Five-year clinical outcomes using the bioresorbable vascular scaffold: Insights from the FRANCE ABSORB registry

BACKGROUND

Randomized trials comparing the first-generation absorb bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, CA, USA) with a drug-eluting stent showed a moderate but significant increase in the rate of 3-year major adverse cardiac events and scaffold thrombosis, followed by a decrease in adverse events after 3 years.

AIM

The objective of this study was to assess the 5-year outcomes of patients treated with at least one absorb BVS and included in the FRANCE ABSORB registry.

METHODS

All patients treated in France with an absorb BVS were prospectively included in a large nationwide multicentre registry. The primary efficacy outcome was the occurrence of 5-year major adverse cardiac events. Secondary efficacy outcomes were the rates of 5-year target vessel revascularization and definite/probable scaffold thrombosis.

RESULTS

Between September 2014 and April 2016, 2,070 patients were included in 86 centres (mean age 55±11 years; 80% men; 49% with acute coronary syndrome). The rates of 1-, 3- and 5-year major adverse cardiac events were 3.9%, 9.4% and 12.1%, respectively (including cardiac death in 2.5% and target vessel revascularization in 10.4%). By multivariable analysis, diabetes, oral anticoagulation, the use of multiple Absorb BVSs and the use of a 2.5mm diameter absorb BVS were associated with 5-year major adverse cardiac events. The rates of 1-, 3- and 5-year definite/probable scaffold thrombosis were 1.5%, 3.1% and 3.6%, respectively. By multivariable analysis, older age, diabetes, anticoagulation at discharge and the use of a 2.5mm diameter absorb BVS were associated with 5-year scaffold thrombosis.

CONCLUSIONS

Absorb BVS implantation was associated with low rates of 1-year major adverse cardiac events, which increased significantly at 3-year follow-up. There was a clear decrease in the rates of scaffold thrombosis and major adverse cardiac events after 3 years.

Feasibility and safety of oversizing self-expandable valves for transcatheter aortic valve implantation, according to aortic annulus maximal diameter

Background

Transcatheter aortic valve implantation (TAVI) can lead to paravalvular leak (PVL) in 15% to 20% of cases, which remains an important prognostic factor and an independent predictor of mortality in short and long-term follow-up.

Objectives

To evaluate feasibility and safety of oversizing Medtronic Self-Expandable Valve (Dvalve), calculated according to the aortic annulus maximal diameter (Dmax), on the incidence of PVL and in-hospital mortality after TAVI.

Methods

We retrospectively analyzed the data of 610 patients treated with TAVI between January 2016 and December 2018. A group of 45 patients of the oversized group (October 2017 to December 2018) accordingly to the Dmax, when (Dvalve − Dmax) | <2 mm in the absence of contraindication was compared to a control group of 213 patients whose prosthesis size had been chosen according to the aortic annulus perimeter (January 2016 to September 2017).

Results

In the “oversized” group, no patient had a significant PVL after TAVI compared with the control group (0% vs. 7.51%; p=0.041). Balloon post-dilatation was significantly less frequent in the “oversized” group (0% vs. 10.3%; p=0.012). Per-procedural irradiation and the average length of in-hospital stay were significantly lower (PDS = 2,296.05±1,667.94 cGy·mm2 vs. 4,568±1,352.84 cGy·mm2; p<0.001; and 5.23±1.74 days vs. 6.33±3.23 days; p=0.029, respectively). No case of annulus rupture occurred in the “oversized” group. The incidences of high-degree atrioventricular block with definitive pacing and in-hospital mortality were similar between the two groups.

Conclusion

Oversizing the self-expandable valve, according to the aortic annulus maximal diameter, significantly reduced PVL after TAVI, balloon post-dilatation, per-procedural irradiation, and the length of hospital stay, without increasing the risk of mechanical, rhythmic, conductive and coronary occlusion complications. It does not increase the in-hospital mortality rate either. Randomized controlled trials are needed to establish a firm conclusion about its feasibility and safety.

Funding Acknowledgement

Type of funding source: None

Transcarotid trancatheter aortic valve implantation under local anesthesia in real life, a retrospective observational comparison with femoral access

Background

Trans-femoral approach is the most commonly used access for trans-catheter aortic valve implantation (TAVI). However, in case of unsuitability, several alterative access routes have been described, namely trans-axillary, trans-aortic and trans-apical. The trans-carotid approach, rarely used, can be of particular help.

Purpose

To compare trans-carotid with trans-femoral access for TAVI, regarding epidemiological, clinical, procedural features and in hospital prognosis.

Methods

We retrospectively analyzed the data of 1272 patients treated with TAVI between January 2013 and December 2019. Patients were divided into 2 groups and compared according to the vascular approach: trans-carotid group (n=84) and trans-femoral group (n=1188).

Results

The trans-carotid group, representing 6.6% of all patients undergoing TAVI, had significantly more hypertension (89.9% vs 75.8%; p=0.002), history of coronary artery disease (78.6% vs 50.5%; p<0.001), peripheral arteriopathy (58.7% vs 9.3%; p<0.0001), ischemic stroke (24% vs 10.5%; p=0.03), chronic obstructive pulmonary disease (30.8% vs 18.4%; p=0.004), surgical aortic valve replacement (12% vs 4.3%; p=0.008) and contralateral carotid endarterectomy (4% vs 0.4%; p=0.012). Average scores of LOGISTIC EUROSCORE and EUROSCORE II were significantly higher in this group (respectively 22.4 vs 15.2 and 8.3 vs 5.56; p<0.0001) and patients were more frequently considered by the Heart Team as at high surgical risk (91.3% vs 68.2%; p<0.0001).

When performing TAVI, balloon predilatation and postdilatation were significantly less frequent in the trans-carotid group (respectively 13.3% vs 26.4%; p=0.03 and 21.7% vs 37.6%; p=0.006). However, there was no significant difference between the 2 groups concerning neither the implantation of self-expanding/balloon-expandable valves nor in the fluoroscopy time and dose-area product averages. On post-procedural echocardiographic findings, transaortic mean gradient average and the incidence of significant paravalvular leak were similar.

During intra-hospital follow-up, patients in the trans-carotid group had significantly less vascular complications (9.3% vs 23%; p=0.02) and less urgent need of endovascular repair (0% vs 15.8%; p=0.013) without any impact on the need for transfusion. However, the incidence of atrial fibrillation was significantly higher (17.4% vs 9.4%; p=0.036). There was no significant difference between the two groups for the incidence of haemodynamic and neurological complications, high-degree atrioventricular block and in-hospital mortality.

Conclusion

According to our study, trans-carotid TAVI under local anesthesia can be feasible and safe, especially in more friable patients at higher risk. It was associated with lower incidence of vascular complications but a higher incidence of atrial fibrillation, without impact on in-hospital mortality. Randomized controlled trials are needed to establish a firm conclusion about this novel approach.

Funding Acknowledgement

Type of funding source: None

High post-procedural transvalvular gradient or delayed gradient increase after transcatheter aortic valve implantation: the FRANCE-2 registry

Background

Mean gradient (MG) elevation can be detected immediately post-procedure or secondarily during follow-up. Comparison between these two parameters and impact on outcomes has not previously been investigated.

Objectives

The study aimed to identify incidence, influence on prognosis and parameters associated with immediate high post-procedural mean transvalvular gradient (PPMG) and delayed mean gradient increase (DMGI), in the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry.

Methods

The registry includes all consecutive symptomatic patients with severe aortic stenosis. Three groups were analyzed: 1) PPMG <20mmHg without DMGI >10 mmHg (control); 2) PPMG <20mmHg with DMGI >10 mmHg (group 1); 3) PPMG ≥20 mmHg (group 2).

Results

From January 2010 to January 2012, 4201 consecutive patients were prospectively enrolled in the registry. The control group comprised 2078 patients; the group 1, 131 patients; and the group 2, 144 patients. DMGI exceeded 10 mmHg in 5.6%, and was not associated with greater 4-year mortality than in control group (32.6% vs. 40.1%, p=0.27, respectively). PPMG was at least 20 mmHg in 6.1%, and was associated with higher 4-year mortality than in control group (48.7% versus 40.1%, p=0.005, respectively) (Figure 1). Two-thirds of patients with initial PPMG ≥20 mmHg had finally a MG <20 mmHg at 1 year, with mortality similar to controls (39.2% vs. 40.1%, p=0.73).

Conclusions

Patients with PPMG >20 mmHg 1 year post-TAVI had higher 4-year mortality than the general population of the registry, unlike patients with MG normalization at 1 year.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): French National Society of Cardiology

[Para valvular leak closure in TAVI]

Literature concerning transcutaneous symptomatic para valvular cardiac leaks closure (PVLC) after trans aortic valve implantation (TAVI) is relatively scarce. Hereby we present 2 clinical cases, one on an Edwards® Sapien 3 valve and the other one on a Medtronic® Evolut R valve. We present also the preliminary results of the 7 PVLC on TAVI included in our prospective FFPP registry during the 2 first years of enrolment (2017-2018), for a total of 158 inclusions for all valves. Seven procedures were performed on 8 leaks, using a majority of vascular plugs (3 Abbott® Amplatzer Vascular Plugs 2 (AVP2), 3 AVP3, 1 AVP4, and 1 muscular Ventricular Septal Defect (VSD) occluder). All procedures were successful without complication. At 1-month follow-up, all patients became asymptomatic. One-year follow-up was already available for 4 patients: 3 of them were symptoms free, and one-who had a second leak not suitable for PVLC-, underwent a « TAVI in TAVI » procedure 2 months after PVLC. This short experience demonstrates the feasibility, the efficacy and the safety of PVLC on TAVI. We expect to be able to offer more in depth information at the end of our prospective ongoing study.

Intra-coronary morphine versus placebo in the treatment of acute ST-segment elevation myocardial infarction: the MIAMI randomized controlled trial

BACKGROUND

Experimental studies suggest that morphine may protect the myocardium against ischemia-reperfusion injury by activating salvage kinase pathways. The objective of this two-center, randomized, double-blind, controlled trial was to assess potential cardioprotective effects of intra-coronary morphine in patients with ST-segment elevation myocardial infarction (STEMI) referred for primary percutaneous intervention.

METHODS

Ninety-one patients with STEMI were randomly assigned to intracoronary morphine (1 mg) or placebo at reperfusion of the culprit coronary artery. The primary endpoint was infarct size/left ventricular mass ratio assessed by magnetic resonance imaging on day 3-5. Secondary endpoints included the areas under the curve (AUC) for troponin T and creatine kinase over three days, left ventricular ejection fraction assessed by echocardiography on days 1 and 6, and clinical outcomes.

RESULTS

Infarct size/left ventricular mass ratio was not significantly reduced by intracoronary morphine compared to placebo (27.2% ± 15.0% vs. 30.5% ± 10.6%, respectively, p = 0.28). Troponin T and creatine kinase AUCs were similar in the two groups. Morphine did not improve left ventricular ejection fraction on day 1 (49.7 ± 10.3% vs. 49.3 ± 9.3% with placebo, p = 0.84) or day 6 (48.5 ± 10.2% vs. 49.0 ± 8.5% with placebo, p = 0.86). The number of major adverse cardiac events, including stent thrombosis, during the one-year follow-up was similar in the two groups.

CONCLUSIONS

Intracoronary morphine at reperfusion did not significantly reduce infarct size or improve left ventricular systolic function in patients with STEMI. Presence of comorbidities in some patients may contribute to explain these results.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01186445 (date of registration: August 23, 2010).

Atrial Fibrillation During or After TAVI: Incidence, Implications and Therapeutical Considerations

INTRODUCTION

Aortic stenosis is one of the most frequent valvulopathy of modern time necessitating interventional therapy when symptoms arise and stenosis becomes severe. First line treatment has traditionally been surgical aortic valve replacement (SAVR). However in the last decade transcatheter aortic valve implantation (TAVI) with bioprosthetic valves has proved to be a sound solution for high-risk for SAVR or inoperable patients. As expected implantation of the bioprosthetic device requires administration of antiplatelet regimen to the patients for a certain period. Atrial fibrillation (AF) may occur frequently during the peri-procedural period. In this background, the occurrence of AF after device implantation may be a challenging issue.

METHODS

We performed a literature search of PubMed and Embase database. Published articles reporting the incidence, clinical implications and description of antithrombotic regimen of New-onset atrial fibrillation (NOAF) in individuals undergoing TAVI were considered eligible. Incidence, Implications and Antithrombotic Regimen: The overall occurrence of NOAF is reported to be 1%-32% after TAVI. Left atrial enlargement and transapical approach constitute independent predictors for NOAF. Additionally it has been shown that patients with AF face an increased risk of death irrespective of the type of AF. Patients, with a history of AF, present greater rate of death than individuals with NOAF. NOAF is responsible for cerebrovascular events (CVE) occurring in the subacute phase (days 1-30) after the procedure. The risk of stroke/transient ischemic attack after TAVI is increased at least two fold by the presence of atrial fibrillation. Empirically, a dual antiplatelet strategy has been used for patients undergoing TAVR, including aspirin and a thienopyridine. In cases where patients are in need of oral anticoagulation after TAVI a combination of aspirin or thienopyridine with acenocoumarol has been the preferred regimen.

DISCUSSION

Despite the continuously crescent use of TAVI for patients with symptomatic severe aortic stenosis, there are still many aspects of this procedure to be clarified. A lack of data exists from the available clinical trials regarding the appropriate anticoagulation therapy for patients with greater risk for thromboembolic events. As a result, patient's treatment remains at the discretion of the physician.

CONCLUSION

Limited data are available regarding the optimal therapeutic regimen in patients undergoing TAVI who need therapy for AF. Carefully designed clinical studies might further clarify the incidence and interrelation between atrial fibrillation and TAVI. The balance between the efficacy and risk of anticoagulation needs to be further clarified in patients undergoing TAVI.

Antiplatelet Therapy in TAVI: Current Clinical Practice and Recommendations

Transcatheter aortic valve implantation (TAVI) is all the more used therapeutic option for patients suffering from symptomatic severe aortic valvular stenosis declined by surgeons because of high surgical risk. Given the high bleeding and ischemic risk of this vulnerable population, their antithrombotic treatment becomes a crucial issue. There is no consensus on antithrombotic treatment after TAVI and dual antiplatelet therapy (DAPT) with aspirin (indefinitely) and clopidogrel (1-6 months) is, in general, recommended. With regards to patients with an indication for oral anticoagulation (OAC), a combination of OAC plus aspirin or clopidogrel is commonly suggested. This review underscores that it is extremely difficult to compare different antithrombotic regimens in patients undergoing TAVI because of their variable demographic characteristics. Nevertheless, available data suggest that DAPT results to more bleeding events. Still, whether it positively affects ischemic episodes is doubtful. Ongoing trials are expected to draw a clearer picture on the field.

Non-invasive diagnosis of ischaemic heart failure using 64-slice computed tomography

AIMS

We evaluated the accuracy of 64-slice computed tomography (CT) to identify ischaemic aetiology of heart failure (IHF).

METHODS AND RESULTS

Ninety-three consecutive patients in sinus rhythm with dilated cardiomyopathy but without suspicion of coronary artery disease (CAD) were enrolled when admitted for angiography. Accuracy of CT to detect significant stenosis (>50% lumen narrowing) was compared with quantitative coronary angiography. IHF was defined as a significant stenosis on left main or proximal left anterior descending artery or two or more vessels. Forty-three out of 1395 segments (3%) were heavily calcified and excluded. CT correctly assessed 103 of 142 (73%) significant stenosis and identified 46 of 50 (92%) patients without and 42 of 43 (98%) patients with CAD, 60 of 62 (97%) patients without and 28 of 31 (90%) patients with IHF. Overall, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT for identifying CAD by segment was 96, 73, 99, 92, and 97%, respectively; by patient was 95, 98, 92, 91, and 98%, respectively; and for identifying IHF was 95, 90, 97, 93, and 95%, respectively.

CONCLUSION

Non-invasive 64-slice CT assessment of the extent of CAD may offer a valid alternative to angiography for the diagnosis of IHF.

Acute Myocardial Infarction Early Viability Assessment by 64-Slice Computed Tomography Immediately After Coronary Angiography

OBJECTIVES

Early evaluation of myocardial viability in acute myocardial infarction is useful to guide therapy. Therefore, we assessed 64-slice computed tomography (CT) immediately after coronary angiography in this setting.

BACKGROUND

Recent preliminary studies have shown the promising usefulness of late hyperenhancement multislice computed tomography (MSCT) for non-viability assessment.

METHODS

Thirty-six patients admitted for a first acute myocardial infarction had a coronary angiogram early after admission followed by 64-slice CT without iodine reinjection. The 16 segments of the left ventricle depicted by the American Society of Echocardiography were graded: no, subendocardial, or transmural hyperenhancement. No or subendocardial hyperenhancement were expected to reflect viability. Two to 4 weeks later, the same segments' contractility was evaluated at rest. Low-dose dobutamine echocardiography was performed in case of akinetic segment at rest.

RESULTS

Mean delay between coronary angiography and MSCT was 24 +/- 11 min (range 7 to 51 min). We compared 576 segments evaluated by each method. Agreement was noted for 560 segments (97%) and disagreement for 16 segments (3%). Thus, 64-slice CT after coronary angiography for an acute myocardial infarction had 98% sensitivity, 94% specificity, 97% accuracy, and 99% positive and 79% negative predictive values for detecting viable myocardial segments at a very early stage of an acute myocardial infarction. On a per-patient analysis, sensitivity, specificity, accuracy, and positive and negative predictive values were 92%, 100%, 94%, and 100% and 85%, respectively.

CONCLUSIONS

A 64-slice CT after coronary angiography for an acute myocardial infarction is a promising method for early evaluation of viable myocardium.

[Visualization of the intra-stent lumen in the coronary arteries and detection of restenoses with 64-slices tomography scanners with cardiac synchronization: first experience]

PURPOSE

to assess the value of the new high spatial resolution 64-slice CT (0.4 mm collimation) technology for non-invasive visualization of coronary artery stent lumen and the characterization of significant in-stent restenosis.

MATERIALS AND METHODS

a total of 100 stents were visualized in 50 consecutive patients. All CT examinations were performed with a 64-slice CT (sensation 64; Siemens), with a slice thickness of 0.75 mm at 0.5 mm intervals with retrospective gating. Images were evaluated by two readers and the quality of the in-stent lumen was classified on 5-point scale (1 = not visible; 5 = excellent visibility). Fifty-eight stents in 29 patients were also examined by conventional coronary angiography one week after CT examination. Attenuation values were measured in the vessel upstream from the stent and within the stent, using 1 mm2 regions of interest. The intra stent attenuation ratio (ISAR) was calculated as vessel enhancement/intra stent hypodense area. Interobserver agreement was evaluated by kappa statistics,

RESULTS

the interobserver agreement was k= 0.82. The in-stent lumen was visible (score > or =3) in 88 stents (88%), with good visibility (> or = 4) in 54% of stents. Unsatisfactory in-stent lumen visibility was associated with heart rate > 65 beat/min (p < 0.001) and stent size < 3 mm (p < 0.0001). In-stent visibility was also lower in circumflex than other arteries (p= 0.02). Thirteen stenoses or occlusions were detected in 8 patients. In-stent restenosis was associated with hypodense areas within the stent. A ISAR>2 was an accurate criteria (2 false positives, 0 false negative) for detection of significant (> 50%) intra-stent restenosis.

CONCLUSION

high resolution 64-slice CT allows reliable in-stent visualization for stents of 3 mm or more in diameter, if heart rate is below 65 bpm. Significant restenosis can be detected with a high sensitivity by determining the ISAR. Arch Mal

Non-Invasive Detection of Coronary Artery Disease in Patients With Left Bundle Branch Block Using 64-Slice Computed Tomography

OBJECTIVES

The goal of this study was to evaluate the diagnostic accuracy of 64-slice computed tomography (CT) to identify coronary artery disease (CAD) in patients with complete left bundle branch block (LBBB).

BACKGROUND

Left bundle branch block increases risk of cardiac mortality, and prognosis is primarily determined by the underlying coronary disease. Non-invasive stress tests have limited performance, and conventional coronary angiography (CCA) is usually required.

METHODS

Sixty-six consecutive patients with complete LBBB and sinus rhythm admitted for CCA were enrolled. Computed tomography was performed 3 +/- 3.9 days before CCA. The accuracy of 64-slice CT to detect significant stenosis (>50% lumen narrowing) was compared with quantitative coronary angiography. All segments were analyzed regardless of image quality from coronary calcification or motion artifacts. Results were analyzed by patient and by coronary segment (990) using the American Heart Association 15-segment model.

RESULTS

Lower heart rates were associated with improved image quality. Computed tomography correctly identified 35 of 37 (95%) patients without significant stenosis and 28 of 29 (97%) patients with significant stenosis on CCA. Computed tomography correctly assessed 68 of 94 (72%) significant stenosis. Overall, accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 64-slice CT for identifying CAD by patient was 95%, 97%, 95%, 93%, and 97%, respectively, and by segment was 97%, 72%, 99%, 91%, and 97%, respectively.

CONCLUSIONS

In a routine clinical practice, 64-slice CT detects with excellent accuracy a significant CAD in patients with complete LBBB. A normal CT in this clinical setting is a robust tool to act as a filter and avoid invasive diagnostic procedures.

Comparison of coronary minimal lumen area quantification by sixty-four-slice computed tomography versus intravascular ultrasound for intermediate stenosis

The present study assessed 64-slice computed tomographic accuracy to quantify minimal lumen area (MLA) and determine lesion severity in intermediate stenosis by angiography compared with intravascular ultrasound (IVUS). Sixty-four-slice computed tomography (CT) has been shown to be effective in coronary stenotic assessment by visual estimation compared with angiography. However, angiography is not an accurate gold standard for intermediate stenotic quantification compared with IVUS. Forty patients (54 lesions) with 30% to 70% coronary stenosis by angiography in a major coronary branch were included. All patients underwent quantitative angiography, retrospective electrocardiographically gated 64-slice CT (Siemens), and IVUS (40-MHz Atlantis; Boston Scientific). MLA was manually traced by 2 blinded and independent operators on 64-slice computed tomographic cross-sectional reconstruction and compared with IVUS MLA. A lesion was considered significant if the MLA was <or=6 mm(2) for the left main coronary artery and <or=4 mm(2) for another epicardial vessel with CT and IVUS. The correlation between IVUS MLA and computed tomographic MLA was r = 0.88 (p <0.001). Interobserver variabilities (mean +/- SD) were 1.2 mm(2) for CT and 1.1 mm(2) for CT versus IVUS. Bland-Altman analysis showed a 95% confidence interval of -42% to +44% for computed tomographic measurement using IVUS as a reference. Sensitivity, specificity, accuracy, and Cohen's kappa coefficient for significant lesion classification using CT were 87%, 72%, 80%, and 0.6, respectively (p <0.0001). In conclusion, when using MLA, 64-slice CT was able to quantify coronary stenosis with good correlation compared with IVUS and determine lesion severity in patients with intermediate lesions by angiography.

Comparison of lumens of intermediate coronary stenosis using 16-slice computed tomography versus intravascular ultrasound

We aimed to quantify ambiguous coronary stenosis using the minimal lumen area with 16-slice computed tomography compared with intravascular ultrasound. The sensitivity, specificity, and accuracy for significant lesion classification was 68%, 86%, and 78%, respectively. The correlation between intravascular ultrasound and CT minimal lumen area was r = 0.73 (p <0.001), and the 95% confidence interval for CT measurement was -72% to +56%.

[Anomalies in myocardial contrast uptake revealed by multislice cardiac CT during acute myocarditis]

Acute myocarditis can display many various clinical appearances. Endomyocardial biopsy is an invasive investigation for which the sensibility is insufficient in mild cases and when it is performed too early. Multislice cardiac CT with ECG synchronisation and injection of contrast medium allows visualisation of the coronary arteries and the study of myocardial contrast uptake. We report the cases of two patients with a mild myocarditis where multislice CT performed early showed multiple areas of increased myocardial contrast uptake consistent with a diffuse inflammatory disorder. Coronary angiography was normal in these two patients. Multislice cardiac CT could be a useful non-invasive investigation for the early diagnosis of this disease.

Characterization of vulnerable nonstenotic plaque with 16-slice computed tomography compared with intravascular ultrasound

We compared 16-slice computed tomography with intravascular ultrasound in the detection of unstable component characteristics of nonstenotic plaque responsible for acute coronary syndrome. Computed tomography accurately assessed plaque eccentricity, calcification, and remodeling, and intraplaque hypodensity correlated with intravascular ultrasound echolucent area.

[Diagnosis of acute myocardial infarction using multislice computed tomography in emergency room]

Managing chest pain in emergency remains a diagnostic challenge because of the speediness and the accuracy that request. The authors report the case of a 40 years old patient admitted for chest pain with suspected aortic dissection. Multislice computed tomography (sixteen-slice CT) was performed at the patient's admission, initial diagnosis was rapidly corrected, showing both and accurately show both antero-septal defect perfusion and an acute occlusion of the proximal left anterior descending artery. Angioplasty was performed in emergency within the 6 first hours after onset of the symptoms. Multislice computed tomography was able to identify accurately not only the chest pain etiology but also to show the culprit artery, leading to quick and oriented percutaneous coronary intervention.

[Non-invasive coronarography: myth or reality]

Slice Imaging technology progress allows a good approach of coronary arteries. MRI and Multislice Computed Tomography (MSCT) are in competition. Inspite of important progress, MRI of coronary artery disease remains "disappointing". With this imaging technology, there is a good plaque burden and myocardium visualisation. MST, and particularly with 16 slice technology, allows a good coronary stenosis identification. This technology enables soft plaque and myocardial ischemia detection. It is now possible to detect coronary heart disease with MSCT, which can replace or help a coronary angiogram in some indications.

Long-term efficacy of myoblast transplantation on regional structure and function after myocardial infarction

BACKGROUND

Transplantation (Tx) of skeletal myoblasts (SM) within an infarcted myocardium improves global left ventricular (LV) function, although a direct systolic effect remains controversial.

METHODS AND RESULTS

Global and regional LV functions were studied in a sheep model (n=16) of infarction before (baseline), and 4 (M4), and 12 (M12) months after in-scar injections of autologous SM or culture medium (CM). LV end-diastolic volume (EDV), ejection fraction (EF), wall motion score (WMS), and systolic myocardial velocity gradient (MVG) across the scar were measured by echocardiography with tissue Doppler imaging. Parameters were similar at baseline between groups. At M4, Tx of SM reduced the postinfarction increase in EDV (72+/-8 versus 105+/-13 mL in the CM group, P<0.05) and the decrease in EF (48+/-5 versus 33+/-3% in the CM group, P=0.006) although it improved WMS (5.4+/-1.2 versus 13+/-2.2 in the CM group, P<0.01) and SMVG (0.60+/-0.13 versus -0.04+/-.13 seconds(-1) in the CM group, P<0.05). Results were similar at M12. In-scar accumulation of myotubes and SM were detected in all Tx animals up to M12, with co-expression of fast and slow isoforms of the myosin heavy chain (MHC) (30% of the fibers versus 0% in the normal skeletal muscle) and decreased collagen density (30+/-2% versus 73+/-3%, P<0.0001).

CONCLUSIONS

For up to 1 year, Tx of SM limits postinfarction EF deterioration and improves systolic scar function through colonization of fibrosis by skeletal muscle cells with expression of both MHC isoforms, which may confer to the graft the ability to withstand a cardiac-type workload.

Chronic V2 vasopressin receptor stimulation increases basal blood pressure and exacerbates deoxycorticosterone acetate-salt hypertension

The present study was intended to determine whether the long-term V2 receptor-mediated effects of vasopressin on sodium reabsorption in the renal collecting duct is an aggravating factor in salt-sensitive hypertension. Deoxycorticosterone acetate (DOCA)-salt hypertension was induced in uninephrectomized rats that had been chronically pretreated with a V2 agonist (dDAVP; 1-deamino-8D-arginine vasopressin; 0.6 microg/kg.d) or a V2 antagonist (SR121463, 3 mg/kg.d) or were untreated. Plasma osmolality and natremia were not significantly different in the groups. Blood pressure was significantly increased by dDAVP pretreatment (+11 mm Hg; P = 0.006), and this effect was exacerbated after DOCA-salt-induced hypertension (+17 mm Hg; P = 0.042). The dDAVP-treated rats had a lower hematocrit (40 +/- 2% vs. 47 +/- 1% and 45 +/- 2%) and markedly higher albuminuria (91 +/- 9 vs. 17 +/- 8 and 15 +/- 8 mg/d), mortality rate (50% vs. 0% and 0%), and cardiac and renal hypertrophy than the control and SR121463 groups. Histological renal lesions were worsened by V2 agonism and prevented by V2 antagonism. Renal mRNA expression of beta- and gamma-subunits of the epithelial sodium channel was significantly increased by dDAVP treatment (P < 0.05). These findings provide evidence that chronic stimulation of vasopressin V2 receptor raises basal blood pressure in rats and exacerbates the development of DOCA-salt hypertension, organ damage, and mortality. These effects could be due at least in part to the sustained stimulation of sodium reabsorption by epithelial sodium channel in the distal part of the nephron, which promotes sodium retention.

Is skeletal myoblast transplantation clinically relevant in the era of angiotensin-converting enzyme inhibitors?

BACKGROUND

There is compelling experimental evidence that autologous skeletal muscle (SM) cell transplantation improves postinfarction cardiac function. This study assessed whether this benefit is still manifested in the clinically relevant setting of a treatment by ACE inhibitors.

METHODS AND RESULTS

A myocardial infarction was created in 99 rats by coronary artery ligation. They were divided into 4 groups. Two groups did not receive any drug and were intramyocardially injected 7 days after the infarct with either culture medium alone (control rats, n=16) or autologous SM cells (2.3x10(6) myoblasts) previously expanded ex vivo for 7 days (myoblasts, n=24). Two other groups received the ACE inhibitor perindoprilat (1 mg. kg(-1). d(-1)), started the day of the infarct and continued uninterruptedly thereafter, and underwent time-matched procedures, that is, they were intramyocardially injected at 7 days after infarction with either culture medium alone (ACE inhibitors, n=22) or autologous SM cells (2.5x10(6) myoblasts) previously expanded ex vivo for 7 days (ACE inhibitors+myoblasts, n=37). Left ventricular function was assessed by 2D echocardiography. At the end of the 2-month study, left ventricular ejection fraction (%, mean+/-SEM) was increased in all groups (myoblasts, 37.4+/-1.2; ACE inhibitors, 31.6+/-1.7; ACE inhibitors+myoblasts, 43.9+/-1.4) compared with that in control rats (19.8+/-0.7) (P<0.0001). The improvement in ejection fraction was similar in the ACE inhibitor and the myoblast groups (31.6+/-1.7 versus 37.4+/-1.2, P=0.0636). However, in the ACE inhibitor+myoblast group, this improvement was greater than that seen in hearts receiving either treatment alone (43.9+/-1.4 versus 31.6+/-1.7 in the ACE inhibitor group and 43.9+/-1.4. versus 37.4+/-1.2 in the myoblast group, P<0.0001 and P=0.0084, respectively).

CONCLUSIONS

These data provide further support for the clinical relevance of autologous SM cell transplantation in that its cardioprotective effects are additive to those observed with ACE inhibitors.