Silicosis and tuberculosis: A systematic review and meta-analysis

INTRODUCTION

Silicosis mostly happens in workers with high silica exposure and may accompany the development of various diseases like tuberculosis, cancer, or autoimmune diseases. The term silico-tuberculosis describes a condition in which an individual is affected by both silicosis and tuberculosis at the same time. This systematic review and meta-analysis study was conducted to evaluate the risk of tuberculosis in silicosis patients and individuals exposed to silica dust.

METHODS

We performed a systematic search for relevant studies up to 6 September 2022 using PubMed/ Medline, and Embase with the following keywords in titles or abstracts: "silicosis" OR "silicoses" OR "pneumoconiosis" OR "pneumoconioses" AND "tuberculosis". Cohort and case-control studies containing relevant and original information about tuberculosis infection in silicosis patients were included for further analysis. Pooled estimates and 95% confidence intervals (CI) for the relative risk of tuberculosis in individuals with silicosis compared to those without; these were evaluated using the random effects model due to the estimated heterogeneity of the true effect sizes.

RESULTS

Out of 5352 potentially relevant articles, 7 studies were eligible for systematic review, of which 4 cohort studies were included for meta-analysis. The total population of all studies was 5884, and 90.63% were male. The mean age of participants was 47.7 years. Our meta-analysis revealed a pooled risk ratio of 1.35 (95%CI 1.18-1.53, I ²: 94.30%) which means an increased risk of silicosis patients and silica-exposed individuals to tuberculosis infection.

CONCLUSION

Silicosis and silica dust exposure increase the risk of tuberculosis. Therefore, we suggest that individuals with long-time silica exposure, like mine workers, be routinely considered for both silicosis and tuberculosis screening programs.

Clinical Features and Prognoses of Middle-Aged Women With ST-Elevation Myocardial Infarction With a Focus on Spontaneous Coronary Artery Dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) has become an increasingly recognized cause of acute coronary syndrome, particularly in young women, over the last decade. The goal of this study was to determine the prognoses and characteristics of adult women with SCAD who presented with ST-elevation myocardial infarction (STEMI).

METHODS

This retrospective cohort study enrolled all adult women under the age of 60 who had undergone coronary artery angiography in the setting of STEMI. The patients were divided into 3 groups based on their angiographic characteristics: STEMI-SCAD (STEMI due to SCAD), STEMI-ATH (STEMI caused by an atherosclerotic lesion), and STEMI-others (STEMI due to other etiologies including Takotsubo cardiomyopathy and myopericarditis, as well as STEMI despite a normal epicardial coronary angiography).

RESULTS

Fifteen women out of 311 female patients aged below 60 years with STEMI were diagnosed with SCAD (4.8%). There were no significant differences in body mass index, hypertension, dyslipidemia, smoking status, opium addiction status, family history, previous percutaneous coronary intervention, coronary artery bypass grafting, and cerebrovascular accidents between the STEMI-SCAD and STEMI-ATH groups. Nevertheless, the STEMI-SCAD and STEMI-others groups were more likely to be younger, less likely to be diabetic, and less likely to have 3 cardiovascular risk factors or more than was the STEMI-ATH group. The left anterior descending artery was the most common culprit lesion in the STEMI-SCAD group (80%) and the other 2 groups. Out of the 311 patients, 7 patients died during the index hospitalization: 1 patient in the STEMI-SCAD group, 6 patients in the STEMI-ATH group, and 0 patients in the STEMI-others group. None of the patients in the STEMI-others group experienced any major adverse cardiac events during the follow-up. In the other 2 groups, the most experienced outcomes were myocardial infarction and in-hospital cardiac death, followed by target lesion revascularization and target vessel revascularization.

CONCLUSIONS

STEMI-SCAD is one of the known causes of STEMI in young women. Still, despite the complexity of revascularization in our patients with STEMI-SCAD, they had more favorable prognoses in both conservative and revascularization management modalities than our patients with STEMI-ATH.

Drug-coated balloons for de novo lesions in small coronary arteries: rationale and design of BASKET-SMALL 2

The treatment of coronary small vessel disease (SVD) remains an unresolved issue. Drug‐eluting stents (DES) have limited efficacy due to increased rates of instent‐restenosis, mainly caused by late lumen loss. Drug‐coated balloons (DCB) are a promising technique because native vessels remain structurally unchanged. Basel Stent Kosten‐Effektivitäts Trial: Drug‐Coated Balloons vs. Drug‐Eluting Stents in Small Vessel Interventions (BASKET‐SMALL 2) is a multicenter, randomized, controlled, noninferiority trial of DCB vs DES in native SVD for clinical endpoints. Seven hundred fifty‐eight patients with de novo lesions in vessels <3 mm in diameter and an indication for percutaneous coronary intervention such as stable angina pectoris, silent ischemia, or acute coronary syndromes are randomized 1:1 to angioplasty with DCB vs implantation of a DES after successful initial balloon angioplasty. The primary endpoint is the combination of cardiac death, nonfatal myocardial infarction, and target‐vessel revascularization up to 1 year. Secondary endpoints include stent thrombosis, Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding, and long‐term outcome up to 3 years. Based on clinical endpoints after 1 year, we plan to assess the noninferiority of DCB compared to DES in patients undergoing primary percutaneous coronary intervention for SVD. Results will be available in the second half of 2018. This study will compare DCB and DES regarding long‐term safety and efficacy for the treatment of SVD in a large all‐comer population.

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed. In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients. Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively. Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Technique of Minimally Invasive Transverse Aortic Constriction in Mice for Induction of Left Ventricular Hypertrophy

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure overload-induced left ventricular hypertrophy (LVH) and its progression to heart failure. In the majority of the reported investigations, this procedure is performed with intubation and ventilation of the animal which renders it demanding and time-consuming and adds to the surgical burden to the animal. The aim of this protocol is to describe a simplified technique of minimally invasive TAC without intubation and ventilation of mice. Critical steps of the technique are emphasized in order to achieve low mortality and high efficiency in inducing LVH. Male C57BL/6 mice (10-week-old, 25-30 g, n=60) were anesthetized with a single intraperitoneal injection of a mixture of ketamine and xylazine. In a spontaneously breathing animal following a 3-4 mm upper partial sternotomy, a segment of 6/0 silk suture threaded through the eye of a ligation aid was passed under the aortic arch and tied over a blunted 27-gauge needle. Sham-operated animals underwent the same surgical preparation but without aortic constriction. The efficacy of the procedure in inducing LVH is attested by a significant increase in the heart/body weight ratio. This ratio is obtained at days 3, 7, 14 and 28 after surgery (n = 6 - 10 in each group and each time point). Using our technique, LVH is observed in TAC compared to sham animals from day 7 through day 28. Operative and late (over 28 days) mortalities are both very low at 1.7%. In conclusion, our cost-effective technique of minimally invasive TAC in mice carries very low operative and post-operative mortalities and is highly efficient in inducing LVH. It simplifies the operative procedure and reduces the strain put on the animal. It can be easily performed by following the critical steps described in this protocol.

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm²/m², is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery (ALCAPA)

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly which is one of leading causes of myocardial ischemia and infarction in children. If left untreated, it results in a 90% mortality rate in the first year of life. In patients who survive to the adulthood, the coronary steal phenomenon and retrograde left-sided coronary flow provide a substrate for chronic subendocardial ischemia, which may lead to left ventricular dysfunction, ischemic mitral regurgitation, malignant ventricular arrhythmias, and sudden cardiac death. The average age of life-threatening presentation is 33 years and of sudden cardiac death 31 years. Therefore, surgical correction is highly recommended as soon as the diagnosis is made, regardless of age. In adult-type ALCAPA originating from the right-facing sinus of the pulmonary artery, direct re-implantation of the ALCAPA into the aorta is the more physiologically sound repair technique to re-establish the dual-coronary perfusion system and is recommended. This protocol describes the technique of direct re-implantation of adult-type ALCAPA into the aorta.

A novel approach to treat in-stent restenosis: 6- and 12-month results using the everolimus-eluting bioresorbable vascular scaffold

AIMS

The treatment of in-stent restenosis (ISR) remains challenging. Small case series have described successful utilisation of bioresorbable vascular scaffolds (BVS) (Absorb; Abbott Vascular, Santa Clara, CA, USA) to treat ISR. We report our experience with this novel approach.

METHODS AND RESULTS

Patients with ISR in native coronary arteries undergoing percutaneous coronary intervention (PCI) for ISR were treated using BVS. A total of 84 ISR lesions were treated in 65 patients. The mean age was 66±11 years, 28% had acute coronary syndrome (ACS) and 28% were diabetic. PCI was successful in all patients and all scaffolds were delivered and deployed successfully in the target lesion. All 65 patients had six-month follow-up and 49 patients had 12-month clinical follow-up. The target lesion revascularisation (TLR) rate was 3.1% at six months and 12.2% at 12 months. The mean duration from PCI to TLR was 301±148 days. No scaffold thrombosis occurred during the study period.

CONCLUSIONS

This proof of concept study demonstrates that ISR treatment utilising BVS is feasible and appears to have acceptable target lesion failure rates. Prospective randomised trials are necessary to assess whether BVS are more effective than drug-eluting stents or drug-eluting balloons to treat ISR.

Impact of Patient and Lesion Complexity on Long-Term Outcomes Following Coronary Revascularization With New-Generation Drug-Eluting Stents

Long-term clinical outcomes of new-generation drug-eluting stents in complex anatomic and clinical settings are not well defined. This study assessed the impact of patient and lesion complexity on 2-year outcomes after coronary revascularization with ultrathin strut biodegradable-polymer (BP) sirolimus-eluting stents (SES) versus durable-polymer (DP) everolimus-eluting stents (EES). In a prespecified analysis of the BIOSCIENCE randomized trial (NCT01443104), complex patients (911 of 2,119; 43%) were defined by the presence of acute ST-elevation myocardial infarction (MI); left ventricular ejection fraction ≤30%; renal dysfunction; insulin-treated diabetes; treatment of ostial lesion, bypass graft, unprotected left main lesion; or 3-vessel intervention. The primary end point was target lesion failure (TLF), a composite of cardiac death, target vessel MI, and clinically indicated target lesion revascularization. At 2 years, complex compared with simple patients had a greater risk of TLF (14.5% vs 7.4%, risk ratio 2.05, 95% confidence interval 1.56 to 2.69; p <0.001). The difference was sustained beyond 1 year on landmark analysis. Complex patients had higher rates of the patient-oriented composite end point of death, any MI, or any revascularization (23% vs 14.4%; p <0.001) as well as definite stent thrombosis (1.6% vs 0.4%, p = 0.006). There were no differences in TLF and patient-oriented composite end point between the BP-SES versus DP-EES, consistently among simple and complex patients. In conclusion, patient and lesion complexity had a durable adverse impact on clinical outcomes throughout 2 years of follow-up in this all-comers randomized trial. Safety and efficacy of new-generation BP-SES and DP-EES were comparable, irrespective of complexity status.

Angiographic complexity of coronary artery disease according to SYNTAX score and clinical outcomes after revascularisation with newer-generation drug-eluting stents: a substudy of the BIOSCIENCE trial

AIMS

We sought to assess the performance of drug-eluting stents combining an ultrathin cobalt-chromium platform with a biodegradable polymer across categories of increasing SYNTAX score (SS).

METHODS AND RESULTS

Patients included in the BIOSCIENCE trial and randomly allocated to treatment with biodegradable polymer sirolimus-eluting stents (BP-SES) or durable polymer everolimus-eluting stents (DP-EES) were categorised according to SS tertiles (low <8, medium 8-15, high >15). The primary endpoint, target lesion failure (TLF), was defined as a composite of cardiac death, target vessel myocardial infarction and clinically indicated target lesion revascularisation. The patient-oriented endpoint (POCE) included death, myocardial infarction, or any repeat revascularisation. The SS was available in 2,041 out of 2,119 patients (96.3%). At two-year follow-up, patients with an SS >15 experienced higher rates of both TLF and POCE as compared to patients with medium and low SS (14.5% vs. 8.1% and vs. 5.9%, p<0.001; 22.7% vs. 14.9% and vs. 12.4%; p<0.001), respectively. Comparable rates of the composite endpoints were documented for both stent types in each category of SS.

CONCLUSIONS

Increasing lesion complexity as assessed by SS was associated with higher rates of TLF and POCE in a contemporary PCI population with minimal exclusion criteria. BP-SES and DP-EES showed comparable performance across the entire spectrum of CAD severity.

Diastolic Filling Reserve Preservation Using a Semispherical Dacron Patch for Repair of Anteroapical Left Ventricular Aneurysm

In postinfarction left ventricular aneurysm, abnormal geometry and desynchronized wall motion may cause a highly inefficient pump function. The traditional endoventricular patch plasty according to the Dor technique might result in a truncated and restrictive left ventricular cavity in small adults. We report a modified technique of left ventricular anteroapical aneurysm repair by using a semispherical reshaping patch to restore the left ventricular geometry.

Optical Coherence Tomography Findings in Bioresorbable Vascular Scaffolds Thrombosis

BACKGROUND

Everolimus-eluting bioresorbable vascular scaffolds have been developed to improve late outcomes after coronary interventions. However, recent registries raised concerns regarding an increased incidence of scaffold thrombosis (ScT). The mechanism of ScT remains unknown.

METHODS AND RESULTS

The present study investigated angiographic and optical coherence tomography findings in patients experiencing ScT. Fifteen ScT (14 patients, 79% male, age 59±10 years) occurred at a median of 16 days (25%-75% interquartile range: 1-263 days) after implantation. Early ScT (<30 days) occurred in 8 cases (53%). Possible causal factors in these patients included insufficient platelet inhibition in 2 cases and procedural factors (scaffold underexpansion, undersizing, or geographical miss) in 4 cases. No obvious cause could be found in 2 early ScT. In late (>1 month) and very late (>1 year) ScT (respectively, 5 and 2 cases), 5 scaffolds showed intimal neovessels or marked peristrut low-intensity areas. Scaffold fractures were additionally found in 2 patients, and scaffold collapse was found in 1 patient with very late ScT. Extensive strut malapposition was the presumed cause for ScT in 1 case. One scaffold did not show any morphological abnormality. Thrombectomy specimens were analyzed in 3 patients and did not demonstrate increased numbers of inflammatory cells.

CONCLUSIONS

The mechanisms of early ScT seem to be similar to metallic stents (mechanical and inadequate antiplatelet therapy). The predominant finding in late and very late ScT is peristrut low-intensity area.

Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Stent Versus Durable-Polymer Everolimus-Eluting Stent for Percutaneous Coronary Revascularization: 2-Year Results of the BIOSCIENCE Trial

Background

No data are available on the long‐term performance of ultrathin strut biodegradable polymer sirolimus‐eluting stents (BP‐SES). We reported 2‐year clinical outcomes of the BIOSCIENCE (Ultrathin Strut Biodegradable Polymer Sirolimus‐Eluting Stent Versus Durable Polymer Everolimus‐Eluting Stent for Percutaneous Coronary Revascularisation) trial, which compared BP‐SES with durable‐polymer everolimus‐eluting stents (DP‐EES) in patients undergoing percutaneous coronary intervention.

Methods and Results

A total of 2119 patients with minimal exclusion criteria were assigned to treatment with BP‐SES (n=1063) or DP‐EES (n=1056). Follow‐up at 2 years was available for 2048 patients (97%). The primary end point was target‐lesion failure, a composite of cardiac death, target‐vessel myocardial infarction, or clinically indicated target‐lesion revascularization. At 2 years, target‐lesion failure occurred in 107 patients (10.5%) in the BP‐SES arm and 107 patients (10.4%) in the DP‐EES arm (risk ratio [RR] 1.00, 95% CI 0.77–1.31, P=0.979). There were no significant differences between BP‐SES and DP‐EES with respect to cardiac death (RR 1.01, 95% CI 0.62–1.63, P=0.984), target‐vessel myocardial infarction (RR 0.91, 95% CI 0.60–1.39, P=0.669), target‐lesion revascularization (RR 1.17, 95% CI 0.81–1.71, P=0.403), and definite stent thrombosis (RR 1.38, 95% CI 0.56–3.44, P=0.485). There were 2 cases (0.2%) of definite very late stent thrombosis in the BP‐SES arm and 4 cases (0.4%) in the DP‐EES arm (P=0.423). In the prespecified subgroup of patients with ST‐segment elevation myocardial infarction, BP‐SES was associated with a lower risk of target‐lesion failure compared with DP‐EES (RR 0.48, 95% CI 0.23–0.99, P=0.043, P_interaction=0.026).

Conclusions

Comparable safety and efficacy profiles of BP‐SES and DP‐EES were maintained throughout 2 years of follow‐up.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01443104.

Coronary artery dimensions: Iranian population versus Indo-Asians and Caucasians

BACKGROUND

The dimensions of the coronary arteries have been shown to vary among ethnic groups. There are no data available regarding the normal size of coronary arteries in Iranians. This study aimed to investigate normal coronary artery dimensions in a Northwestern Iranian population and to compare it with pooled data of Indo-Asians and Caucasians in previous studies.

METHODS

The study included 200 adults with suspected coronary disease who were referred for elective coronary angiography between June 2012 and March 2013 and were found to have normal epicardial flow in the coronary arteries. Quantitative coronary angiography was carried out on the longest atheroma-free part of the proximal segment of each coronary artery in all patients. Two Indo-Asian and Caucasian groups were selected and pooled for comparison with the available reports on individuals without coronary artery disease.

RESULTS

The mean diameters of the left main coronary artery, proximal left anterior descending artery, proximal left circumflex, and proximal right coronary artery were 4.58 ± 0.80, 3.69 ± 0.64, 3.37 ± 0.73, and 3.47 ± 0.68 mm, respectively. The dimensions of the proximal part of the left main coronary artery and right coronary artery were significantly greater in the Northwestern Iranian population compared to the pooled Caucasian group. This difference was maintained even after correction for body surface area.

CONCLUSION

Our data indicate larger coronary diameters in the Iranian population compared to Caucasians or South-Asians. Hence the high prevalence of coronary artery disease in Iran cannot be explained by coronary dimensions.

[Current Treatment of Stable Angina]

Current therapy for stable angina includes surgical and percutaneous revascularization, which has been improved tremendously over the last decades. Smoking cessation and regular exercise are the cornerstone for prevention of further cerebrovascular events. Medical treatment includes treatment of cardiovascular risk factors and antithrombotic management, which can be a challenge in some patients. Owing to the fact the coronary revascularization is readily accessible these days in many industrialized countries, the importance of antianginal therapy has decreased over the past years. This article presents a contemporary overview of the management of patients with stable angina in the year 2015.

Clinical Outcomes According to Diabetic Status in Patients Treated With Biodegradable Polymer Sirolimus-Eluting Stents Versus Durable Polymer Everolimus-Eluting Stents

Background—

Ultrathin strut biodegradable polymer sirolimus-eluting stents (BP-SES) proved noninferior to durable polymer everolimus-eluting stents (DP-EES) for a composite clinical end point in a population with minimal exclusion criteria. We performed a prespecified subgroup analysis of the Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Stent Versus Durable Polymer Everolimus-Eluting Stent for Percutaneous Coronary Revascularisation (BIOSCIENCE) trial to compare the performance of BP-SES and DP-EES in patients with diabetes mellitus.

Methods and Results—

BIOSCIENCE trial was an investigator-initiated, single-blind, multicentre, randomized, noninferiority trial comparing BP-SES versus DP-EES. The primary end point, target lesion failure, was a composite of cardiac death, target-vessel myocardial infarction, and clinically indicated target lesion revascularization within 12 months. Among a total of 2119 patients enrolled between February 2012 and May 2013, 486 (22.9%) had diabetes mellitus. Overall diabetic patients experienced a significantly higher risk of target lesion failure compared with patients without diabetes mellitus (10.1% versus 5.7%; hazard ratio [HR], 1.80; 95% confidence interval [CI], 1.27–2.56; P =0.001). At 1 year, there were no differences between BP-SES versus DP-EES in terms of the primary end point in both diabetic (10.9% versus 9.3%; HR, 1.19; 95% CI, 0.67–2.10; P =0.56) and nondiabetic patients (5.3% versus 6.0%; HR, 0.88; 95% CI, 0.58–1.33; P =0.55). Similarly, no significant differences in the risk of definite or probable stent thrombosis were recorded according to treatment arm in both study groups (4.0% versus 3.1%; HR, 1.30; 95% CI, 0.49–3.41; P =0.60 for diabetic patients and 2.4% versus 3.4%; HR, 0.70; 95% CI, 0.39–1.25; P =0.23, in nondiabetics).

Conclusions—

In the prespecified subgroup analysis of the BIOSCIENCE trial, clinical outcomes among diabetic patients treated with BP-SES or DP-EES were comparable at 1 year.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01443104.

Full-root aortic valve replacement with stentless xenograft achieves superior regression of left ventricular hypertrophy compared to pericardial stented aortic valves

BACKGROUND

Full-root aortic valve replacement with stentless xenografts has potentially superior hemodynamic performance compared to stented valves. However, a number of cardiac surgeons are reluctant to transform a classical stented aortic valve replacement into a technically more demanding full-root stentless aortic valve replacement. Here we describe our technique of full-root stentless aortic xenograft implantation and compare the early clinical and midterm hemodynamic outcomes to those after aortic valve replacement with stented valves.

METHODS

We retrospectively compared the pre-operative characteristics of 180 consecutive patients who underwent full-root replacement with stentless aortic xenografts with those of 80 patients undergoing aortic valve replacement with stented valves. In subgroups presenting with aortic stenosis, we further analyzed the intra-operative data, early postoperative outcomes and mid-term regression of left ventricular mass index.

RESULTS

Patients in the stentless group were younger (62.6 ± 13 vs. 70.3 ± 11.8 years, p < 0.0001) but had a higher Euroscore (9.14 ± 3.39 vs.6.83 ± 2.54, p < 0.0001) than those in the stented group. In the subgroups operated for aortic stenosis, the ischemic (84.3 ± 9.8 vs. 62.3 ± 9.4 min, p < 0.0001) and operative times (246.3 ± 53.6 vs. 191.7 ± 53.2 min, p < 0.0001) were longer for stentless versus stented valve implantation. Nevertheless, early mortality (0% vs. 3%, p < 0.25), re-exploration for bleeding (0% vs. 3%, p < 0.25) and stroke (1.8% vs. 3%, p < 0.77) did not differ between stentless and stented groups. One year after the operation, the mean transvalvular gradient was lower in the stentless versus stented group (5.8 ± 2.9 vs. 13.9 ± 5.3 mmHg, p < 0.0001), associated with a significant regression of the left ventricular mass index in the stentless (p < 0.0001) but not in the stented group (p = 0.2).

CONCLUSION

Our data support that full-root stentless aortic valve replacement can be performed without adversely affecting the early morbidity or mortality in patients operated on for aortic valve stenosis provided that the coronary ostia are not heavily calcified. The additional time necessary for the full-root stentless compared to the classical stented aortic valve replacement is therefore not detrimental to the early clinical outcomes and is largely rewarded in patients with aortic stenosis by lower transvalvular gradients at mid-term and a better regression of their left ventricular mass index.

Ultrathin strut biodegradable polymer sirolimus-eluting stent versus durable polymer everolimus-eluting stent for percutaneous coronary revascularisation (BIOSCIENCE): a randomised, single-blind, non-inferiority trial

BACKGROUND

Refinements in stent design affecting strut thickness, surface polymer, and drug release have improved clinical outcomes of drug-eluting stents. We aimed to compare the safety and efficacy of a novel, ultrathin strut cobalt-chromium stent releasing sirolimus from a biodegradable polymer with a thin strut durable polymer everolimus-eluting stent.

METHODS

We did a randomised, single-blind, non-inferiority trial with minimum exclusion criteria at nine hospitals in Switzerland. We randomly assigned (1:1) patients aged 18 years or older with chronic stable coronary artery disease or acute coronary syndromes undergoing percutaneous coronary intervention to treatment with biodegradable polymer sirolimus-eluting stents or durable polymer everolimus-eluting stents. Randomisation was via a central web-based system and stratified by centre and presence of ST segment elevation myocardial infarction. Patients and outcome assessors were masked to treatment allocation, but treating physicians were not. The primary endpoint, target lesion failure, was a composite of cardiac death, target vessel myocardial infarction, and clinically-indicated target lesion revascularisation at 12 months. A margin of 3·5% was defined for non-inferiority of the biodegradable polymer sirolimus-eluting stent compared with the durable polymer everolimus-eluting stent. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT01443104.

FINDINGS

Between Feb 24, 2012, and May 22, 2013, we randomly assigned 2119 patients with 3139 lesions to treatment with sirolimus-eluting stents (1063 patients, 1594 lesions) or everolimus-eluting stents (1056 patients, 1545 lesions). 407 (19%) patients presented with ST-segment elevation myocardial infarction. Target lesion failure with biodegradable polymer sirolimus-eluting stents (69 cases; 6·5%) was non-inferior to durable polymer everolimus-eluting stents (70 cases; 6·6%) at 12 months (absolute risk difference -0·14%, upper limit of one-sided 95% CI 1·97%, p for non-inferiority <0·0004). No significant differences were noted in rates of definite stent thrombosis (9 [0·9%] vs 4 [0·4%], rate ratio [RR] 2·26, 95% CI 0·70-7·33, p=0·16). In pre-specified stratified analyses of the primary endpoint, biodegradable polymer sirolimus-eluting stents were associated with improved outcome compared with durable polymer everolimus-eluting stents in the subgroup of patients with ST-segment elevation myocardial infarction (7 [3·3%] vs 17 [8·7%], RR 0·38, 95% CI 0·16-0·91, p=0·024, p for interaction=0·014).

INTERPRETATION

In a patient population with minimum exclusion criteria and high adherence to dual antiplatelet therapy, biodegradable polymer sirolimus-eluting stents were non-inferior to durable polymer everolimus-eluting stents for the combined safety and efficacy outcome target lesion failure at 12 months. The noted benefit in the subgroup of patients with ST-segment elevation myocardial infarction needs further study.

FUNDING

Clinical Trials Unit, University of Bern, and Biotronik, Bülach, Switzerland.

Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome

OBJECTIVE

Analyse 2-year outcomes after MitraClip therapy and identify predictors of outcome.

METHODS

Consecutive patients (n=74) undergoing MitraClip therapy were included in the MitraSWISS registry and followed prospectively.

RESULTS

A reduction of mitral regurgitation (MR) to ≤ mild was achieved in 32 (43%) patients and to moderate in 31 (42%) patients; 16/63 (25%) patients with initially successful treatment developed recurrent moderate to severe or severe MR during the first year and only 1 patient did so during the second year. At 2 years, moderate or less MR was more frequently present in patients with a transmitral mean gradient <3 mm Hg at baseline (73% vs 23%, p < 0.01) and in patients with a left atrial volume index (LAVI) <50 mL/m(2) at baseline (86% vs 52%, p=0.03). More than mild MR post MitraClip, N-terminal probrain natriuretic peptide ≥5000 ng/L at baseline, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were associated with reduced survival.

CONCLUSIONS

A mean transmitral gradient <3 mm Hg at baseline, an LAVI <50 mL/m(2), the absence of COPD and CKD, and reduction of MR to less than moderate were associated with favourable outcome. Given a suitable anatomy, such patients may be excellent candidates for MitraClip therapy. Between 1 and 2 years follow-up, clinical and echocardiographic outcomes were stable, suggesting favourable, long-term durability of the device.

Impact of preload changes on positive and negative left ventricular dP/dt and systolic time intervals: preload changes on left ventricular function

AIM/OBJECTIVES

Previous work has shown that the electromechanical activation time (EMAT) is prolonged in patients with abnormally low left ventricular (LV) dP/dt. In the present study, we investigated whether EMAT was responsive to rapid changes in LV systolic function induced by abrupt increases in LV preload.

METHODS AND RESULTS

A total of 116 patients were assessed before and after LV angiography with a bolus injection of 40 mL of non-ionic contrast dye. Left ventricular end-diastolic pressure (LVEDP) increased from 18 ± 7 mmHg to 20 ± 8 mmHg (P < 0.01). In patients with a baseline dP/dt < 1500 mmHg/sec, dP/dt increased from 1098 ± 213 mmHg/sec to 1146 ±306 mmHg/sec (P=0.02) and EMAT decreased from 106 ± 29 ms to 103 ±18 ms (P=0.02). In patients with a baseline dP/dt > 1500 mmHg/sec, dP/dt decreased from 1894 ± 368 mmHg/sec to 1762 ± 403 mmHg/sec (P=0.01) and EMAT increased from 88 ± 13 ms to 93 ± 16 ms (P=0.02). Changes in negative dP/dt were similar to changes in dP/dt.

CONCLUSION

Electromechanical activation time is a non-invasively measured parameter that allows accurate and rapid detection of changes in LV contractility.

Is leukocytosis a predictor for recurrence of ischemic events after coronary artery bypass graft surgery? A cohort study

Objective. Studies have shown that inflammation plays an important role in pathogenesis of coronary artery disease. The present study was designed to evaluate the role of high WBC count before CABG in predicting the risk of ischemic events after CABG. Methods and Results. This prospective study was carried out on 380 patients who underwent CABG surgery. Ninety seven patients (25.5%) had recurrent ischemic event. Mean WBC count before CABG surgery in patients with recurrent ischemic event was 7267 mic/lit ± 1863, which was significantly higher than the others, with a mean WBC count of 6721 mic/lit ± 1734 (P = 0.011). Patients with a WBC count more than 6000 mic/lit were at the highest risk for recurrent ischemic event (OR = 2.11, 95% CI = 1.18–3.44, P = 0.009). After adjustment for age, sex, family history, smoking, hyperlipidemia, Logestic Euro score, post opretive enzyme release (CK.mb), arterial graft and BMI, the relationship between the group with WBC count higher than 6000 mic/lit and recurrent of ischemic event remained significant (OR = 2.25, 95% CI = 1.2 to 4, P = 0.005). Conclusions. High WBC count before CABG surgery is an independent risk factor for ischemic events one year after the surgery.

Deviation from Murray's law is associated with a higher degree of calcification in coronary bifurcations

OBJECTIVE

Murray's law describes the optimal branching anatomy of vascular bifurcations. If Murray's law is obeyed, shear stress is constant over the bifurcation. Associations between Murray's law and intravascular ultrasound (IVUS) assessed plaque composition near coronary bifurcations have not been investigated previously.

METHODS

In 253 patients plaque components (fibrous, fibro-fatty, necrotic core, and dense calcium) were identified by IVUS in segments proximal and distal to the bifurcation of a coronary side branch. The ratio of mother to daughter vessels was calculated according to Murray's law (Murray ratio) with a high Murray ratio indicating low shear stress. Analysis of variance was used to detect independent associations of Murray ratio and plaque composition.

RESULTS

Patients with a high Murray ratio exhibited a higher relative amount of dense calcium and a lower amount of fibrous and fibro-fatty tissue than those with a low Murray ratio. After adjustment for age, sex, cardiovascular risk factors or concomitant medications, the Murray ratio remained significantly associated with fibrous volume distal (F-ratio 4.90, P=0.028) to the bifurcation, fibro-fatty volume distal (F-ratio 4.76, P=0.030) to the bifurcation, and dense calcium volume proximal (F-ratio 5.93, P=0.016) and distal (F-ratio 5.16, P=0.024) to the bifurcation.

CONCLUSION

This study shows that deviation from Murray's law is associated with a high degree of calcification near coronary bifurcations. Individual deviations from Murray's law may explain why some patients are prone to plaque formation near vessel bifurcations.

The impact of stepwise stent deployment on the angiographic and clinical outcome of coronary angioplasty in the setting of an acute myocardial infarction

OBJECTIVE

To detect a reduction in the incidence of no-reflow, and a possible improvement in angiographic and clinical outcome after stepwise stenting in comparison with conventional method in the percutaneous coronary intervention (PCI) of patients with anterior ST elevation myocardial infarction.

METHODS

Between March 2007 and December 2009, patients with anterior acute myocardial infarction (AMI) treated with streptokinase less than 6 hours from presentation who underwent early PCI were enrolled in this multicenter randomized clinical trial. The study was carried out in the Cardiology Departments of Valiasr Hospital of Zanjan, Imam Reza, and Shahid Madani Heart Hospitals, Tabriz, Iran.

RESULTS

Four hundred and three patients were enrolled in this study. Patients were randomly divided into 2 groups: Group I (n=202) with stepwise stent deployment (SSD), and Group II (n=201) with routine conventional stent deployment (CSD). The patients' mean age was 57.7 +/- 10.7 years. After PCI, thrombolysis in myocardial infarction myocardial perfusion grade (TMPG) 0/1, suggestive of no-reflow was significantly higher in CSD group (p=0.0001). In hospital based, death occurred in 15 patients (7.5%) from CSD group while 4 (2%) from the SSD group (p=0.01). The TMPG was also significantly higher in SSD group (average 2.32 +/- 0.18) compared with CSD group, (average 1.66 +/- 0.24) (p=0.0001). Conventional stenting technique was an independent predictor of no-reflow in multivariate logistic regression analysis (hazard ratio - 1.43; 95% confidence interval: 1.15-1.73; p=0.01).

CONCLUSION

The SSD was associated with improved angiographic reperfusion indices and reduced mortality in early PCI for AMI.

Thromboembolic acute myocardial infarction in a congenital double chambered left ventricle

A 61-year-old woman with a congenital double-chamber left ventricle (DCLV) was admitted because of an anterior ST-elevation myocardial infarction (STEMI). Urgent coronary angiography showed a thrombotic occlusion of the distal part of the left anterior descending artery (LAD). The left ventricular injection revealed a slightly reduced ejection fraction, antero-apical akinesia and an accessory chamber. Two dimensional and three dimensional echocardiography showed anterior akinesia with an accessory chamber at the apex which was separated by a fibromuscular ridge distal to the papillary muscles. The DCLV with myocardial contraction in the additional chamber was originally diagnosed seven years ago during a routine follow-up echocardiography in the course of management for thyroid cancer and at that time left ventricular function was described to be normal. Thromboembolism was assumed to have originated from the hypocontractile left accessory chamber and the patient was set on oral anticoagulation. During follow-up global left ventricular function normalized.

Progression of coronary artery disease during long-term follow-up of the Swiss Interventional Study on Silent Ischemia Type II (SWISSI II)

BACKGROUND

This study evaluates cardiovascular risk factors associated with progression of coronary artery disease (CAD) in patients with silent ischemia following myocardial infarction.

HYPOTHESIS

Coronary artery disease only progresses slowly with comprehensive risk factor intervention.

METHODS

A total of 104 of 201 patients (51.7%) of the Swiss Interventional Study on Silent Ischemia Type II (SWISSI II) with baseline and follow-up coronary angiography were included. All patients received comprehensive cardiovascular risk factor intervention according to study protocol. Logistic regression was used to evaluate associations between baseline cardiovascular risk factors and CAD progression.

RESULTS

The mean duration of follow-up was 10.3+/-2.4 years. At baseline, 77.9% of patients were smokers, 45.2% had hypertension, 73.1% had dyslipidemia, 7.7% had diabetes, and 48.1% had a family history of CAD. At last follow-up, only 27 patients of the initial 81 smokers still smoked, only 2.1% of the patients had uncontrolled hypertension, 10.6% of the patients had uncontrolled dyslipidemia, and 2.1% of the patients had uncontrolled diabetes. Coronary artery disease progression was found in up to 81 (77.9%) patients. Baseline diabetes and younger age were associated with increased odds of CAD progression. The time interval between baseline and follow-up angiography was also associated with CAD progression.

CONCLUSION

Coronary artery disease progression was highly prevalent in these patients despite comprehensive risk factor intervention. Further research is needed to optimize treatment of known risk factors and to identify other unknown and potentially modifiable risk factors.

Differences in coronary artery plaques between target and non-target vessels

OBJECTIVE

We used intravascular ultrasound (IVUS) and virtual histology (VH) to assess the differences of plaque burden and composition between target coronary arteries containing the culprit lesion and non-target coronary arteries.

METHODS

Sixty patients referred for acute (n = 19) or elective (n = 41) coronary angiography were included. The target vessel containing the culprit lesion was identified by angiography. A non-target coronary artery was chosen for comparison. The first 4 cm of each vessel were analyzed with IVUS and VH.

RESULTS

Total plaque burden was higher in the target vessel compared to the non-target vessel (52.4% vs. 45.9%, a relative difference of 14.2%; p < 0.001). The plaque composition of the target vessel correlated strongly with the plaque composition of the non-target vessel, but the relative amount of necrotic core was significantly higher in the target vessels (21.7% vs 19.2%; p = 0.028), whereas the amount of fibrolipidic material was significantly greater in non-target vessels (10.6% vs. 12.7%; p = 0.035).

CONCLUSIONS

We conclude that in patients with relevant coronary artery disease, plaque burden and the amount of necrotic core material are greater in the target vessel. There is a strong correlation of plaque composition between target and non-target coronary arteries.

Coronary artery disease is common in asymptomatic patients with signs of myocardial ischemia

BACKGROUND

The incidence of coronary artery disease (CAD) in totally asymptomatic patients with myocardial ischemia during stress testing is unknown.

METHODS

54 patients with asymptomatic myocardial ischemia participated in the Swiss Interventional Study on Silent Ischemia type I (SWISSI I). Asymptomatic myocardial ischemia was verified by bicycle ergometry and stress imaging (echocardiography or scintigraphy). Findings from coronary angiographies in the course of the study constituted the main outcome.

RESULTS

Of the 54 study participants, 29 patients (53.7%) underwent coronary angiography. CAD was found in 27 of 29 patients (93.1%). In those 27 patients with CAD, 9 patients (33.3%) suffered from single vessel disease, 9 patients (33.3%) from two vessel disease, and 9 patients (33.3%) from triple vessel disease. Two patients showed left main coronary artery stenosis.

CONCLUSION

This study shows a high incidence of relevant CAD among totally asymptomatic patients with myocardial ischemia during stress testing. Previously healthy subjects with exercise-induced ST-segment depression at check-up examinations, even if asymptomatic, should have further diagnostic evaluation.

Intravascular ultrasound-based left main coronary artery assessment: comparison between pullback from left anterior descending and circumflex arteries

OBJECTIVE

We compared continuous pullback from the left anterior descending artery (LAD) with pullback from the circumflex artery (CX) for the assessment of the left main coronary artery (LMCA) by intravascular ultrasound (IVUS).

BACKGROUND

Gray-scale IVUS and virtual histology by IVUS (IVUS-VH) overcome many shortcomings of contrast angiography in diagnostic assessment of the LMCA. IVUS of LCMA can be acquired by continuous pullback from LAD or CX. Equivalence of the two pullback methods has not been investigated.

METHODS

LMCA morphology was assessed by IVUS in 65 patients referred for elective or rescue coronary angiography. In each patient IVUS was performed once using pullback from the LAD and once using pullback from the CX. Intraclass correlation coefficients (ICC) were calculated to measure the degree of reliability.

RESULTS

The mean age of patients was 60.4 +/- 9.5 years (range 40-84). The IVUS-determined degree of stenosis in the LMCA was a mean of 30% +/- 8% (range 15-52%). The ICC showed excellent reliability (ICC > 0.8) for volume measurements within the plaque (lipid volume, fibrolipidic volume, lipid core volume and calcified volume) and for the measurement of large or averaged diameters (maximal vessel diameter, average vessel diameter, average lumen diameter). The ICC was intermediate (ICC 0.5-0.8) for the measurement of small diameters (minimal vessel diameter, minimal lumen diameter, maximal lumen diameter) and for area calculations (minimal lumen area) based on small diameters.

CONCLUSIONS

Overall, there was excellent reliability between IVUS-based LMCA morphology assessment using pullback from either the LAD or the CX.

Acoustic cardiographic parameters and their relationship to invasive hemodynamic measurements in patients with left ventricular systolic dysfunction

Data obtained at cardiac catheterization were used to evaluate the utility of acoustic cardiographic data in assessing the hemodynamic abnormalities associated with left ventricular systolic dysfunction (LVSD). Thirty-seven patients (mean age, 62.6 years) underwent catheterization, and hemodynamic data were recorded. Acoustic cardiographic recordings were obtained using a system that records and algorithmically interprets diastolic heart sounds and parameters analogous to traditional systolic time intervals. Seventeen patients had LVSD (defined as ejection fraction <50%). The 17 patients with LVSD composed the cohort for analysis. There were strong associations between acoustic cardiographic parameters and left ventricular end-diastolic pressure, ejection fraction, and maximum contractility. Heart rate tended to influence the strength of these correlations. The authors conclude that acoustic cardiographic data can be used in the evaluation of patients with known or suspected LVSD, and specifically in the selection of patients for cardiac resynchronization therapy and the optimization of the settings of implanted resynchronization devices.

Congenital Anomalies of the Coronary Arteries

Multiple variations of congenital anomalies of the coronary arteries exist that may occur in isolation or in association with other congenital anomalies. They can cause myocardial ischaemia. A rare but potentially lethal condition is the anomalous origin of the left coronary artery from the pulmonary artery. The most common haemodynamically significant coronary abnormalities are coronary artery fistulae. A left-toright shunt exists in more than 90% of cases. The origin of the left coronary artery from the proximal right coronary artery (RCA) or the right aortic sinus with subsequent passage between the aorta and the right ventricular outflow tract has been associated with sudden death during or shortly after exercise in young persons. High anterior origin of the RCA is commonly encountered but is of no haemodynamic significance. It is difficult to engage the ostium of the RCA selectively using conventional catheter manipulation. In this article we will discuss various types of congenital coronary anomaly, providing examples.

Transpulmonary closing of left internal mammary artery to pulmonary artery fistula with polytetrafluoroethylene covered stent: a case report and review of literature

Internal mammary artery (IMA) to pulmonary vasculature fistula is a rare condition that can be congenital or associated with coronary artery bypass grafting surgery (CABG), trauma, inflammation, or neoplasia. This complication may cause myocardial ischemia. CABG with an IMA conduit accounts for most iatrogenic cases, thus this problem may be encountered more in the future as the number of patients undergoing CABG and redo-CABG increases. The natural history of IMA-to-pulmonary artery (PA) fistulas is unknown and therefore optimal treatment remains controversial. We describe a case of left IMA-to-PA fistula treated with balloon expandable covered stent with a transpulmonary approach, and we review previously reported cases.

In-stent restenosis and thrombosis 41 months after drug-eluting stent implantation

Evidence indicates that very late stent thrombosis (>1 year) occurs more frequently in drug-eluting stents than in bare metal stents after discontinuation of clopidogrel. We present a case of an 83 year old man with an LAD in-stent thrombosis 41 months after stenting with a sirolimus-eluting stent in whom clopidogrel was discontinued after 6 months based on these days' guidelines. In-stent thrombus was aspirated and intracoronary ultrasound (ICUS) showed significant in-stent restenosis which had narrowed the minimal lumen diameter by 1 mm. The lesion was stented with a bare metal stent. The patient was discharged after recovery and had no recurrence of stent thrombosis in one month follow-up. We recommended indefinite dual antiplatelet therapy with aspirin and clopidogrel.

"Apical ballooning" - what is the cause?

The pathophysiology of takotsubo cardiomyopathy remains enigmatic. Here we attempted to define the link between the coronary arteries and the histopathological involvement of the left ventricle. We observed similarities and discrepancies between patients. All patients experienced stress prior to the event. We found a reduced coronary flow reserve in all patients and signs of hibernating myocardium on biopsy specimen. This raises a strong suspicion of stress-induced endothelial dysfunction with hibernating myocardium in the pathogenesis of this cardiomyopathy.

Functional mitral stenosis: a rare complication of the Impella assist device

In patients with left ventricular output failure, the Impella left ventricular assist device increases total cardiac output despite a drop in output provided by the left ventricle itself. We present a patient with cardiogenic shock after myocardial infarction in whom an Impella recover 2.5 was implanted. Correct placement was ensured by fluoroscopy, pressure and current signals displayed on the console of the system, and transthoracic echocardiography. On follow-up, the Impella device was dislocated with the shaft of the device lying on the anterior mitral leaflet causing a functional mitral stenosis evident by an increased transmitral diastolic flow gradient. After removing the device, the patients' haemodynamics improved within minutes. Other than a mild regurgitation, mitral valve was without pathological findings. Although infrequent, this case shows a possible complication of the Impella ventricular assist device and highlights the importance of periodical echocardiographic surveillance, especially in patients who show a poor response to therapy.

Comparison of different approaches for optimization of atrioventricular and interventricular delay in biventricular pacing

AIMS

It has been shown that optimizing atrioventricular (AV) and interventricular (VV) delay improves cardiac performance in patients with biventricular pacemakers. However, there is no standard method for optimization available yet. The aim of this study was to compare echocardiographic parameters-displacement imaging, A wave duration, and aortic velocity time integral (VTI)-and acoustic cardiography derived electromechanical activation time (EMAT) using different approaches of AV and VV delay optimization. We tested whether the initial optimization of the AV interval followed by VV optimization at that optimal AV interval or initial optimization of the VV interval followed by AV optimization at the determined optimal VV interval was accurate and consistent, and how this compared to testing every conceivable combination of AV and VV intervals available.

METHODS AND RESULTS

A group of 20 patients with biventricular pacemakers was included. Displacement imaging, A wave duration, and aortic VTI were determined at different combinations of AV (100, 150, 200, 250 ms) and VV (RV40, 0, LV40 ms) intervals. If AV duration was determined first, displacement imaging identified the best setting in 8/20, aortic VTI in 10/20, A duration in 13/20, and EMAT in 18/20 patients. With VV duration determined first, the best setting was more difficult to identify regardless of the method used. There was a poor agreement in optimal AV and VV delays of the different methods, and there was no single patient in whom all four methods yielded the same delay combination.

CONCLUSION

It is advisable to measure a full grid of AV and VV delays to identify optimal settings rather than optimizing one of the two delays first. Different techniques for delay optimization resulted in different optimal delay combinations.