Wojciech Wróbel

Sudden death in hypertrophic cardiomyopathy: old risk factors re-assessed in a new model of maximalized follow-up.

AIMS in hypertrophic cardiomyopathy (HCM), the following five risk factors have a major role in the primary prevention of sudden death (SD): family history of SD (FHSD), syncope, massive wall thickness (MWTh) >30 mm, non-sustained ventricular tachycardia (nsVT) in Holter monitoring of electrocardiography, and abnormal blood pressure response to exercise (aBPRE). In HCM, as a genetic cardiac disease, the risk for SD may also exist from birth. The aim of the study was to compare the survival curves constructed for each of the five risk factors in a traditional follow-up model (started at the first presentation of a patient at the institution) and in a novel follow-up model (started at the date of birth). In an additional analysis, we compared the survival rate in three subgroups (without FHSD, with one SD, and with two or more SDs in a family). METHODS AND RESULTS a total of 1306 consecutive HCM patients (705 males, 601 females, mean age of 47 years, and 193 patients were <18 years) evaluated at 15 referral centres in Poland were enrolled in the study. In a novel method of follow-up, all the five risk factors confirmed its prognostic power (FHSD: P = 0.0007; nsVT: P < 0.0001; aBPRE: P = 0.0081; syncope: P < 0.0001; MWTh P> 0.0001), whereas in a traditional method, only four factors predicted SD (except aBPRE). In a novel model of follow-up, FHSD in a single episode starts to influence the prognosis with a delay to the fifth decade of life (P = 0.0007). Multiple FHSD appears to be a very powerful risk factor (P < 0.0001), predicting frequent SDs in childhood and adolescence. CONCLUSION the proposed concept of a lifelong calculated follow-up is a useful strategy in the risk stratification of SD. Multiple FHSD is a very ominous risk factor with strong impact, predicting frequent SD episodes in the early period of life.

Predictive value of ischemic mitral regurgitation during the acute phase of ST elevation myocardial infarction treated with primary coronary intervention for left ventricular remodeling in long-term follow-up.

Reperfusion therapy, mainly primary percutaneous coronary intervention (PCI), has improved survival and lowered complication rate in patients with ST elevation myocardial infarction (STEMI). Nevertheless, some patients develop left ventricular remodeling (LVR) during long-term follow-up. AimsTo assess the incidence of ischemic mitral regurgitation (MR) in the acute phase of STEMI treated with primary PCI. To assess prognostic value of MR during acute STEMI for prediction of LVR during long-term follow-up. MethodsThis is a prospective, single-center study in 83 patients with the first STEMI. Inclusion criteria were as follows: time from symptom onset to PCI less than 12 h and successful restoration of blood flow (thrombolysis in myocardial infarction 3) in the infarct-related coronary artery. Transthoracic echocardiography was performed at discharge and 6 months after the MI. ResultsAt hospital discharge, ischemic MR was found in 35 (42%) patients. At 6 months follow-up, LVR was present in 21 (25%) patients. Univariate analysis revealed that remodeling could be predicted by age, weight, treatment with abciximab, left ventricular ejection fraction (LVEF), leaflets coaptation, coaptation height, tenting area, presence of MR, degree of MR. The best multivariate logistic regression model for remodeling prediction at 6 months was combination of ischemic MR degree (odds ratio (OR)=14.5; 95% confidence interval (CI): 3.89–54.0, P<0.00005), abciximab therapy (OR=0.09; 95% CI: 0.01–0.84, P<0.03) and LVEF (OR=0.89; 95% CI: 0.81–0.99, P<0.03). ConclusionIschemic MR in STEMI is frequent, even despite effective primary PCI. The regurgitation grade and lower LVEF assessed at hospital discharge and lack of abciximab administration could predict development of LVR at 6 months.

Microvascular damage prevention with thrombaspiration during primary percutaneous intervention in acute myocardial infarction.

BackgroundDespite rapid and complete recanalization of infarct-related artery with percutaneous coronary intervention, microvascular integrity is not often preserved. Several mechanical devices have been proposed to prevent distal embolization, but the impact of these devices on myocardial perfusion remains controversial. AimThe aim of our study was to assess microvascular damage reduction with quantitative myocardial contrast perfusion echocardiography among patients with the first anterior acute myocardial infarction treated with thromboaspiration during percutaneous coronary intervention. MethodsForty-two patients (57.4±10 years, 74% males) with first anterior acute myocardial infarction were randomized 1 : 1 to intracoronary thromboaspiration followed by stenting, or to a conventional strategy of stenting alone. Echocardiogram and quantitative myocardial contrast echocardiography were performed 7 days and 1 month later, respectively. Parameter A (reflecting myocardial blood volume), &bgr; (reflecting velocity, myocardial blood flow), and product of A and &bgr; as indicator of myocardial blood flow were analyzed. For each patient mean value of A, &bgr;, and A×&bgr; from all dysfunctional segments was calculated. ResultsThe study population was divided into two groups: thromboaspiration (group I, 19 patients) and stenting alone (group II, 23 patients). No difference was observed between the both groups in demographic, clinical, echocardiographic, and angiographic data. Parameter A and A×&bgr; were significantly higher in group I than in group II: 8.58±2.54 versus 5.29±3.18 dB (P<0.001) and 5.29±3.73 versus 2.78±3.03 dB/s (P<0.001). Multivariate step-down regression analysis revealed that only thromboaspiration before stenting and lower maximum troponin I have been associated with viability preservation in infarcted region. ConclusionThromboaspiration before stenting in patients with the first anterior myocardial infarction improves myocardial perfusion at the tissue level assessed by quantitative myocardial contrast echocardiography.

Low-dose dobutamine stress echo for reverse remodeling prediction after cardiac resynchronization

PURPOSE Cardiac resynchronization therapy (CRT) is a valuable option for patients with heart failure and wide QRS to reduce electromechanical dyssynchrony (DYS). High non-responders rate (30%) urges the need to improve selection of candidates for CRT. We hypothesized that low-dose dobutamine stress echocardiography (DSE) can help unmask dyssynchronous motion. The aim of this study is comparison between dyssynchrony index at rest and during low-dose dobutamine stress to predict left ventricular reverse remodeling after CRT. PATIENTS AND METHODS Prospectively, 57 consecutive patients (37 male) aged 61.8±9 who qualified for CRT according to current guidelines were enrolled. Two dimensional echocardiography and tissue Doppler imaging (TDI) were performed before and 6 month after CRT to assess reverse remodeling (rLV). Additionally DSE was performed before CRT. DYS was assessed at rest (DYSr) and peak DSE (DYSd) separately, as a difference between time to peak systolic velocity (Ts) of septum and lateral wall. Ts was corrected for heart rate. RESULTS rLV defined as decrease ≥15% of LVESV at follow-up was found in 38 (67%) patients. DYSr and DYSd were independent predictors of rLV (OR=1.04, Cl ±1.02-1.06, p<0.02 and OR=1.05, Cl±1.03-1.08, p<0.0002 respectively). ROC analysis found that DYSr>42ms and DYSd>59ms had sensitivity of 70% and 87%, specificity of 61% and 78%, and accuracy of 70% and 84% respectively for prediction of reverse remodeling LV. Area under Receiver Operating Characteristic Curve for DYSd was higher than for DYSr (0.89 vs 0.71, p<0.007). CONCLUSION Exercise intraventricular dyssynchrony assessed by dobutamine stress echo is a strong independent predictor of cardiac resynchronization therapy response.

Role of left atrial speckle tracking echocardiography in predicting persistent atrial fibrillation electrical cardioversion success and sinus rhythm maintenance at 6 months.

PURPOSE We assessed the value of left atrium speckle tracking imaging (STI) indices, and clinical and other echocardiographic parameters in persistent atrial fibrillation (AF) patients to predict the efficacy of electrical cardioversion (EC) and sinus rhythm (SR) maintenance at 6 months. MATERIAL/METHODS Eighty persistent AF patients planned to receive EC, underwent echocardiography including STI. After 24h, patients with successful EC were examined to predict SR maintenance. After 6 months patients with no AF recurrence in electrocardiogram (ECG) underwent 7-day ECG to exclude silent AF. Every AF>1 min was a recurrence. RESULTS SR restored in 61 patients, 19 unsuccessful. Prior use of statins (68.8% vs. 42.1%, p=0.03) was the only factor, determined later by univariate analysis to be a significant EC success predictor (OR=1.09, CL ± 95% 1.001-1.019, p<0.03). Both groups received similar antiarrhythmics and had similar echocardiographic parameters. After 6 months, SR was maintained in 19 patients (31.1%, Group I); AF recurrences were registered in 42 patients (68.8%, Group II). In Group I, only the mitral valve deceleration time (MVDT) 224.18 ± 88.13 vs. 181.6 ± 60.6 in Group II, p=0.04) and the dispersion of time to peak longitudinal strain (dTPLS) (86.0 ± 68.3 vs. 151.8 ± 89.6, p=0.03) differed significantly. The univariate analysis revealed dTPLS as a significant predictor of SR maintenance. CONCLUSION High EC efficacy and frequent AF recurrences were observed. The dispersion of time to the maximal longitudinal strain (LS) of left atrial segments facilitated prediction of SR maintenance. The value of 7-day ECG monitoring for detection of arrhythmia after 6 months was limited.

Left ventricular diverticulum mimicking cardiac tumor

Left ventricular (LV) diverticulum represents a rare and frequently asymptomatic congenital anomaly, which is incidentally discovered during routine transthoracic echocardiography. We present a case of a 66‐year‐old female patient who was admitted to the cardiology department due to incidental finding of a tumor‐like mass associated with the posterior mitral leaflet. Preliminary echocardiographic evaluation revealed a solid structure, suspected of mitral annulus calcification or LV malignancy. However, cardiac contrast‐enhanced computed tomography confirmed the presence of LV diverticulum, partially filled with calcified thrombus. Conservative management was recommended. This case underscores the importance of multimodality imaging for differentiation of LV tumor‐like structures.

Fracture of a carotid stent and restenosis of common carotid artery.

In recent years we have observed dynamic growth in the amount of carotid stenting (CAS) as an alternative to surgical endarterectomy (CEA) [1]. We present a case of stent fracture of a balloon-expanding stent in a patient who underwent stenting for stenoses of the common and internal left carotid arteries. A 56-year-old hypertensive woman was admitted to our institution in March 2007 due to symptomatic recurrent left carotid artery stenosis, manifested by headaches, dizziness, and transient visual disorders. In 1998, she experienced a stroke, after which she underwent a bilateral carotid endarterectomy. On admission, the patient reported periodic headaches and dizziness, transient visual disorders, and persistent aphasia. Additionally, she complained of some chest pain on exertion (class 3 CCS). Neurological examination revealed discrete symptoms of left-sided paresis, pyramidal signs on the right side, and a small motor aphasia. The patient was on permanent treatment with aspirin, clopidogrel, β-blockers, angiotensin-converting enzymes inhibitors, calcium channel blockers, diuretics and statins. Nuclear magnetic resonance (NMR) performed in ambulatory conditions did not indicate central nervous system damage. An ultrasound scan revealed a high-grade stenosis in the left internal carotid artery (LICA) – restenosis after CEA, with no significant flow disturbances in the right internal carotid artery (RICA). On angiography, the LICA stenosis was confirmed, but also a second critical stenosis was diagnosed at the ostium of the left common carotid artery (LCCA, Figure 1). Figure 1 High-grade stenosis at the ostium and bifurcation of left common carotid artery A decision for carotid stenting was made, and this was performed on March 27, 2007. A balloon-expandable, stainless-steel Genesis stent (Cordis), 8 mm × 24 mm, was implanted (10 atm – 30 s) at the ostium of the LCCA. There was not much resistance in dilating the stenotic segment. At this moment we decided to stop the procedure (Figure 2), and to perform the stenting of the LICA in the second stage, a couple of weeks later. The patient was discharged from the hospital with no complications after 2 days. Combined antiplatelet therapy was recommended, with 75 mg clopidogrel, for 4 weeks, in combination with 75 mg aspirin as permanent therapy. Figure 2 Angiographic result after stenting the ostium of the left common carotid artery On July 8, 2007 the patient was readmitted with the intent of treating the LICA stenosis. However, selective left carotid angiography revealed an in-stent restenosis within the previously implanted stent at the ostium of the LCCA. Furthermore, a fracture in the mid part of the stent was diagnosed with complete separation of the stent fragments. The fracture correlated with the area of restenosis (Figures 3A and ​and3B3B). Figure 3 A – In-stent restenosis after stenting the ostium of the left common carotid artery. B – Stent fracture at the ostium of the left common carotid artery After surgical consultation it was decided that the patient would be treated with repeated percutaneous intervention. The procedure was performed on August 2, 2007. This time we decided to treat both segments of the left carotid artery. The LCCA was approached using a Judkins right 8F guiding catheter. Then a cerebral protection device, EmboShield 5.5-7.0 mm (Abbott Vascular), was positioned in a distal part of the LICA. The distal lesion was pre-dilated (12 atm – 15 s) using an XTRM-WAY 4.0/15 mm balloon (Blue Medical Devices B.V.). The proximal lesion was predilated with the same balloon and a pressure of 10 atm. Subsequently, a Viatrac 5.5/15 mm balloon (Abbott Vascular) was positioned within the ostium of the LCCA and inflated twice with a pressure of 10 atm for 15 s. Then, a self-expanding, nitinol AccuLink stent (Abbott Vascular) 10/30 mm was positioned and opened in the distal lesion. The stent was post-dilated with the same Viatrac balloon and a pressure of 10 atm for 15 s. An optimal angiographic result was obtained, with a residual stenosis of less than 20% for both treated segments (Figures 4A, ​,B).B). The post-procedural course was uneventful, and the patient was discharged from the hospital the day after the procedure. Double antiplatelet therapy was recommended for 2 months. Figure 4 A, B. Balloon angioplasty of the left common carotid artery ostium In March 2010, a control angiography was performed, which revealed 40% stenosis at the ostium of the left common carotid artery (Figure 5). Figure 5 The 40% stenosis at the ostium of the left common carotid artery In peripheral vessels, stent fractures are quite common after femoral and popliteal artery stenting. Only a few cases of carotid stent fracture have been reported and almost all of them concern self-expandable stents implanted in the region of the bifurcation of the common carotid artery [1, 2]. The main reason for stent fracture in this region may be the exposure of the device to different directional forces. In the neck, a significant rotational stress is put on a carotid stent as a result of movement around the atlanto-axial pivot joint. Also, flexional/extensional stresses are created by movements of the cervical vertebral joints. There are some additional risk factors such as calcification and angulation of the internal carotid artery [3]. A rare cause of stent fracture may be neck trauma [4]. Some studies show that internal carotid artery (ICA) stent fractures may be quite common. Regular surveillance with plain radiography in addition to duplex ultrasonography recognizes fracture in 1.9% to 29% of implants [3, 5]. Fracture of a stent may cause restenosis, except for areas of relatively large vessel diameter [6]. In a series of 14 consecutive patients with stent fracture, instent restenosis occurred in three of them (21%) [5]. So far, only one case of balloon-expandable stent fracture in the common carotid artery (CCA) has been reported [7]. In this case however, the event was not associated with in-stent restenosis. The explanation may be the fact that the proximal segments of this artery are partially protected by the wall of the chest, and no rapid movement, stretch or compression of the artery in this region is possible. Nevertheless, in our case the stent was implanted at the most proximal part of the CCA, at its origin from the aorta. Also unique is the fact that the fracture occurred very early, within three months after implantation. Certainly the fracture must have contributed to the in-stent restenosis, with significant narrowing of the vessel in the fractured area. The stent was widely and symmetrically opened with a pressure of 10 atm, which suggests that the vessel was not severely calcified. Another important issue is the treatment of instent restenosis of the carotid arteries. Single reports suggest an endovascular approach with the use of another type of stent, while some others suggest stent-graft implantation or surgical treatment with stent removal, and possible accompanying endarterectomy as needed [3, 8–10]. In our case, a difficult and unfavorable localization of the stent (the ostium of the common carotid artery) was a substantial contraindication to surgical treatment. Out of multiple options for endovascular treatment we chose the simplest one – balloon angioplasty. The decision was made not only because of the simplicity of this technique, but also because of the need for additional stenting of the ICA, which we wanted to perform in a single-stage procedure. The effect of angioplasty in a broken stent by means of a smaller-diameter balloon using similar pressure remains unknown due to the impossibility of angiographic verification. It cannot be ruled out that the episode of transient ischemic attack and passing left-sided paresis could be related to the increased area of restenosis of the proximal part of the brachiocephalic trunk. Administration of antiplatelet agents is an essential component of care before the carotid stenting procedure. Most available data on adjunctive antiplatelet therapy and angioplasty pertain to the treatment of coronary occlusive disease. Performing the stenting procedure in our patient, we lacked sufficient literature evidence and recommendations for adjunctive therapy. Therefore clopidogrel was administered empirically for 5 days before the procedure, and this therapy was continued for 4 weeks thereafter. One can exclude, however, that either aspirin or clopidogrel could be responsible for in-stent restenosis and stent fracture. In view of our present experience, we would continue this antiplatelet therapy even longer, 3 to 6 months after the procedure. The neurological improvement (mostly in terms of speech) after 16 months of observation of the patient treated by balloon angioplasty, however, suggests that the blood circulation in the central nervous system during this period has not worsened. This is confirmed by the ultrasound results, which showed no significant differences in the speeds of flow in both carotid arteries. Control angiography would reveal the actual status of the vessel but unfortunately the patient declined this procedure. In light of our experience there still remains an open question as to the causes of rapid stent fracture with restenosis development and the choice of therapy in such cases.