events after stenting. Ninety consecutive patients who underwent percutaneous transluminal coronary angioplasty with stenting using low‐pressure stent deployment (mean 8.1 atmospheres) with concomitant anti‐platelet therapy based on ticlopidine and aspirin were followed. The 30‐day outcome revealed a stent thrombosis rate of 6.4%, while the 9‐month major clinical event rate was 8.6%. Low‐pressure stent deployment appears to confer added risk for acute or sub‐acute thrombosis even when aspirin and ticlopidine are used. Conversely, low‐pressure inflation is associated with excellent long‐term results.

Prediction of readmissions and mortality in patients with heart failure: lessons from the IMPEDANCE‐HF extended trial

Readmissions for heart failure (HF) are a major burden. We aimed to assess whether the extent of improvement in pulmonary fluid content (ΔPC) during HF hospitalization evaluated by lung impedance (LI), or indirectly by other clinical and laboratory parameters, predicts readmissions.

NON-INVASIVE LUNG IMPEDANCE-GUIDED PREEMPTIVE TREATMENT IN CHRONIC HEART FAILURE PATIENTS: A RANDOMIZED CONTROLLED TRIAL (IMPEDANCE-HF TRIAL)

Previous investigations have suggested that lung impedance (LI)-guided treatment reduces hospitalizations for acute heart failure (HF). A single-blind two-center trial was performed to evaluate this hypothesis. Study population included 256 patients from 2 medical centers with CHF and LVEF ≤35%