Marco Turri

Comparison between low-dose dobutamine echocardiography and thallium-201 scintigraphy in the detection of myocardial viability in patients with recent myocardial infarction

AIM To compare the predictive value of thallium-201 single photon emission computed tomography (SPECT) scintigraphy (Sci) and low-dose dobutamine echocardiography (Dob) in predicting late recovery of dysfunctioning myocardium in patients with recent, uncomplicated myocardial infarction (MI). METHODS AND RESULTS 19 patients (18 male, aged 58+/-8 years) with recent MI and ejection fraction <50% (35.5+/-8.3%) underwent 5-15 microg/kg per min Dob, rest-redistribution Sci and coronary angiography, respectively, 14+/-6, 16+/-7 and 17+/-5 days after MI. On an eleven-segment ventricular model devised to compare Dob and Sci segment by segment, each dysfunctioning ventricular segment was considered viable if it showed recovery of mechanical function at the echocardiographic follow-up, performed 6.3+/-1.5 months after revascularization (five PTCA, five GABG) or medical therapy. Among the 104 dysfunctioning segments, of which 26 (25%) showed recovery at follow-up, Dob and Sci gave a concordant response in 50 (48%, k = 0.13), correctly predicting the recovery (or not) of function in 42. Forty-two of 54 discordant responses were due to segments judged viable only by Sci and which had no recovery at follow-up (of these 37 were akinetic or severely hypokinetic at baseline). At the segment-by-segment analysis, the sensitivity, specificity, and accuracy in predicting recovery of function at follow-up were, respectively, 69, 88 and 84% for Dob as against 88, 36 and 49% for Sci (P<0.001 for both specificity and accuracy, P=NS for sensitivity). CONCLUSION In patients with recent MI, the specificity of Dob in the detection of myocardium capable of late mechanical recovery is significantly higher with respect to Sci, whereas sensitivity is slightly, not significantly higher for the latter. It is conceivable that Sci detects viable myocardium even if it is transmurally limited to epicardial layers in segments with severely impaired mechanical function in which viability will not affect late recovery of function.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy presenting as ST-segment elevation myocardial infarction: A case report

Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is often challenging due to differing clinical presentations and unpredictable progression of the disease. We report a case of ARVD/C that presented as cardiac arrest in an 18-year-old male while playing soccer. The electrocardiographic features after resuscitation were typical of anterior ST-segment elevation acute myocardial infarction, and the patient was initially managed accordingly. Importantly, an urgent coronary angiogram revealed completely normal coronary arteries. ARVD/C was first suspected following an echocardiogram, and was later confirmed by cardiac magnetic resonance. One month before the event, the patient had been evaluated for ventricular extrasystoles and an abnormal resting electrocardiogram, however ARVD/C was ruled out because of the presence of only two minor diagnostic criteria (T-wave inversion in anterior precordial leads in the absence of right bundle branch block and more than 1000 ventricular extrasystoles during 24-h Holter monitoring). In consequence, physical activity was not forbidden. In conclusion, this case report enforces the need for a strict prohibition of physical activity and serial evaluation of individuals with only minor diagnostic criteria for ARVD/C, for lacking sensibility of Task Force diagnostic criteria.

Quantitative angiographic identification of functional left ventricular aneurysms

Thirty-three 30 degrees RAO left-ventricular angiograms with postinfarction aneurysms were analyzed to determine whether some quantitative variables could describe their morphological characteristics. Seventeen aneurysms were classified as functional (localized without a clear neck), and 16 as true (with a saccular shape). Left-ventricular volumes and global ejection fractions did not differ between the two types. The volume of functional aneurysms as a fraction of global end-diastolic volume was significantly larger (24.4+or-10.6% versus 13.2+or-8.5%, p=0.01). The end-systolic shape of ventricles with a functional aneurysm was more circular (77+or-6 versus 71+or-7, p<0.05) and showed a significantly smoother transition between contractile and noncontractile regions in the anterior site. The anatomic characteristics of resected areas in operated patients were similar in the two types of aneurysms.<<ETX>>

Recanalization of a Challenging Chronic Total Occlusion of the Superficial Femoral Artery through the Profunda Femoris Using a Pure Retrograde Technique

avoid extension of the stent into the extrahepatic portal vein. When this happens, split-liver variant anatomy transplantation may not be possible, necessitating wholeliver transplantation. This may also require the transplant surgeon to dissect into the retroperitoneum to find a tributary of the superior mesenteric vein to obtain adequate venous pedicle length for the transplant portal vein anastomosis. In summary, the modified DIPS technique via a percutaneous approach is a useful alternative to conventional TIPS creation to overcome the technical challenges of TIPS creation in the pediatric population.

Endothelial dysfunction late after coronary angioplasty: a quantitative coronary angiographic study in patients without restenosis

Endothelial function after coronary angioplasty (PTCA) has been evaluated by quantitative coronary angiography in 18 patients with no evidence of significant restenosis at routine angiographic followup. Increasing doses of acetylcholine (Ach) were infused in the dilated coronary artery, followed by a 250 mu g bolus of nitroglycerin. Total PTCA segments examined were 21. The PTCA treated vessels showed abnormal response to Ach in all their segments. This vasoconstriction was more evident not only at the site of previous maximal stenosis but also in normal vascular sites stretched by the balloon. Vascular response to Ach suggests that endothelial function of neointima is impaired late after PTCA.<<ETX>>

Myocardial perfusion after percutaneous coronary angioplasty

To study the time-course of myocardial perfusion after coronary angioplasty, electrocardiogram (ECG)-gated coronary angiography was performed before, immediately after, and 24 hours after successful dilatation of 22 isolated left anterior descending coronary arteries. Minimal cross-sectional areas before, immediately after, and 24 hours after percutaneous transluminal coronary angioplasty (PTCA) were 0.59+or-0.46 mm/sup 2/, 3.05+or-1.17 mm/sup 2/, and 2.88+or-1.42 mm/sup 2/ respectively. At the same time, myocardial blood flow at maximal hyperemia, expressed as 1/mean transit time, improved in all patients (from 0.14+or-0.05 a/s to 0.20+or-0.07 a/s, p<0.0001). The results persisted after 24 hours, and associated with the recovery of the regional left ventricular function.<<ETX>>