Jochen Spiess

Prospective randomised trial evaluating a paclitaxel-coated balloon in patients treated with endothelial progenitor cell capturing stents for de novo coronary artery disease

Background Percutaneous coronary intervention with stent implantation is limited by the occurrence of re-stenosis and the risk of stent thromboses. Objective To define the impact of paclitaxel-coated balloon angioplasty plus endothelial progenitor cell capturing (EPC) stent implantation in de novo coronary artery disease. This combination may reduce neointimal proliferation within the EPC stent and address the risk of stent thrombosis by facilitating rapid endothelialisation. Methods In this prospective single-blind multicentre randomised trial, 120 patients with a de novo lesion in a native coronary artery were randomly assigned to undergo treatment with paclitaxel-coated balloon plus EPC stent or EPC stent alone. Dual antiplatelet therapy was prescribed for 3 months. Angiographic follow-up was scheduled at 6 months. The primary endpoint was in-stent late lumen loss. The secondary clinical endpoint was a composite of death from a cardiac cause, myocardial infarction attributed to the target vessel or target lesion revascularisation. Results There was no difference in patient baseline characteristics or procedural results. The angiographic follow-up rate was 96%. Treatment with paclitaxel-coated balloon plus EPC stent was superior to EPC stent alone, with an in-stent late loss of 0.34±0.45 mm versus 0.88±0.48 mm (p<0.001). The re-stenosis rate was reduced from 23.2% to 5.1% (p=0.006) and the clinical endpoint was reduced from 17.2% to 4.8% (p=0.039). There was no definite or probable stent thrombosis. Conclusions Paclitaxel-coated balloon plus EPC stent implantation is superior to EPC stent implantation alone for treatment of de novo coronary artery disease. Trial registration NCT00732953.

Combined Assessment of Myocardial Perfusion and Late Gadolinium Enhancement in Patients After Percutaneous Coronary Intervention or Bypass Grafts : A Multicenter Study of an Integrated Cardiovascular Magnetic Resonance Protocol

OBJECTIVES We sought to assess the accuracy of an integrated cardiac magnetic resonance (CMR) protocol for the diagnosis of relevant coronary artery or bypass graft stenosis in patients with suspected coronary artery disease (CAD) or with previously performed percutaneous coronary intervention (PCI) or coronary bypass graft surgery (CABG). BACKGROUND CMR is suitable for diagnosing inducible myocardial ischemia in patients with suspected CAD and has been proven to be a helpful diagnostic tool for decision of further treatment. However, little is known about its diagnostic accuracy in patients with known CAD who previously were treated by PCI or CABG. METHODS A total of 477 patients with suspected CAD, 236 with previous PCI, and 110 after CABG referred for coronary X-ray angiography (CXA) underwent an integrated CMR examination before CXA. Myocardial ischemia was assessed using first-pass perfusion after vasodilator stress with adenosine (140 microg/kg/min for 3 min) using gadolinium-based contrast agents (0.1 mmol/kg). Late gadolinium enhancement (LGE) was assessed 10 min after a second contrast bolus. RESULTS CXA demonstrated a relevant coronary vessel stenosis (> or =70% luminal reduction) in 313 (38%) patients using quantitative coronary analysis. The combination of CMR perfusion and LGE assessment for detecting a relevant coronary stenosis in patients with suspected CAD yielded sensitivity and specificity of 0.94 and 0.87, in PCI patients 0.91 and 0.90, and in CABG patients 0.79 and 0.77, respectively. CONCLUSIONS A combined CMR protocol for the assessment of myocardial perfusion and LGE is feasible for the detection of relevant coronary vessel stenosis even in patients who previously were treated by PCI or CAG in a routine clinical setting. However, diagnostic accuracy is reduced in patients with CABG. This could be due to different flow and perfusion kinetic. Further studies are needed to optimize the clinical protocols especially in post-surgical patients.

Whole-heart coronary vein imaging: a comparison between non-contrast-agent- and contrast-agent-enhanced visualization of the coronary venous system.

The feasibility of three‐dimensional (3D) whole‐heart imaging of the coronary venous (CV) system was investigated. The hypothesis that coronary magnetic resonance venography (CMRV) can be improved by using an intravascular contrast agent (CA) was tested. A simplified model of the contrast in T2‐prepared steady‐state free precession (SSFP) imaging was applied to calculate optimal T2‐preparation durations for the various deoxygenation levels expected in venous blood. Non‐contrast‐agent (nCA)‐ and CA‐enhanced images were compared for the delineation of the coronary sinus (CS) and its main tributaries. A quantitative analysis of the resulting contrast‐to‐noise ratio (CNR) and signal‐to‐noise ratio (SNR) in both approaches was performed. Precontrast visualization of the CV system was limited by the poor CNR between large portions of the venous blood and the surrounding tissue. Postcontrast, a significant increase in CNR between the venous blood and the myocardium (Myo) resulted in a clear delineation of the target vessels. The CNR improvement was 347% (P < 0.05) for the CS, 260% (P < 0.01) for the mid cardiac vein (MCV), and 430% (P < 0.05) for the great cardiac vein (GCV). The improvement in SNR was on average 155%, but was not statistically significant for the CS and the MCV. The signal of the Myo could be significantly reduced to about 25% (P < 0.001). Magn Reson Med 57:1019–1026, 2007.

Impact of Percutaneous Device Implantation for Closure of Patent Foramen Ovale on Valve Insufficiencies

Background— In patients with percutaneous device implantation for closure of patent foramen ovale (PFO), a 10% incidence of new or worsened aortic regurgitation within 12 months has been reported with echocardiography. Cardiac magnetic resonance imaging is a powerful noninvasive tool to quantify volume and fraction of valve insufficiencies. We studied the acute and long-term impact of percutaneous device implantation for PFO closure on valve insufficiencies in cardiac magnetic resonance imaging. Methods and Results— Sequential cardiac magnetic resonance imaging studies were performed in 102 patients with cryptogenic ischemic events. Cardiac magnetic resonance imaging was performed before PFO closure, the day after device implantation, and at 12 months of follow-up. There was no difference in volumetric and hemodynamic parameters before PFO closure compared with 12 months of follow-up. With a cutoff for relevant regurgitation fraction of 5%, there were no statistically significant differences in regurgitation fraction of the semilunar and atrioventricular valves. The median fraction of aortic valve insufficiency was 3.9% (interquartile range [IQR] 2.0% to 5.1%) before PFO closure, 5.4% (IQR 4.1% to 5.9%) after device implantation, and 4.3% (IQR 3.3% to 6.0%) at 12 months of follow-up. The size and type of the occluder had no impact on aortic valve insufficiency. Median regurgitation fraction for the pulmonary valve was 3.6% (IQR 2.4% to 6.7%) before intervention, 7.3% (IQR 5.1% to 8.2%) after occluder implantation and 5.8% (IQR 4.8% to 7.4%) at 12 months of follow-up. Values for the mitral valve were 3.1% (IQR 1.4% to 6.0%), 5.5% (IQR 3.5% to 7.3%), and 3.8% (IQR 1.5% to 7.9%) and for the tricuspid valve were 5.4% (IQR 0.1% to 8.8%), 5.8% (IQR 1.4% to 9.2%), and 6.0% (IQR 1.1% to 8.4%), respectively. Conclusions— Percutaneous PFO closure with device implantation has no impact on valve insufficiencies as determined by cardiac magnetic resonance imaging.

Local excitation black blood imaging at 3T: application to the carotid artery wall.

A novel approach for imaging large sections of the carotid artery wall at isotropic spatial resolution is presented. Local excitation by means of 2D excitation pulses was combined with a diffusion‐prepared segmented steady‐state black‐blood gradient echo technique enabling the assessment of the carotid arterial wall over a range of up to 15 cm. The carotid arteries of five healthy volunteers were imaged with the proposed technique. Signal‐to‐noise ratio (SNR), wall‐lumen contrast‐to‐noise ratio (CNR), and vessel dimensions were assessed and compared to conventional excitation techniques. In all experiments black‐blood contrast could be realized over the covered carotid arteries with similar SNR and CNR as the conventional technique covering the region of the bulbus only. The proposed technique enables the time‐efficient coverage of the carotid arteries without compromising wall‐lumen CNR and geometrical accuracy. Furthermore, the proposed technique appears to be less sensitive to motion and swallowing artifacts due to the local character of the excitation. Magn Reson Med, 2008.

Valvular Strands and Ischemic Stroke

We report the case of a previously healthy 47-year-old woman suffering an acute embolic stroke in the left middle cerebral artery distribution. A filiform structure along the line of the aortic valve was first identified by transesophageal echocardiography, leading to the diagnosis of a valvular strand. These masses are thought to represent giant Lambl’s excrescences, although differential diagnoses include several benign cardiac tumors, e.g. papillary fibroelastoma. Valvular strands have previously been associated with embolic events including stroke, although exact pathogenetic mechanisms and further patient management have not yet been fully established. This case report additionally provides a short overview of the currently existing literature. As a conclusion, standard recommendations for patient management and treatment cannot be derived from currently available evidence.

Cardiac phase-specific shimming (CPSS) for SSFP MR cine imaging at 3 T

The application of steady-state-free-precession (SSFP) techniques at 3 T systems is still limited by their sensitivity to magnetic field inhomogeneities. Especially during imaging of the heart, the arising signal voids and distortions in the myocardium currently often limit the diagnostic value of the resulting images. Dedicated shim systems providing higher order shimming capabilities have been applied to improve the field homogeneity across the heart. In this study, the potential benefit of applying a cardiac phase-specific shim (CPSS) was investigated. The cardiac phase dependence of the magnetic field distortions over the heart was assessed and the potential gain in field homogeneity by CPSS was evaluated. CPSS was successfully applied in volunteers and yielded significant improvement in the main magnetic field homogeneity over the entire cardiac cycle.

Isolated Whipple's Endocarditis: An Underestimated Diagnosis That Requires Molecular Analysis of Surgical Material

Tropheryma whipplei is known as the bacterium that causes Whipples disease, a rare systemic illness typically affecting gastrointestinal tract, joints, and central nervous system. In addition, T whipplei infection may present as an isolated endocarditis. Although previously regarded as a rare condition, T whipplei has been recognized as a major cause of culture-negative endocarditis when integrating specific molecular analysis of surgical material into the diagnostic algorithm. Here, we report the case of a 67-year-old man undergoing mitral valve replacement due to T whipplei endocarditis, and discuss diagnostic and therapeutic implications.

Cardiac metastasis of a gastric adenocarcinoma.

A 76-year-old male was presented for artificial hip operation due to extensive arthrosis and reduced walking distance caused by pain. As the patient reports to suffer occasionally from palpitations on admission, further cardiologic examination is planned before the operation. On conventional transthoracic echocardiography, a mass of unknown origin is seen in the left atrium. Multi-slice thoracic computed tomography revealed a mass adjacent to the heart of unknown origin with a diameter of 60 mm ( Panel A ). Thus, the patient is referred for …

Value of the proximal flow convergence method for quantification of the regurgitant volume in mitral regurgitation

In der vorliegenden Untersuchung sollte der Stellenwert der proximalen Flusskonvergenzmethode zur Bestimmung des Regurgitationsvolumens der Mitralklappeninsuffizienz in Abhängigkeit von der Ursache der Insuffizienz, der Flusskonvergenzdarstellung und der Anwendung verschiedener Korrekturalgorithmen untersucht werden. Das Regurgitationsvolumen wurde bei 45 Patienten (Alter 61±13 Jahre) mit organischer (n=19) oder funktioneller (n=26) Mitralklappeninsuffizienz durch Messung der proximalen Flusskonvergenzradien bei Aliasinggeschwindigkeiten zwischen 14 und 64 cm/s im 2D-Farbdoppler bestimmt. Dabei wurden verschiedene Berechnungsalgorithmen wie eine geometrische Korrektur bei wandadhärenter Flusskonvergenzzone und ein vereinfachter Algorithmus, der als einzigen Messparameter den Flusskonvergenzradius benötigt, angewandt. Der Flusskonvergenzradius im M-Mode-Farbdoppler wurde bei einer Aliasinggeschwindigkeit von 28 cm/s dargestellt. Als Referenzmethode diente die quantitative Dopplerechokardiographie. Bei organischer Mitralklappeninsuffizienz ergaben sich Korrelationskoeffizienten/ mittlere Differenzen zwischen der Flusskonvergenzmethode und der Referenzmethode von 0,25–0,43/46–111 ml vor und 0,58–0,67/15–17 ml nach geometrischer Korrektur für die untersuchten Aliasinggeschwindigkeiten. Im M-Mode-Farbdoppler fanden sich Werte von 0,68/85 ml. Die entsprechenden Werte bei funktioneller Insuffizienz lagen bei 0,74–0,88/–5–8 ml vor und 0,74–0,88/–7–5 ml nach geometrischer Korrektur im 2D-Farbdoppler und bei 0,88/–1 ml im M-Mode-Farbdoppler. Der vereinfachte Algorithmus ergab Regurgitationsvolumina, die den unkorrigierten Werten entsprachen. Das Regurgitationsvolumen wurde bei Patienten mit organischer Mitralklappeninsuffizienz durch die Methode der proximalen Flusskonvergenz unabhängig von einer Korrektur und der Darstellung überschätzt, was den Stellenwert der Methode bei diesen Patienten erheblich einschränkte. Eine ausreichend zuverlässige Bestimmung des Regurgitationsvolumens war dagegen bei funktioneller Mitralklappeninsuffizienz möglich. Dabei konnte ein einfacher Berechnungsalgorithmus für das Regurgitationsvolumen verwendet werden. The purpose of this study was to evaluate whether the underlying mechanism of mitral regurgitation influences the reliability of the proximal flow con- vergence method to assess the regurgitant volume. Furthermore, the mode of imaging the flow convergence region and different correction algorithms for calculation of the regurgitant volume were compared. Regurgitant volume was assessed in 45 patients (age 61±13 years) with organic (n=19) and functional (n=26) mitral regurgitation by the proximal flow convergence method for aliasing velocities between 14 and 64 cm/s using two-dimensional color Doppler imaging. Different correction and calculation algorithms were compared. In addition, regurgitant volume was determined using color Doppler M-mode for an aliasing velocity of 28 cm/s. The quantitative Doppler method was used as reference. In organic mitral regurgitation correlation coefficients (mean differences) between the proximal flow convergence method and the reference method were 0.25–0.43/ 0.58–0.67 (46–111 ml/15–17 ml) before/after geometric correction of the regurgitant volume for the aliasing velocities investigated. The correlation coefficient (mean difference) using color Doppler M-mode imaging was 0.68 (85 ml). The corresponding values in functional mitral regurgitation were 0.74–0.88/0.74–0.88 (–5–8 ml/–7–5 ml) for two-dimensional color Doppler and 0.88 (–1 ml) for M-mode imaging. The regurgitant volume was overestimated by the proximal flow convergence method in organic mitral regurgitation irrespective of the application of different correction algorithms or the use of color Doppler M-mode. A sufficiently reliable determination of the regurgitant volume by the proximal flow convergence method was possible in functional mitral regurgitation. In that case a simplified calculation of the regurgitant volume based on the proximal flow convergence method was feasible.