Stephan Hill

Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) Study.

OBJECTIVES This study was conducted to clarify the incidence of coronary spasm in emergency patients with suspected acute coronary syndrome (ACS) and acute chest pain at rest. BACKGROUND Chest pain at rest is a frequent symptom in the emergency room. Acute coronary syndrome is suspected in patients with elevation of cardiac markers, ischemic electrocardiographic changes, or simply typical clinical symptoms of unstable (usually resting) angina. However, of all patients with suspected ACS who undergo coronary angiography, up to 30% have nonobstructed coronary arteries. We sought to clarify how many of these patients suffer from coronary spasm as a possible cause of their chest pain. METHODS In a prospective study from June to December 2006, all patients with suspected ACS who underwent coronary angiography and had no culprit lesion underwent intracoronary provocation with acetylcholine. The ACH testing was considered positive at a vasoconstriction of >/=75% relative to the diameter after intracoronary nitroglycerine when the initially reported symptoms could be reproduced. RESULTS Of 488 consecutive patients, 138 had no culprit lesion (28%). Twenty-two were found to have another diagnosis. The ACH testing was performed in 86 of the remaining 116 patients. In 42 patients, coronary spasm was verified (49%). CONCLUSIONS Every fourth patient with ACS had no culprit lesion. Coronary spasm could be documented in nearly 50% of the patients tested by ACH. Coronary spasm is a frequent cause of ACS and should regularly be considered as a differential diagnosis.

Long-Term Follow-Up of Biopsy-Proven Viral Myocarditis Predictors of Mortality and Incomplete Recovery

OBJECTIVES This study sought to evaluate the long-term mortality in patients with viral myocarditis, and to establish the prognostic value of various clinical, functional, and cardiovascular magnetic resonance (CMR) parameters. BACKGROUND Long-term mortality of viral myocarditis, as well as potential risk factors for poor clinical outcome, are widely unknown. METHODS A total of 222 consecutive patients with biopsy-proven viral myocarditis and CMR were enrolled. A total of 203 patients were available for clinical follow-up, and 77 patients underwent additional follow-up CMR. The median follow-up was 4.7 years. Primary endpoints were all-cause mortality and cardiac mortality. RESULTS We found a relevant long-term mortality in myocarditis patients (19.2% all cause, 15% cardiac, and 9.9% sudden cardiac death [SCD]). The presence of late gadolinium enhancement (LGE) yields a hazard ratio of 8.4 for all-cause mortality and 12.8 for cardiac mortality, independent of clinical symptoms. This is superior to parameters like left ventricular (LV) ejection fraction, LV end-diastolic volume, or New York Heart Association (NYHA) functional class, yielding hazard ratios between 1.0 and 3.2 for all-cause mortality and between 1.0 and 2.2 for cardiac mortality. No patient without LGE experienced SCD, even if the LV was enlarged and impaired. When focusing on the subgroup undergoing follow-up CMR, we found an initial NYHA functional class >I as the best independent predictor for incomplete recovery (p = 0.03). CONCLUSIONS Among our population with a wide range of clinical symptoms, biopsy-proven viral myocarditis is associated with a long-term mortality of up to 19.2% in 4.7 years. In addition, the presence of LGE is the best independent predictor of all-cause mortality and of cardiac mortality. Furthermore, initial presentation with heart failure may be a good predictor of incomplete long-term recovery.

Comparative Evaluation of Left and Right Ventricular Endomyocardial Biopsy Differences in Complication Rate and Diagnostic Performance

Background— Endomyocardial biopsy (EMB) represents the gold standard for diagnosing myocarditis and nonischemic cardiomyopathies. This study focuses on the risk of complications and the respective diagnostic performance of left ventricular (LV), right ventricular (RV), or biventricular EMB in patients with suspected myocarditis and/or cardiomyopathy of unknown origin. Methods and Results— In this 2-center study, 755 patients with clinically suspected myocarditis (n=481) and/or cardiomyopathy of nonischemic origin including those with infiltrative or connective tissue disease (n=274) underwent either selective LV-EMB (n=265; 35.1%), selective RV-EMB (n=133; 17.6%), or biventricular EMB (n=357; 47.3%) after coronary angiography and exclusion of significant coronary artery disease. Cardiovascular magnetic resonance, including late gadolinium enhancement, imaging was performed in 540 patients (71.5%). The major complication rate for LV-EMB was 0.64% and for RV-EMB, 0.82%. Considering postprocedural pericardial effusion that occurred after biventricular EMB, the minor complication rate for LV-EMB varied between 0.64% to 2.89% and for RV-EMB, between 2.24% and 5.10%. Diagnostic EMB results were achieved significantly more often in those patients who underwent biventricular EMBs (79.3%) compared to those who underwent either selective LV-EMB or selective RV-EMB (67.3%; P<0.001). In patients with biventricular EMB, myocarditis was diagnosed in LV-EMB samples in 18.7% and in RV-EMB samples in 7.9% (P=0.002), and it was diagnosed in both ventricles in 73.4%. There were no differences in the number of positive LV-EMB, RV-EMB, or LV- and RV-EMB findings when related to the site of cardiovascular magnetic resonance–based late gadolinium enhancement. Conclusions— Both LV-EMB and RV-EMB are safe procedures if performed by experienced interventionalists. The diagnostic yield of EMB may be optimized when samples from both ventricles are available. Preferential biopsy in regions showing late gadolinium enhancement on cardiovascular magnetic resonance does not increase the number of positive diagnoses of myocarditis.

Clinical Usefulness, Angiographic Characteristics, and Safety Evaluation of Intracoronary Acetylcholine Provocation Testing Among 921 Consecutive White Patients With Unobstructed Coronary Arteries

Background— Coronary spasm can cause myocardial ischemia and angina in patients with and those without obstructive coronary artery disease. However, provocation tests using intracoronary acetylcholine administration are rarely performed in clinical routine in the United States and Europe. Thus, we assessed the clinical usefulness, angiographic characteristics, and safety of intracoronary acetylcholine provocation testing in white patients with unobstructed coronary arteries. Methods and Results— From September 2007 to June 2010, a total of 921 consecutive patients (362 men, mean age 62±12years) who underwent diagnostic angiography for suspected myocardial ischemia and were found to have unobstructed coronary arteries (no stenosis ≥50%) were enrolled. The intracoronary acetylcholine provocation testing was performed directly after angiography according to a standardized protocol. Three hundred forty-six patients (35%) reported chest pain at rest, 222 (22%) reported chest pain on exertion, 238 (24%) reported a combination of effort and resting chest pain, and 41 (4%) presented with troponin-positive acute coronary syndrome. The overall frequency of epicardial spasm (>75% diameter reduction with angina and ischemic ECG shifts) was 33.4%, and the overall frequency of microvascular spasm (angina and ischemic ECG shifts without epicardial spasm) was 24.2%. Epicardial spasm was most often diffuse and located in the distal coronary segments (P<0.01). No fatal or irreversible nonfatal complications occurred. However, 9 patients (1%) had minor complications (nonsustained ventricular tachycardia [n=1], fast paroxysmal atrial fibrillation [n=1], symptomatic bradycardia [n=6], and catheter-induced spasm [n=1]). Conclusions— Epicardial and microvascular spasm are frequently found in white patients with unobstructed coronary arteries. Epicardial spasm is most often diffuse and located in the distal coronary segments. The intracoronary acetylcholine provocation test is a safe technique to assess coronary vasomotor function.

Usefulness of Pericardial Effusion as New Diagnostic Criterion for Noninvasive Detection of Myocarditis

Cardiovascular magnetic resonance (CMR) imaging holds promise for diagnosing myocarditis in vivo. The CMR diagnosis of myocarditis is determined by the ventricular morphology/function, late gadolinium enhancement, and T(2)-weighted imaging for myocardial edema. However, in routine clinical practice, we encounter patients with suspected myocarditis in the absence of left ventricular dysfunction, myocardial edema, or late gadolinium enhancement. In the present study, we sought to determine whether the presence of pericardial effusion could serve as a new diagnostic criterion and improve the sensitivity of CMR imaging to detect myocarditis. A total of 35 consecutive patients with biopsy proven virus-associated myocarditis, onset of clinical symptoms within the past 3 months, and normal left ventricular function were enrolled in the present study. All patients underwent echocardiography, CMR imaging, and endomyocardial biopsy for workup of myocarditis. Late gadolinium enhancement was present in 16 patients (46%). Myocardial edema on T(2)-weighted imaging was present in 4 patients, but in just 1, it was the only abnormal finding. Pericardial effusion was present in 14 patients (40%). In 7 patients with myocarditis (20%), pericardial effusion was the only abnormal finding. Pericardial effusion, used as an additional diagnostic criterion, improved the sensitivity of CMR imaging for myocarditis from 46% to 66% (p = 0.023). In conclusion, pericardial effusion detected by CMR imaging might serve as a new diagnostic criterion for the noninvasive diagnosis of myocarditis in patients with recent onset of clinical symptoms and normal left ventricular function.

Exercise-Induced Spastic Coronary Artery Occlusion at the Site of a Moderate Stenosis Neither Prinzmetal's Angina nor Cardiac Syndrome X but “Prinzmetal X”

A 44-year-old man was referred to our hospital to undergo coronary angiography because of suspected coronary artery disease. For approximately 2 weeks, the patient had been experiencing typical symptoms of angina pectoris that occurred exclusively during physical exercise and predominantly in the morning hours when he bicycled to work. His general practitioner had performed a bicycle exercise test. In his written report, the practitioner noted that he suspected hemodynamically significant coronary artery disease because of reproduction of typical angina pectoris in addition to ischemic ECG changes. On admission, the patient was in good general condition with no symptoms at rest. Coronary angiography revealed an ≈80% stenosis in the small right coronary artery and an ≈50% stenosis in the proximal segment of the left anterior descending artery (LAD), although systolic left ventricular function was normal (Figure 1). Fractional flow measurements (fractional flow reserve) were performed in the right coronary artery and the LAD and revealed a significantly impaired fractional flow reserve only in the right coronary artery (fractional flow reserve 70%) and not in the LAD (fractional flow reserve 85%). Thus, the right coronary artery stenosis was treated with a drug-eluting stent (Figure 1), and the patient was discharged on medical therapy. Figure 1. Coronary angiograms of the left coronary artery (LCA) and right coronary artery (RCA) at first presentation. A stenosis of ≈50% was observed in the proximal segment of the LAD (left; black arrow), and an ≈80% stenosis was observed in the RCA (middle; black arrow). The stenosis of the RCA was stented successfully with a drug-eluting stent (right; black arrow). PCI indicates percutaneous coronary intervention. Six weeks later, the patient was referred again to our department because of unchanged symptoms of exercise-induced …

Contained aortic annulus rupture with persisting false aneurysm after transfemoral transcatheter aortic valve implantation

With older age and increasing comorbidities, conventional operative procedures for severe symptomatic aortic stenosis are associated with a high surgical risk. To date, transfemoral transcatheter aortic valve implantation (TF-TAVI) represents an accepted alternative method of intervention with a cardiovascular and all-cause mortality similar to operative replacement at early and long-term follow-up in this high risk population (Thomas et al., Circulation 124:425–433, 2011). Despite growing experience of the operators and improvement of the devices procedural and perioperative complications still occur (Panchal et al., Am J Cardiol, 2013). Aortic annulus rupture as well as the rupture of the membranous ventricular septum has been reported (Aminian et al., Catheter Cardiovasc Interv 81:E72–E75, 2013). We present the unusual case of an 80-year-old female who developed a false aneurysm following a contained aortic annulus rupture during a TF-TAVI procedure.

Conventional versus Transapical Aortic Valve Replacement: Is It Time for Shift in Indications?

Background The incidence of degenerative aortic valve diseases has increased along with the life expectancy of our population. Although conventional aortic valve replacement (AVR) is the gold standard for symptomatic aortic stenosis, transcatheter procedures have proven to be a valid therapeutic option in high‐risk patients. The aim of this study was to compare these procedures in a high‐risk cohort. Methods We retrospectively analyzed all symptomatic (dyspnea or angina) high‐risk patients (logistic EuroSCORE ≥ 15%) fulfilling the transcatheter aortic valve implantation (TAVI) indications. Most of the AVR patients (n = 180) were operated on before the implementation of TAVI. All TAVI procedures (n = 127) were performed transapically (TA). After matching for age, logistic EuroSCORE, and left ventricular ejection fraction, 82 pairs of patients were evaluated. Results When comparing AVR with TA‐TAVI, there was no difference between groups in survival after 1 year (Kaplan‐Meier analysis, 81.1% [95% CI: 72.5‐89.7%] vs. 75.8% [95% CI: 66.2‐75.9%], Log tank p = 0.660) and the complication rates (n for AVR vs. TA‐TAVI: stroke, 2 vs. 0, p = 0.580; acute renal insufficiency, 8 vs. 12, p = 0.340; atrial fibrillation, 24 vs. 26, p = 0.813; pacemaker implantation, 4 vs. 4, p > 0.999). In addition, quality of life did not differ between groups. Patients in the TA‐TAVI group had lower mean valvular gradients postoperatively compared with the AVR group (14.6 ± 6.6 vs. 10.2 ± 4.9 mm Hg, p < 0.001). Conclusion For high‐risk patients, the TAVI procedure is comparable with conventional AVR, but is not advantageous. These results do not support the expansion of TAVI to low‐ or intermediate‐risk patients.

Case report: acute coronary artery spasm in a patient in the setting of non-cardiac surgery.

Sirs: Coronary artery spasm reduces coronary blood flow and consequently oxygen delivery to the myocardium. It may occur suddenly and may be associated with a severe reduction in blood pressure and cardiac arrest. It must be recognised early because delayed treatment (that consists of giving vasodilators, particularly nitrates) may have fatal consequences, while appropriate and immediate treatment is associated with a good prognosis. This is a report of a patient with coronary artery spasm in the setting of noncardiac surgery. We report the case of a 45-year-old male patient with a significant smoking history (40 pack years). His past medical history was unremarkable and he had no history of recurrent chest pain or coronary artery disease (CAD). He presented to the referring hospital with a 4-week history of progressively increasing dyspnoea on exertion. Examination revealed a right pleural effusion which on aspiration revealed thick purulent material. Blood tests were significant for leukocytosis: 27.8 9 10/mm (normal range 3.9–10.2 9 10/mm) and a raised C-reactive protein: 24.4 mg/dl (normal range 0.1–0.5 mg/dl). The chest radiographs further confirmed a right pleural empyema for which he underwent thoracotomy and decortication under general anaesthesia. The depth of anaesthesia was monitored using BIS methods. Vital signs before surgery were within normal limits. Initial ECG showed no pathological findings (Fig. 1). Intraoperatively, copious purulent secretions were seen in the lungs and bronchial system, blood gases deteriorated momentarily in surgery with SaO2 between 66.6 and 86.4 %, and PaO2 between 55.2 and 67.3 mmHg with acidosis (pH 7.093–7.279), but this improved to normal levels following removal of the copious material and continuous administration of oxygen. Two hours after the onset of surgery, the patient deteriorated and was hemodynamically unstable with a drop in blood pressure and circulatory collapse. This was initially thought to be due to sepsis, and the patient was given nor-adrenaline and intravenous normal saline with a temporary improvement in blood pressure levels. Following the surgery, he was moved to the intensive care unit where his clinical state worsened, and the patient was placed on continuous infusion of adrenaline. The patient developed cardiovascular collapse with ventricular fibrillation and was resuscitated. Blood tests taken immediately post-operatively showed a raised troponin-T level of 135 pg/ml (normal range\14 pg/ml). The ECG showed ST segment elevation in the leads V1–V4 suggestive of anteroseptal myocardial infarction (Fig. 2), and the patient was referred to the cardiac unit of our hospital. On presentation, the patient was in a poor clinical state, on a continuous infusion of adrenaline at a dose of 0.5 mcg/kg/min, intubated, tachycardic with a pulse of 120/min and with hypotensive blood pressure of 70/40 mmHg. Serial blood troponin-T levels revealed increasing levels up to 1,790 pg/ml in the first 24 h after presentation. The patient underwent an emergency cardiac catheterisation. The first coronary angiograms showed a severe stenosis of the proximal left anterior descending coronary artery (LAD) distal to the left main with diffuse non-calcified plaque throughout the LCA. Surprisingly, this stenosis quickly and completely disappeared after intracoronary infusion of 0.2 mg nitroglycerine (Fig. 3a, b). The patient remained clinically stable following the procedure and was discharged back to the referring hospital N. Aikpokpo (&) S. Hill U. Sechtem Department of Cardiology, Robert Bosch Krankenhaus, Auerbachstrasse 110, 70376 Stuttgart, Germany e-mail: ginnyaik@yahoo.com

Response to Letters Regarding Article, “Clinical Usefulness, Angiographic Characteristics, and Safety Evaluation of Intracoronary Acetylcholine Provocation Testing Among 921 Consecutive White Patients With Unobstructed Coronary Arteries”

We thank Dr Mohri for his insightful comments. We completely agree with Dr Mohri that standardization of intracoronary provocation testing for coronary spasm with respect to dosage, infusion time, and a route of administration is urgently needed, as mentioned in our article.1 As highlighted in the Methods section of our article, the maximum dosage of 200 μg acetylcholine for the left coronary artery was derived from the Evaluation of Nifedipine on Coronary Endothelial Function (ENCORE) study. In this trial, the dose for the left anterior descending artery and for the left circumflex artery was 100 μg in each vessel injected via a selective catheter in a coronary segment without significant coronary artery disease. In the most constricting segment, this dose of acetylcholine reduced the coronary diameter …