Jindra Vainer

Percutaneous Mitral Annuloplasty for Functional Mitral Regurgitation: Results of the CARILLON Mitral Annuloplasty Device European Union Study

Background— Functional mitral regurgitation (FMR), a well-recognized component of left ventricular remodeling, is associated with increased morbidity and mortality in heart failure patients. Percutaneous mitral annuloplasty has the potential to serve as a therapeutic adjunct to standard medical care. Methods and Results— Patients with dilated cardiomyopathy, moderate to severe FMR, an ejection fraction <40%, and a 6-minute walk distance between 150 and 450 m were enrolled in the CARILLON Mitral Annuloplasty Device European Union Study (AMADEUS). Percutaneous mitral annuloplasty was achieved through the coronary sinus with the CARILLON Mitral Contour System. Echocardiographic FMR grade, exercise tolerance, New York Heart Association class, and quality of life were assessed at baseline and 1 and 6 months. Of the 48 patients enrolled in the trial, 30 received the CARILLON device. Eighteen patients did not receive a device because of access issues, insufficient acute FMR reduction, or coronary artery compromise. The major adverse event rate was 13% at 30 days. At 6 months, the degree of FMR reduction among 5 different quantitative echocardiographic measures ranged from 22% to 32%. Six-minute walk distance improved from 307±87 m at baseline to 403±137 m at 6 months (P<0.001). Quality of life, measured by the Kansas City Cardiomyopathy Questionnaire, improved from 47±16 points at baseline to 69±15 points at 6 months (P<0.001). Conclusions— Percutaneous reduction in FMR with a novel coronary sinus-based mitral annuloplasty device is feasible in patients with heart failure, is associated with a low rate of major adverse events, and is associated with improvement in quality of life and exercise tolerance.

Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction

OBJECTIVES The study assessed the value of the electrocardiogram (ECG) as predictor of the left anterior descending coronary artery (LAD) occlusion site in relation to the first septal perforator (S1) and/or the first diagonal branch (D1) in patients with acute anterior myocardial infarction (AMI). BACKGROUND In anterior AMI, determination of the exact site of LAD occlusion is important because the more proximal the occlusion the less favorable the prognosis. METHODS One hundred patients with a first anterior AMI were included. The ECG showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site as determined by coronary angiography. RESULTS ST-elevation in lead aVR (ST elevation(aVR)), complete right bundle branch block, ST-depression in lead V5 (ST depression(V5)) and ST elevation(V1) > 2.5 mm strongly predicted LAD occlusion proximal to S1, whereas abnormal Q-waves in V4-6 were associated with occlusion distal to S1 (p = 0.000, p = 0.004, p = 0.009, p = 0.011 and p = 0.031 to 0.005, respectively). Abnormal Q-wave in lead aVL was associated with occlusion proximal to D1, whereas ST depression(aVL) was suggestive of occlusion distal to D1 (p = 0.002 and p = 0.022, respectively). For both the S1 and D1, inferior ST depression > or = 1.0 mm strongly predicted proximal LAD occlusion, whereas absence of inferior ST depression predicted distal occlusion (p < or = 0.002 and p < or = 0.020, respectively). CONCLUSIONS In anterior AMI, the ECG is useful to predict the LAD occlusion site in relation to its major side branches.

Beating-heart surgical treatment of atrial fibrillation with microwave ablation

BACKGROUND In this feasibility study, early results are presented of our first series of patients with microwave ablation for atrial fibrillation (AF) on the beating heart. METHODS From June 2001 until December 2001, a total of 24 patients underwent beating-heart epicardial ablation for AF. With a microwave antenna, the left and right pulmonary veins were isolated and connected to each other followed by amputation of the left atrial appendage. Subsequently, patients underwent either off-pump coronary artery bypass graft or valve surgery on pump. The mean age of the patients was 67.4 +/- 6 years. Three patients experienced paroxysmal atrial fibrillation and all others chronic AF. Mean left atrial diameter was 5.4 +/- 0.6 cm, and mean ablation time was 13 min. RESULTS All procedures but one were completed successfully on the beating heart. All patients were in sinus rhythm after the procedure. A total of 15 patients experienced periods with postoperative AF during hospital stay; 9 of these patients were discharged with AF. All patients received either sotalol or amiodarone. At latest follow-up (3 to 9 months), 20 of 23 patients were in sinus rhythm. CONCLUSIONS With microwave ablation, electrical isolation of the pulmonary veins can be achieved epicardially without cardiopulmonary bypass support.

Effectiveness and Safety of Percutaneous Coronary Sinus-Based Mitral Valve Repair in Patients With Dilated Cardiomyopathy (from the AMADEUS Trial)

This report presents the procedural results from the AMADEUS trial that support coronary sinus (CS)-based percutaneous mitral annuloplasty. Despite therapeutic advances, functional mitral regurgitation (MR) continues to be a significant clinical problem for patients with dilated cardiomyopathy. CS approaches to mitral valve repair have been viewed with skepticism because of the distance of the CS/great cardiac vein from the mitral valve annulus and the potential to compress a coronary artery. This report presents the procedural results from the AMADEUS trial that support CS-based percutaneous mitral annuloplasty. Patients who met the inclusion criteria were eligible to receive a mitral annuloplasty device. Transesophageal echocardiography was used to assess changes in MR, angiography was used to assess the coronary arteries, and multislice computed tomography was used to evaluate the anatomic relations between the coronary venous system and the mitral valve. Acute MR reduction (grade 3.0 +/- 0.6 to 2.0 +/- 0.8, p <0.0001) and permanent implantation were achieved in 30 of 43 patients in whom an attempt was made. Additional measurements in 20 patients with implants showed reductions in the vena contracta (0.69 +/- 0.29 to 0.46 +/- 0.26 cm, p <0.0001), effective regurgitant orifice area (0.33 +/- 0.17 to 0.19 +/- 0.08 cm(2), p <0.0001), regurgitant volume (40 +/- 20 to 24 +/- 11 ml, p = 0.0005), and jet area/left atrial area (45 +/- 13% to 32 +/- 12%, p <0.0001). The coronary arteries were crossed in 36 patients (84%). Arterial compromise contributed to a lack of implantation in 6 patients (14%). No difference was found in the CS/great cardiac vein position relative to the annulus between the patients who did and did not have a reduction in MR. In conclusion, percutaneous mitral annuloplasty reduces MR and permanent implantation can be achieved in most eligible patients.

Ten-Year Experience With Early Angioplasty in 759 Patients With Acute Myocardial Infarction

OBJECTIVES How effective and safe is rescue percutaneous transluminal coronary angioplasty [PTCA] compared with primary PTCA, and is it cost effective? BACKGROUND In acute myocardial infarction (AMI), primary PTCA has been shown to be beneficial in terms of clinical outcome. In contrast, the value of rescue PTCA has not been established. METHODS In a retrospective analysis, we compared the angiographic and clinical outcomes of 317 consecutive patients who had rescue PTCA approximately 90 min after failed thrombolysis and 442 patients treated with primary PTCA. An estimation of interventional costs was compared with the strategies of primary and rescue PTCA or with the strategy of thrombolysis with rescue PTCA, when indicated. RESULTS Baseline characteristics between primary and rescue PTCA were comparable for most variables. Treatment delay was longer for patients who had rescue PTCA: 240 min. versus 195 min. Coronary patency after PTCA was comparable: 90.2% for rescue PTCA and 91.4% for primary PTCA (p = 0.67, power 71.9%). In-hospital mortality rates were 4.7% and 6.6%, respectively (p = 0.37). Also, the other complications were fairly similar during the in-hospital phase and during one-year follow-up. Predictors of death were age, infarct size, localization of AMI, failed PTCA and left main stem occlusion. The estimated interventional costs during one-year follow-up were

Tropical endomyocardial fibrosis (Davies' disease): case report demonstrating the role of magnetic resonance imaging.

7,377 for primary PTCA and

Clinical Pacing Post-Conditioning During Revascularization After AMI

8,246 for rescue PTCA: difference

Rescue extracorporeal life support as a bridge to reflection in fulminant stress-induced cardiomyopathy

869 (11.7%). CONCLUSIONS In this retrospective analysis of 759 patients with AMI, rescue angioplasty early after failed thrombolysis seems to be as effective and safe as primary PTCA. In the present evaluation, interventional costs of primary PTCA are less than those of rescue PTCA (p = 0.0001).

Elective High-Risk Percutaneous Coronary Interventions Supported by Extracorporeal Life Support

Tropical endomyocardial fibrosis (TEMF), a restrictive cardiomyopathy of unclear etiology, is an endemic disease in equatorial Africa, South America and India. The patients are usually young, the onset of the disease and its clinical manifestations insidious, and the prognosis poor. We currently present a 50-year-old Congolese female who was referred with symptoms of progressive right-sided heart failure due to isolated TEMF of the right ventricle. Surgical resection of regional endomyocardial fibrosis was not possible and our patient was referred for cardiac transplantation. Cardiac magnetic resonance imaging (CMR) demonstrated the primary and secondary structural and functional abnormalities. CMR seems ideally suited to diagnose this condition and monitor response to medical and/or surgical therapy.

infarction Ten-year experience with early angioplasty in 759 patients with acute myocardial

Intermittent dyssynchrony, induced by ventricular pacing, during early reperfusion reduces infarct size in pre-clinical studies. We evaluated cardioprotection by pacing post-conditioning (PPC) in ST-segment elevation myocardial infarction in a randomized, controlled, single-center, single-blinded, first-in-man study. Patients with first ST-segment elevation myocardial infarction received either PPC plus percutaneous coronary intervention (PCI) (n = 30) or PCI (n = 30). PPC consisted of 10 episodes of 30-s right ventricular pacing. Infarct size was measured as the area under the curve of creatine kinase (CK) (primary endpoint) and by contrast-enhanced cardiac magnetic resonance. The CK area under the curve was not significantly different between study groups. Adjusted contrast-enhanced cardiac magnetic resonance data showed ∼25% smaller infarct size in PPC + PCI than in PCI patients after 4 days (p = 0.01), 4 months (p = 0.02), and 1 year of PCI (p = 0.08). In PPC + PCI, (uncomplicated) ventricular fibrillation (n = 3) and paroxysmal atrial fibrillation (n = 4) were observed as opposed to 1 and 0 cases in PCI, respectively. We conclude PPC is feasible and may induce cardioprotection during PCI treatment of ST-segment elevation myocardial infarction, but technical improvements are needed to improve safety. (PROTECT: Pacing to Protect Heart for Damage From Blocked Heart Vessel and From Re-opening Blocked Vessel[s]; NCT00409604).