Raed A. Aqel

Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review.

Spontaneous coronary artery dissection is a rare cause of myocardial ischemia and sudden death. Coronary aneurysms and pseudoaneurysms, which may occur after percutaneous coronary interventions, rarely occur spontaneously. We review the pertinent medical literature and describe the intravascular findings of spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms. (ECHOCARDIOGRAPHY, Volume 21, February 2004)

Role of Myocardial Perfusion Imaging in Patients With End-Stage Renal Disease Undergoing Coronary Angiography

Patients with end-stage renal disease (ESRD) are at high risk of cardiovascular events. This study examined the prognostic power of stress myocardial perfusion imaging (MPI) in 150 patients with ESRD (mean age 53 +/- 9 years; 30% women; 66% with diabetes mellitus) being evaluated for renal transplantation with known coronary anatomy using angiography. Baseline data in addition to perfusion and angiographic parameters were compared between survivors and nonsurvivors. All-cause mortality was defined as the outcome measure. An abnormal MPI result was present in 85% of patients, 30% had left ventricular (LV) ejection fraction (EF) < or =40%, and 40% had multivessel coronary artery disease using angiography. At a mean follow-up of 3.4 +/- 1.5 years, 53 patients died (35%). LVEF < or =40%, LV dilatation (LV end-diastolic volume >90 ml), and diabetes mellitus were associated with higher mortality (all p <0.05). Both total perfusion defect size and mean number of narrowed coronary arteries using angiography were significantly higher in those who died (p <0.05). In a multivariate model, abnormal MPI results (low LVEF or abnormal perfusion) and diabetes alone were independent predictors of death, whereas number of narrowed arteries using coronary angiography was not. Thus, MPI was a strong predictor of all-cause mortality in patients with ESRD. In conclusion, abnormal MPI results independently predicted worse survival and provided more powerful prognostic data than coronary angiography.

Hemodynamic evaluation of coronary artery bypass graft lesions using fractional flow reserve

Coronary angiography is limited by its inability to assess the hemodynamic significance of a coronary artery stenosis. The assessment of the physiological significance of saphenous vein graft (SVG) lesions with a pressure wire to determine the fractional flow reserve (FFR) is lacking.

Relation Between Heart Rate Response to Adenosine and Mortality in Patients With End-Stage Renal Disease

This study examined the relation between heart rate (HR) response to adenosine and outcome in patients with end-stage renal disease (ESRD). The usual HR increase during adenosine infusion was caused by direct sympathetic stimulation. It was hypothesized that a blunted HR response, which was probably caused by sympathetic denervation, would be associated with a worse outcome in patients with ESRD. One hundred thirty-nine patients with ESRD being evaluated for renal transplantation who underwent coronary angiography and adenosine gated single-photon emission computed tomographic myocardial perfusion imaging were followed up for all-cause mortality. Percentage of change in HR (%DeltaHR) was calculated as [(peak HR during adenosine infusion - HR at rest)/HR at rest] * 100. A control group of 54 patients (normal renal function and no diabetes) was included for comparison of HR responses. Mean age of patients was 54 +/- 9 years, 30% were women, and 68% had type-2 diabetes mellitus. %DeltaHR was 19.2 +/- 18% in patients with ESRD versus 33 +/- 25% in the control group (p <0.0001). At a mean follow-up of 3.4 +/- 1.5 years, 50 patients (36%) with ESRD died. %DeltaHR was lower in nonsurvivors than survivors (12.6 +/- 14% vs 23 +/- 19%; p = 0.0017). Patients with %DeltaHR less than the median value were more likely to have lower left ventricular ejection fraction and larger end-diastolic volume (p <0.05 for each). In a multivariate logistic regression model, %DeltaHR alone was an independent predictor of all-cause mortality (adjusted odds ratio 5.5, 95% confidence interval 2.3 to 12.9, p = 0.0001). In conclusion, patients with ESRD had a blunted HR response to adenosine, and degree of blunting was strongly associated with all-cause mortality.

Re-stenosis After Drug-eluting Stents in Cardiac Allograft Vasculopathy

BACKGROUND Cardiac allograft vasculopathy (CAV) constitutes a primary cause of death after heart transplantation. Balloon angioplasty and bare metal stents have been used for revascularization but they are associated with a high risk of re-stenosis. Limited data have shown favorable results with drug-eluting stents (DES). This study examines the rate of re-stenosis for DES in CAV as well as predictors for its occurrence. METHODS Cardiac transplant patients who received at least one DES for a previously untreated coronary lesion were included. These patients were retrospectively followed until February 2007. Re-stenosis was defined as >or=50% lumen diameter narrowing on coronary angiography at the site of the DES. RESULTS During the study period, 35 patients underwent percutaneous coronary intervention (PCI) on a total of 84 de novo lesions. The mean follow-up was 22 +/- 14 months. Twenty-six (31%) lesions developed re-stenosis during follow-up. Re-stenosis rates were 18%, 21% and 26% at 6, 9 and 12 months, respectively. Predictors of re-stenosis included non-white race, ischemic etiology, intervention precipitated by symptoms and severe stenosis (>/=90% stenosis) of the target lesion. CONCLUSIONS Use of DES has a favorable outcome when used in heart transplant patients for the treatment of CAV. An aggressive strategy for the treatment of CAV using DES may provide good long-term outcome compared with other available therapies.

Regional pericarditis: a review of the pericardial manifestations of acute myocardial infarction.

Regional pericarditis has been described in several settings, but occurs most frequently after transmural myocardial infarction. While the diagnosis remains elusive, it must be considered in all patients with recurrent chest pain following acute myocardial infarction (AMI). Pericarditis classically presents with positional chest pain, a pericardial friction rub, diffuse ST‐segment elevation, and PR depression, but regional ECG changes associated with infarction‐associated pericarditis sometimes exist. Given the magnitude and frequency of AMI, it is imperative to be aware of the myriad of pericardial manifestations of myocardial injury. An illustrative case and a comprehensive review of the literature will be provided. Copyright

Usefulness of three posterior chest leads for the detection of posterior wall acute myocardial infarction.

A significant proportion of patients with myocardial infarction are missed upon initial presentation to the emergency department. The 12-lead electrocardiogram (ECG) has a low sensitivity for the detection of acute myocardial infarction, especially if the culprit lesion is in the left circumflex artery (LCA). This study was designed to evaluate the benefit of adding 3 posterior chest leads on top of the 12-lead ECG to detect ischemia resulting from LC disease, using a model of temporary balloon occlusion to produce ischemia. We studied 53 consecutive patients who underwent clinically indicated coronary interventions. At the time of coronary angiography, the balloon was inflated to produce complete occlusion of the proximal LCA. We recorded and analyzed the changes noted on the 15-lead ECG, which included 3 posterior leads in addition to the standard 12 leads. In response to acute occlusion of the LCA, the posterior chest leads showed more ST elevation than the other leads, and more patients had ST elevation in the posterior leads than in any other lead. The 15-lead ECG was able to detect>or=0.5 mm (74% vs 38%, p<0.0001) and >or=1 mm (62% vs 34%, p<0.0001) ST elevation in any 2 contiguous leads more frequently than the 12-lead ECG. In conclusion, the 15-lead ECG identified more patients with posterior myocardial wall ischemia because of temporary balloon occlusion of the LC than the 12-lead ECG. This information may enhance the detection of posterior MI in the emergency department and potentially facilitate early institution of reperfusion therapy.

Effect of Alcohol-Induced Septal Ablation on Left Atrial Volume and Ejection Fraction Assessed by Real Time Three-Dimensional Transthoracic Echocardiography in Patients with Hypertrophic Cardiomyopathy

Alcohol‐induced septal ablation (AISA) is an accepted treatment for hypertrophic cardiomyopathy (HCM) patients with left ventricular (LV) outflow obstruction who are unresponsive to medical therapy. As left atrial (LA) enlargement has been correlated with increased morbidity and mortality in HCM, we assessed LA volumes and ejection fraction (EF) prior to and after AISA using real time three‐dimensional (3D) transthoracic echocardiography (TTE) in 12 patients (9 women; mean age 52 ± 15 years; 11 Caucasian). All patients underwent successful AISA with no complications and their resting left ventricular outflow gradients decreased from 40.5 ± 22.2 to 9.1 ± 17.6 mmHg (P < 0.001) while their gradients with provocation decreased from 126.2 ± 31.7 to 21.8 ± 28.0 mmHg (P < 0.001). All patients showed improvements in their New York Heart Association (NYHA) functional class. Both the LA end‐systolic (45.2 ± 12.9 to 37.2 ± 13.7 ml, P < 0.0001) and end‐diastolic (79.6 ± 18.9 to 77.1 ± 18.6 ml, P = 0.001) volumes decreased after AISA. The LA EF increased from 43.1 ± 9.0 to 52.5 ± 8.8% (P = 0.001). The increase in LA EF correlated with the decrease in the resting left ventricular outflow gradient (R =−0.647, P = 0.03). In conclusion, 3D echocardiography can be utilized to follow LA function after AISA for HCM. AISA results in clinical improvement in patients with HCM and in improvement of LA EF that is correlated with the decrease in the left ventricular outflow gradient.

Left Ventricular Collapse Secondary to Pericardial Effusion Treated with Pericardicentesis and Percutaneous Pericardiotomy in Severe Pulmonary Hypertension

A 61‐year‐old white female, a Jehovahs Witness, with severe pulmonary hypertension, presented with worsening heart failure symptoms. She had a pericardial effusion with left ventricular (LV) diastolic collapse on transthoracic echocardiography. She was not a candidate for surgical pericardial window and therefore underwent pericardiocentesis and percutaneous balloon pericardiotomy with remarkable improvement in her clinical condition and with no recurrence of the effusion. LV diastolic collapse, an atypical presentation of cardiac tamponade, is commonly seen in postoperative patients with localized pericardial effusions. However, outside the surgical setting, isolated LV diastolic collapse is rare. Our case is one of the first cases described in the literature of LV diastolic collapse in the setting of severe pulmonary hypertension treated successfully with pericardiocentesis and percutaneous balloon pericardiotomy.

Serial Evaluations of Myocardial Infarct Size After Alcohol Septal Ablation in Hypertrophic Cardiomyopathy and Effects of the Changes on Clinical Status and Left Ventricular Outflow Pressure Gradients

Alcohol septal ablation (ASA) as a treatment for obstructive hypertrophic cardiomyopathy produces septal infarction. There is a concern that such infarcts could be detrimental. Changes in the size of these infarcts by serial perfusion testing have not been studied. We performed resting serial-gated single-photon emission computed tomographic myocardial perfusion imaging in 30 patients (age 51+/-17 years, 57% were women) who had ASA between September 2003 and March 2007 before, 2+/-0.8 days (early), and 8.4+/-6.9 months (late) after ASA. Patients were also followed clinically and with serial 2-dimensional echocardiography. New York Heart Association class decreased from 3.50+/-0.51 before to 1.14+/-0.36 (p<0.0001) 3 months after ASA. The left ventricular (LV) outflow gradient (by Doppler echocardiography) decreased from 63+/-32 mm Hg before to 28+/-23 mm Hg after ASA (p<0.005). None of the patients had perfusion defects at rest before ASA. After ASA, perfusion defect size, involving the basal septum, decreased from 9.4+/-5.8% early to 5.2+/-4.2% of LV myocardium late after ASA (p<0.001). There were no changes in LV size and ejection fraction after ASA. In conclusion, ASA produces small basal ventricular septal infarcts (resting perfusion abnormality) involving<10% of the LV myocardium (including ventricular septum). There is a significant reduction in the perfusion abnormality late after ASA without an increase in LV outflow obstruction or recurrence of symptoms.