U. Rosenschein

Exercise Training Improves Diastolic Function in Heart Failure Patients

PURPOSE The studys purpose was to analyze the effects of exercise training on exercise tolerance and left ventricular systolic function and structure in heart failure patients with preserved, mild, and moderate to severe reduction of left ventricular ejection fraction (LVEF). METHODS Ninety-eight patients with moderate to severe (n = 34), mild (n = 33), and preserved (n = 31) LVEF were randomly assigned to exercise training plus usual care (n = 65) or usual care alone (n = 33) in a randomization ratio of 2:1. Left ventricular function, left ventricular dimensions, and exercise tolerance were assessed before and after each intervention. RESULTS Exercise tolerance and LVEF increased with exercise training in all patient groups, whereas they remained unchanged after usual care alone. Exercise training increased the mean ratio of early to late mitral inflow velocities (E/A ratio) and decreased deceleration time (DT) of early filling in patients with mild and preserved LVEF. In patients with moderate to severe systolic dysfunction and advanced diastolic dysfunction (DT < 160 ms), exercise training decreased E/A ratio and increased DT, both of which were unchanged after usual care alone. In the remaining patients (DT > 160 ms), exercise training also improved mitral inflow patterns. Exercise training decreased left ventricular dimensions in patients with mild and moderate to severe reduction of LVEF but not in patients with preserved LVEF. CONCLUSIONS These results indicate that exercise training can improve the course of heart failure independent of the degree of baseline left ventricular dysfunction.

Huge Pericardial Hemangioma Imaging

A 37-year-old healthy woman presented to our emergency department because of episodes of palpitation and syncope. Her general physical examination was unremarkable. The x-ray of her chest was normal except for bulging near the left border of her heart (Figure 1). Her ECG exhibited sinus tachycardia and short runs of monomorphic ventricular tachycardia. Consequently, the patient was admitted to the cardiology intensive care unit for further investigation. Transthoracic echocardiogram and transesophageal echocardiogram showed a large, rounded, extracardiac hypoechogenic mass within the posterosuperior portion of the heart (Figure 2A). Further evaluation of the mass was performed by cardiac computed tomography angiography using 64-row multidetector computed tomography. Cardiac computed tomography angiography revealed a large, hypodense, epicardial solid mass (9×6×6 cm) with small central areas of enhancement. The mass was located posteriorly to the right ventricle outflow tract and ascending aorta, at the level of the left coronary sinus of Valsalva, causing compression and displacement of the left atrium and the left superior pulmonary vein. In addition, …

Embolic protection: Limitations of current technology and novel concepts

Distal embolic event is one of the major limitations of coronary and non‐coronary vascular interventions. Balloon and filter‐based Embolic Protection Devices (EPDs) are a new class of interventional devices, used to prevent consequential morbidity and mortality of the distal embolic events. Data from first generation EPD supply proof of concept and show approximately 40% reduction in mortality and morbidity, when EPDs are used during saphenous vein grafts (SVGs) interventions. Current limitations of all first generation EPD technology taper their penetration. With breakthroughs in embolic protection technology, it is estimated that, in the near future, EPDs will be used with stenting in all high‐risk lesions (SVGs, carotid arteries and acute coronary syndromes), become the standard of care and even be used in low risk cases.

Left anterior descending coronary artery flow after primary angioplasty in acute anterior ST-elevation myocardial infarction: How much flow is needed for left ventricular functional recovery?

The treatment of choice in acute ST-elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (PPCI). Although, thrombolysis in myocardial infarction (TIMI) and myocardial blush grade (MBG) measures provide semi-quantitative flow evaluation after PPCI, serial and quantitative volumetric flow evaluation is still lacking. Aim: Serial assessment of left anterior descending (LAD) coronary artery flow in patients with anterior myocardial infarction (MI), immediately after PPCI, 48 h later and pre-discharge and compare findings in patients with optimal and suboptimal PPCI result and their relation to left ventricular ejection fraction (LVEF). Methods: Velocities in the LAD were recorded within 6 h after PPCI and one week later in 36 patients presenting with acute anterior STEMI. Sixteen patients had TIMI and MBG less than 3 after PPCI were considered to have suboptimal result. Sampling of LAD coronary artery velocity was obtained from trans-thoracic Doppler. Flow in the LAD coronary artery was estimated using heart rates, Doppler time velocity integrals and LAD color Doppler diameters. Results: Diastolic LAD coronary artery flow immediately after PPCI in subjects with suboptimal PPCI, 29±21 ml/min was lower than in those with optimal result, 39.8±21 ml/min, p<0.05. Diastolic flow in the LAD coronary artery increased to 50.3±28.5 ml/min two days after PPCI in patients with suboptimal PPCI, p=0.04, and to 49.6±13.8 ml/min in those optimal result, p=0.04. LVEF increased by 9% in patients with optimal PPCI, p=0.004, and did not change in the other group. Conclusions: (a) After PPCI, flow in the LAD coronary artery was dynamic; (b) in the presence of suboptimal PPCI, early LAD coronary artery flow was reduced; (c) pre-discharge, LAD coronary artery flow increased; and (d) LVEF increased only in optimal PPCI group associated with higher early LAD coronary artery flow.

Serum Endothelin-1, MMP-9, and Myeloperoxidase and Coronary Artery Morphology as Detected by Multi-Slice CT Angiography in Intermediate and High Risk Asymptomatic Subjects

Objectives: To study possible correlation between Endothelin-1, Matrix-metallo-proteinase- 9, and Myeloper- oxidase serum activity and coronary CT angiography findings of atherosclerotic coronary artery disease in intermediate - high risk asymptomatic subjects. Methods: 65 consecutive asymptomatic subjects, 53 males and 12 females, mean age 58.8 +/-10.9 s.d., referred by their primary practitioner for the evaluation of coronary artery atherosclerotic disease by Cardiac CT exam were selected for the study. One serum sample was drawn from each participant and examined for the levels of Endothelin -1, MMP-9, MPO serum activity. Obstructive coronary artery disease was defined as at least 50 percent stenosis of one or more coro- nary segments. Plaques were identified as calcified or soft according to the CT Hounsfield attenuation number. Results: The Endothelin activity level was significantly elevated in subjects with significant obstructive coronary artery disease (p=0.022). Furthermore, high Endothelin activity level was found to correlate with calcified plaque burden (p=0.006), and to be an independent determinant of lesion severity (R 2 = 0.124, R 2 change = 0.006, p= 0.008) Conclusions: Endothelin-1 may be a marker of significant obstructive coronary disease and calcified plaque burden in as- ymptomatic subjects. The significance of MMP-9 and MPO as markers of atherosclerosis in such subjects has not been definitely clarified.

Platelet counts on admission affect coronary flow, myocardial perfusion and left ventricular systolic function after primary percutaneous coronary intervention.

Background: Patients with acute ST-elevation myocardial infarction (STEMI) and increased platelet count treated by fibrinolysis have worse outcomes. Aim: The aim of this study was to test the hypothesis that platelet blood count at admission in patients with acute STEMI treated by primary percutaneous coronary intervention affects coronary flow, myocardial perfusion and recovery of left ventricular systolic function. Methods: A total of 174 patients presenting with acute anterior STEMI and treated with primary percutaneous coronary intervention were included and divided into subgroups of admission platelet blood count of <200 K, 200–300 K, 300–400 K and >400 K. Evaluation of coronary artery flow and myocardial blush grade was performed according to the TIMI criteria. Electrocardiographic ST elevation resolution post-primary percutaneous coronary intervention was evaluated. Doppler echocardiographic evaluation of left anterior descending coronary artery velocities early and late after primary percutaneous coronary intervention and assessment of left ventricular ejection fraction and wall motion score index (WMSI) of left ventricular and left anterior descending coronary artery territory were performed. Results: Post-primary percutaneous coronary intervention TIMI, myocardial blush grade and ST elevation resolution were similar in all groups. Patients with platelet counts <200 K had higher peak diastolic left anterior descending coronary artery velocity both early and late after primary percutaneous coronary intervention, and higher prevalence of left anterior descending coronary artery velocity deceleration time exceeding 600 ms, (45.5% vs. 40%, P<0.05). Patients with platelet counts >400 K presented with worse left ventricular ejection fraction, left ventricular WMSI and left anterior descending coronary artery WMSI, and before discharge this subgroup had worse left ventricular WMSI and left anterior descending coronary artery WMSI, P<0.01. Conclusions: Patients with anterior STEMI treated by primary percutaneous coronary intervention with lower admission platelet count had higher left anterior descending coronary artery diastolic velocities, better myocardial perfusion with more patients having left anterior descending coronary artery–descending coronary artery velocity deceleration time >600 ms. Patients with higher platelet counts had lower left ventricular systolic function both at admission and before discharge.

Differences in coronary artery blood velocities in the setting of normal coronary angiography and normal stress echocardiography

Background Normal left anterior descending (LAD) coronary artery as determined by coronary angiography is considered not only to reflect normal angiography but also to correlate with normal anatomy and function. However, subjects who undergo coronary angiography may differ from those who do not need to have invasive evaluation even if their functional noninvasive studies like dobutamine stress echocardiography (DSE) were normal. Aim LAD velocities in subjects with normal angiography and those with normal DSE are equal. Methods A total of 244 subjects were evaluated, 78 had normal LAD by angiography and 166 had normal LAD by DSE. All had Doppler sampling of LAD velocities by transthoracic echocardiography. Results Velocity was higher in the angiographic subgroup in diastole 41 ± 23 vs 33 ± 14 cm/s, p = 0.0078; systole 18 ± 14 vs 13 ± 7 cm/s, p = 0.012; diastolic integral 12.6 ± 5 vs 9.8 ± 3.8 cm, p = 3.15 × 10-5; systolic velocity integral 4 ± 2.9 vs 2.8 ± 1.9, p = 0.0014. While heart rate was similar in both groups, the product of diastolic velocity integral and heart rate of the LAD in the angiographic group was higher: 902 ± 450 vs 656 ± 394, p = 0.00599. Diastolic velocity deceleration time was similar in both groups. Coronary flow reserve defined as diastolic velocity ratio before and immediately after DSE correlated negatively with baseline velocity, r = -0.4. Conclusions Mode of defining normality of coronary artery affects velocity behavior of the vessel, reflecting functional differences possibly related to microvasculature and vasodilatation.