Sandra Pujadas

Bioresorbable everolimus-eluting vascular scaffold for the treatment of chronic total occlusions: CTO-ABSORB pilot study.

AIMS We sought to assess the safety and performance of the Absorb everolimus-eluting bioresorbable vascular scaffold (BVS) in percutaneous chronic total occlusion (CTO) revascularisation guided by intracoronary imaging. The feasibility of using the BVS in CTO lesions is unknown. METHODS AND RESULTS Thirty-five consecutive true CTO lesions (EuroCTO Club definition) were included in this prospective registry. After mandatory predilatation and IVUS analysis, all target lesions were treated with BVS and no other stents were deployed. Optical coherence tomography (OCT) was performed after BVS implantation. Multislice computed tomography (MSCT) was performed at baseline and at six to eight months. The mean age was 60.7±9.7 years; 80% were male; 20% were diabetic; 37% had a previous PCI. The most frequently treated vessel was the RCA (46%). According to the Japanese-CTO (J-CTO) complexity score, most lesions were classified as intermediate (49%) or difficult-very difficult (26%); 34% were moderate-severely calcified. Most cases (86%) were treated with an anterograde strategy, 60% by radial or biradial approach. In 71% a cutting balloon was used. The total scaffold length implanted per lesion was 52.5±22.9 mm. All scaffolds were successfully delivered and deployed. Post-dilatation was undertaken in 63%. By OCT, final minimum scaffold area and lumen stenosis were 7.1±1.5 mm2 and 11.7±6.6%, without areas of significant strut malapposition. At complete six-month follow-up, no major adverse events were observed. MSCT identified two cases of scaffold reocclusion. CONCLUSIONS BVS for CTO recanalisation demonstrates excellent feasibility and safety as well as midterm efficacy. Appropriate lesion preparation is key to aiding adequate expansion of these scaffolds in this setting.

Ruling Out Coronary Artery Disease with Noninvasive Coronary Multidetector CT Angiography before Noncoronary Cardiovascular Surgery

PURPOSE To assess the usefulness of preoperative coronary computed tomographic (CT) angiography in the detection of coronary artery disease (CAD) in nonselected patients scheduled to undergo noncoronary cardiovascular surgery to avoid unnecessary invasive coronary angiography (ICA). MATERIALS AND METHODS The institutional review board approved the study protocol; informed consent was given. This prospective study involved 161 consecutive patients who underwent coronary calcium scoring and coronary CT angiography before undergoing noncoronary cardiovascular surgery. Seven patients were excluded because of contraindications to CT angiography. The major indication of noncoronary cardiovascular surgery was valvular heart disease (121 patients). Follow-up was performed at a median of 20 months to define ischemic events described as acute coronary syndrome or death secondary to acute coronary syndrome, arrhythmias, or cardiac failure. Multivariate analysis was performed to determine predictors of nondiagnostic coronary CT angiography. Kaplan-Meier analysis was performed to evaluate outcome at follow-up. RESULTS Twenty-one patients did not undergo surgery, which left 133 patients as the study group. Atrial fibrillation was present in 45 of 133 patients. The interquartile range of the Agatston coronary calcium score was 0-471. Coronary CT angiography was diagnostic in 108 of 133 patients. Of these, 93 of 108 had no significant CAD (≤ 50% stenosis), and noncoronary cardiovascular surgery was performed in them without preoperative ICA. No patients in this group had postoperative ischemic events at follow-up. Coronary CT angiography was nondiagnostic in 25 of 133 patients who were referred for preoperative ICA. Multivariate analysis showed Agatston score to be the only independent predictor of nondiagnostic coronary CT angiography (odds ratio = 1.002; 95% confidence interval: 1.001, 1.003; P = .001). The best Agatston score cutoff for diagnostic coronary CT angiography was 579. CONCLUSION In nonselected patients scheduled to undergo noncoronary cardiovascular surgery, preoperative coronary CT angiography was diagnostic in 81% of cases. Preoperative ICA could be safely avoided in patients without significant CAD by using coronary CT angiography. The Agatston score, but not the presence of atrial fibrillation, was an independent predictor of nondiagnostic coronary CT angiography. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100384/-/DC1.

Eplerenone in systemic right ventricle: Double blind randomized clinical trial. The evedes study☆ , ☆☆

BACKGROUND There is no proven pharmacological strategy for the treatment of the failing systemic right ventricle (SRV) but myocardial fibrosis may play a role in its pathophysiology. METHODS We designed a double-blind, placebo-controlled clinical trial to assess the effects of eplerenone 50mg during 12 months on cardiac magnetic resonance parameters (SRV mass and ejection fraction) and neurohormonal and collagen turnover biomarker (CTB) levels. RESULTS Twenty six patients with atrial switch repair for transposition of the great arteries were randomized to eplerenone (n=14) or placebo (n=12) and 14 healthy volunteers served as controls for comparison of baseline neurohormones and CTB levels. The study population showed a good baseline profile in terms of SRV mass (57.4 ± 17 g/m(2)) and ejection fraction (54.9 ± 7.5%). However, levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), C terminal propeptide of type I procollagen (CICP) and C-terminal Telopeptide of type I Collagen (ICTP) were significantly elevated when compared to healthy controls. After one year of treatment, a trend toward reduction of CICP, N-terminal pro-Matrix Metalloproteinase 1 (NT-proMMP1), Tissue Inhibitor of Metalloproteinases 1 (TIMP1) and galectin 3 levels and a lower increase in ICTP in patients under eplerenone was observed. The reduction of SRV mass and the improvement of SRV function with eplerenone were not conclusive. CONCLUSIONS Patients with SRV treated with eplerenone showed an improvement of an altered baseline CTB profile suggesting that reduction of myocardial fibrosis might be a therapeutic target in these patients.

New electrocardiographic diagnostic criteria for the pathologic R waves in leads V1 and V2 of anatomically lateral myocardial infarction.

AIMS To study the different QRS patterns in leads V1 and V2 in first inferior, lateral, and combined inferolateral myocardial infarction (MI) to recognize which are the ECG criteria that best define the presence of lesions isolated to the anatomically lateral wall of the left ventricle. METHODS AND RESULTS We studied consecutive patients with first inferior (15), lateral (9), or inferolateral (21) MI with reference to contrast enhanced cardiac magnetic resonance (CE-CRM). We measured the R-wave amplitude and duration, the R/S ratio, and the T-wave amplitude and polarity in leads V1 and V2. The specificity of the V1 criteria for lateral MI, that is, R/S amplitude ratio 1 or greater and R duration 40 milliseconds or longer, is very high but its sensitivity is low. We defined 2 new criteria, R/S of 0.5 or greater and R amplitude in V1 greater than 3 mm, with each achieving a sensitivity of 73.3% and specificity of 93.3% for lateral/inferolateral MI location. CONCLUSIONS (1) New ECG criteria for lateral MI (R/S ratio in V1 > or =0.5 and R amplitude in V1 >3 mm) present very high specificity and lower but very acceptable sensitivity for lateral MI. (2) New criteria based on R waves in V2 or T waves in V1 to V2 do not discriminate between inferior and lateral MI. (3) The classical criteria (R/S amplitude ratio > or =1 and R duration > or =40 ms in V1) attain very high specificity but much lower sensitivity than the new criteria.

Improvement of myocardial function and perfusion after successful percutaneous revascularization in patients with chronic total coronary occlusion

BACKGROUND Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of a coronary artery can provide benefits in terms of myocardial function and survival but the procedure is complex and the success rate is relatively low. To assess these benefits, myocardial function, ischemia and viability should be clearly determined by means of a reliable diagnostic test. This study aimed to assess ventricular function and myocardial ischemia before and after PCI for CTO using cardiac magnetic resonance (CMR). NYHA functional class was also assessed before and after PCI. METHODS AND RESULTS CMR studies were performed in 43 consecutive patients (7 females; aged 64 ± 9.6 y.o.) with CTO scheduled for PCI and repeated 6 months post-PCI. PCI was successful in 33 (77%) of them. In this group CMR had shown inducible perfusion defects in 26 (79%) before PCI, while they were observed in 10 (30%) post-PCI CMR study (p < 0.001). The number of segments showing inducible perfusion defect (3.4 ± 2 prevs. 2.9 ± 4.5 post-PCI, p = 0.002) was significantly reduced in this group. Regional contractile function of segments showing viability also improved significantly in the group with successful CTO PCI compared to the group with an unsuccessful procedure. NYHA functional class for angina also improved in patients with successful revascularization while it remained unchanged in the group with unsuccessful procedures. CONCLUSIONS A successful CTO PCI leads to a reduction in inducible myocardial ischemia and to an improvement in regional wall motion, which results in clinical improvement.

Determinantes del éxito de la revascularización de las oclusiones coronarias crónicas: estudio mediante tomografía computarizada con multidetectores

INTRODUCTION AND OBJECTIVES Percutaneous revascularization of chronic total coronary artery occlusion is a technical challenge and has a lower success rate than other angioplasty procedures. Identification of predictors of failure could lead to better selection of patients with the greatest possibility of success. In this study, we investigate the multidetector computed tomography features associated with failure of percutaneous treatment for chronic total coronary occlusion. METHODS This is a prospective, single-center study of 69 consecutive patients with chronic total occlusion in whom multidetector computed tomography study was performed before percutaneous coronary revascularization. RESULTS Seventy-seven lesions were analyzed. The mean length of the occlusion was 19.9 (14.3) mm and the estimated duration of occlusion was 47 (62) months. The only angiographic factor independently predictive of failure was a severe curve between the plaque and the proximal patent vessel (odds ratio 3.8, 95% confidence interval, 1.2-12; P=.02). On multidetector computed tomography, the only factor predictive of failure was an arc of calcium affecting more than 50% of the vessel circumference in the proximal (P=.04) and middle (P=.03) third of the occlusion. CONCLUSIONS Multidetector computed tomography identified a variable that cannot be measured by angiography that can predict failure in percutaneous revascularization of chronic total coronary occlusions. In selected cases, this parameter could be useful for preprocedure screening.

Association between sleep-disordered breathing, aminoterminal pro-brain natriuretic peptide (NT-proBNP) levels and insulin resistance in morbidly obese young women.

OBJECTIVE Sleep-disordered breathing (SDB) is often encountered in morbid obesity (MO) in conjunction with insulin resistance (IR) and several cardio-vascular risk factors. Aminoterminal pro-brain natriuretic peptide (NT-proBNP) is a promising marker for left ventricular dysfunction (LVD) in MO. The aim of this study was to look for possible correlations between SDB, IR, heart structure and function indexes and NT-proBNP levels in MO female subjects. MATERIALS AND METHODS Cross-sectional study involving 110 MO (44.5+/-0.7 kg m(-2)) apparently healthy, young (37.8+/-1.0 y.o.) female patients. NT-proBNP was measured using an ELISA kit (Roche). Echo-cardiograms were performed to quantify left ventricular ejection fraction values (LVEF), cardiac output (CO), left ventricular mass (LVM), left atria size (LA) and left ventricular filling pressures (the E/Em ratio). The Berlin Questionnaire (BQ) was used to assess the risk of SDB. IR and sensitivity were assessed using the HOMA index and adiponectin measurements, respectively. RESULTS All patients had a normal LVEF (>50%). Hypertension and Type 2 diabetes mellitus prevalences were 34.5 and 4.5% (respectively). Log-transformed NT-proBNP levels correlated with BQ categories (P<0.0005), creatinine (P<0.001), age (P<0.05), LVM (P<0.001), CO (P<0.001), LA (P<0.0005) and E/Em (P<0.01). NT-proBNP levels, LVD and LVM increased significantly along with BQ scores (P<0.0001). Stepwise multiple regression analysis identified BQ and log-transformed HOMA as independent variables predicting as much as 48.0% of log-transformed NT-proBNPs variability (dependent variable). CONCLUSIONS NT-proBNP levels are independently predicted by SDB and IR in asymptomatic MO women. Additionally, SDB worsens along with LVH and diastolic dysfunction. Larger prospective studies are warranted.

Delayed-contrast enhancement cardioresonance in transient left ventricular apical ballooning

Transient left ventricular apical ballooning (TAB) is a condition that mimics acute coronary syndrome typically without coronary angiographic stenosis. Patients present with typical chest pain, ECG changes suggesting ischemia, and a slight elevation of myocardial injury markers such as Creatine kinase and Troponines. Ballooning during ventricular systole of the cardiac apex is a characteristic feature of this entity. It is transient and it usually resolves after a few days together with normalization of ECG changes. Initially, apical dyskinesis can be diagnosed by any cardiac imaging technique that allows myocardial wall motion assessment. Recent advances in cardiovascular magnetic resonance imaging (CMR) have made this technique to become the gold-standard method to assess myocardial infarction. CMR provides an excellent and reproducible assessment of segmental wall motion abnormalities and, more importantly, it allows an accurate depiction of myocardial necrotic area by means of delayed contrast-enhancement method. Therefore, it may be particularly useful in the assessment of TAB by demonstrating segmental dysfunction in the absence of myocardial irreversible damage. We report three cases of TAB in which contrast- enhanced CMR emerged as an excellent diagnostic tool.

Coronariografía no invasiva mediante tomografía computarizada con multidetectores en pacientes con sospecha de enfermedad coronaria y ergometría no diagnóstica

BACKGROUND AND OBJECTIVE We aimed to establish the diagnostic and prognostic usefulness of noninvasive coronary angiography using multidetector computer tomography (MDCT) in patients with clinical suspicion of coronary artery disease (CAD) and a non-diagnostic exercise treadmill test result. PATIENTS AND METHOD Retrospective analysis in 33 patients evaluating the incidence of revascularization and hospitalization due to myocardial infarction or angina, and death. RESULTS There were obstructive lesions in 7 (21%), non-obstructive lesions in 18 (55%), absence of lesions in 6 (18%), and, finally, 2 patients (6%) had an MDCT deemed as non-evaluable. The follow-up was extended up to 21 (10) months. Events appeared in 5 (15%) patients: 4 myocardial revascularizations in the group with obstructive coronary stenosis, and 1 cardiovascular death in the group with non-obstructive coronary lesions. No events were recorded among those 6 patients without coronary lesions nor in those 2 with non-evaluable MDCT studies. CONCLUSIONS Patients with suspected CAD and a non-diagnostic exercise test present with a high prevalence of CAD when studied by MDCT and have a high incidence of cardiovascular events. The severity of stenosis as assessed by MDCT relates to cardiovascular events during the follow-up.

Original breveCoronariografía no invasiva mediante tomografía computarizada con multidetectores en pacientes con sospecha de enfermedad coronaria y ergometría no diagnósticaNoninvasive coronary angiography using multidetector computed tomography in patients with suspected coronary artery disease and a non-diagnostic exercise treadmill test result

BACKGROUND AND OBJECTIVE We aimed to establish the diagnostic and prognostic usefulness of noninvasive coronary angiography using multidetector computer tomography (MDCT) in patients with clinical suspicion of coronary artery disease (CAD) and a non-diagnostic exercise treadmill test result. PATIENTS AND METHOD Retrospective analysis in 33 patients evaluating the incidence of revascularization and hospitalization due to myocardial infarction or angina, and death. RESULTS There were obstructive lesions in 7 (21%), non-obstructive lesions in 18 (55%), absence of lesions in 6 (18%), and, finally, 2 patients (6%) had an MDCT deemed as non-evaluable. The follow-up was extended up to 21 (10) months. Events appeared in 5 (15%) patients: 4 myocardial revascularizations in the group with obstructive coronary stenosis, and 1 cardiovascular death in the group with non-obstructive coronary lesions. No events were recorded among those 6 patients without coronary lesions nor in those 2 with non-evaluable MDCT studies. CONCLUSIONS Patients with suspected CAD and a non-diagnostic exercise test present with a high prevalence of CAD when studied by MDCT and have a high incidence of cardiovascular events. The severity of stenosis as assessed by MDCT relates to cardiovascular events during the follow-up.