Compare CPM-RMI trial: intramyocardial transplantation of autologous bone marrow-derived cd133+ cells and mononuclear cells during coronary artery bypass grafting in patients with recent myocardial infarction: a phase II/III, multicenter, placebo-controlled, randomized, double-blind clinical trial

Objective: The regenerative potential of bone marrow-derived mononuclear cells [MNCs] and CD133+ stem cells in the heart varies in terms of their pro-angiogenic effects. This phase II/III, multicenter and double-blind trial is designed to compare the functional effects of intramyocardial autologous transplantation of both cell types and placebo in patients with recent myocardial infarction [RMI] post-coronary artery bypass graft

Materials and Methods: This was a phase II/III, randomized, double-blind, placebo-controlled trial COMPARE CPM-RMI [CD133, Placebo, MNCs - recent myocardial infarction] conducted in accordance with the Declaration of Helsinki that assessed the safety and efficacy of CD133 and MNCs compared to placebo in patients with RMI. We randomly assigned 77 eligible RMI patients selected from 5 hospitals to receive CD133+ cells, MNC, or a placebo. Patients underwent gated single photon emission computed tomography assessments at 6 and 18 months post-intramyocardial transplantation. We tested the normally distributed efficacy outcomes with a mixed analysis of variance model that used the entire data set of baseline and between-group comparisons as well as within subject [time] and group×time interaction terms

Results: There were no related serious adverse events reported. The intramyocardial transplantation of both cell types increased left ventricular ejection fraction by 9% [95% confidence intervals [CI]: 2.14% to 15.78%, P=0.01] and improved decreased systolic wall thickening by -3.7 [95% CI: -7.07 to -0.42, P=0.03]. The CD133 group showed significantly decreased non-viable segments by 75% [P=0.001] compared to the placebo and 60% [P=0.01] compared to the MNC group. We observed this improvement at both the 6- and 18-month time points

Conclusion: Intramyocardial injections of CD133+ cells or MNCs appeared to be safe and efficient with superiority of CD133+ cells for patients with RMI. Although the sample size precluded a definitive statement about clinical outcomes, these results have provided the basis for larger studies to confirm definitive evidence about the efficacy of these cell types

Association between latest activated sites in the left ventricle and akinetic segments in patients with ischemic cardiomyopathy

Background: It is not clear whether the latest activation sites in the left ventricle [LV] are matched with infracted regions in patients with ischemic cardiomyopathy [ICM]. We aimed to investigate whether the latest activation sites in the LV are in agreement with the region of akinesia in patients with ICM

Methods: Data were analyzed in 106 patients [age = 60.5 +/- 12.1 y, male = 88.7%] with ICM [ejection fraction 120 ms

Results: A total of 1 272 segments were studied. The latest activation sites [with longest Ts] were most frequently located in the mid-anterior [n = 32, 30.2%] and basal-anterior segments [n = 29, 27.4%], while the most common sites of akinesia were the mid-anteroseptal [n = 65, 61.3%] and mid-septal [n = 51, 48.1%] segments. Generally, no significant concordance was found between the latest activated segments and akinesia either in all the patients or in the QRS groups. Detailed analysis within the segments indicated a good agreement between akinesia and delayed activation in the basal-lateral segment solely in the patients with QRS duration

Conclusion: The akinetic segment on 2-dimensional echocardiogram was not matched with the latest activation sites in the LV determined by TDI in patients with ICM

Correlation between mitral regurgitation and myocardial mechanical dyssynchrony and QRS duration in patients with cardiomyopathy

Several competing geometric and hemodynamic factors are suggested as contributing mechanisms for functional mitral regurgitation [MR] in heart failure patients. We aimed to study the relationships between the severity of MR and the QRS duration and dyssynchrony markers in patients with ischemic or dilated cardiomyopathy. We prospectively evaluated 251 heart failure patients with indications for echocardiographic evaluation of possible cardiac resynchronization therapy. All the patients were subjected to transthoracic echocardiography and tissue Doppler imaging to evaluate the left ventricular [LV] synchronicity. The patients were divided into two groups according to the severity of MR: /= moderate MR. The effects of different dyssynchrony indices were adjusted for global and regional left ventricular remodeling parameters. From the 251 patients [74.5% male, mean age = 53.38 +/- 16.68 years], 130 had /= moderate MR. There were no differences between the groups regarding the mean age, frequency of sex, and etiology of cardiomyopathy. The LV systolic and diastolic dimensions were greater in the patients with >/= moderate MR [all p values < 0.001]. Among the different echocardiographic factors, the QRS duration [150.75 +/- 34.66 vs. 126.77 +/- 29.044 ms; p value = 0.050] and interventricular mechanical delay [41.60 +/- 29.50 vs. 35.00 ms +/- 22.01; p value = 0.045] were significantly longer in the patients with

Comparison of echocardiographic markers of cardiac dyssynchrony and latest left ventricular activation site in heart failure patients with and without left bundle branch block

Several echocardiographic markers have been introduced to assess the left ventricular [LV] mechanical dyssynchrony. We studied dyssynchrony markers and the latest LV activation site in heart failure patients with and without left bundle branch block [LBBB]. Conventional echocardiography and tissue velocity imaging were performed for 78 patients [LV ejection fraction /= 3 markers was remarkably higher in the LBBB patients [73% vs. 43.9%, respectively; p value = 0.044]. The LBBB patients presented with a higher prevalence of dyssynchrony according to the frequently used echocardiographic markers. The latest activation site was different between the groups

Percutaneous transvenous mitral commissurotomy: significance of echocardiographic assessment in prediction of immediate result

The current study aims to identify demographic, clinical characteristics, echocardiographic and/or mitral valve morphological parameters that may predict the successful result of percutaneous transvenous mitral commissurotomy [PTMC]. The medical records of 196 patients [48 males, mean age: 42.7 +/- 11.5 years] who underwent PTMC were reviewed. Prior to PTMC, a combination of transthoracic and transesophageal echocardiography were used to investigate substantial mitral valve morphological subcomponents [thickening, mobility, calcification, and subvalvular thickness] and suitability for PTMC. The second transthoracic echocardiographic assessment was performed within six weeks after PTMC. Patients were divided into two categories of successful or unsuccessful according to PTMC results. Successful PTMC was defined as: final mitral valve area [MVA] >/= 1.5 cm[2] without a post-procedure mitral regurgitation [MR] grade >2. The significant predictor of the result was identified by comparing demographic data, initial echocardiographic assessment and mitral valve morphological scores within both groups. The mean MVA increased from 1.0 +/- 0.2 cm[2] to 1.7 +/- 0.4 cm[2], and mitral valve mean gradient [MVMG] decreased from 11.5 +/- 5.2 to 5.2 +/- 3.3 mmHg [P < 0.001 for both]. Successful results were obtained in 139 [70.9%] patients compared to unsuccessful results in 57 [29.1%]. Unsuccessful results were due to suboptimal secondary MVA < 1.5 cm[2] in 50 [25.5%] patients and post-procedure MR grade >2 in 7 [3.6%]. Multiple logistic regression analysis indicated that young age, lower size of the left atrium [LA], and smaller degree of mitral valve thickness were the predictors of successful result. Pre-procedure echocardiographic assessment appears to be helpful in predicting PTMC results. Successful PTMC is influenced by the patients' age, LA size, and mitral valve thickness

Five-year follow-up of the local autologous transplantation of CD133+ enriched bone marrow cells in patients with myocardial infarction

The implantation of a CD133+ bone marrow cell population into an ischemic myocardium has emerged as a promising therapeutic modality for myocardial regeneration and restoration of ventricular contractility. While previous studies have documented the short-term safety and efficacy of CD133+ cell transplantation in patients with acute myocardial infarction, there are few reports of long-term follow-up results. Here, we present the results of long-term follow-up of our acute myocardial infarction patients who were treated with intra-myocardial injection of CD133+ cells after coronary bypass graft. After five years, 13 patients in the cell transplantation group and 5 patients in the control group underwent safety and efficacy investigations by New York Heart Association classification and two-dimensional echocardiography [2D echo]. During the five-year study period, no major cardiac adverse events were reported among patients who received CD133+ stem cells. Regarding efficiency, we observed no statistically significant treatment effects for the echocardiographic parameters [left ventricular end-diastolic and end-systolic volumes, and resting ejection fraction] measured during the follow-up period. However, detailed analysis of regional wall motion revealed an improvement in the Wall Motion Score Index from baseline to the six month follow-up, which was maintained during the follow-up period. Taken together, the long-term results of the present study indicate that transplantation of CD133+ is a safe and feasible procedure; however, we could not show any major benefits in our patients. Thus, this issue needs to be addressed by conducting other studies with more patients

Assessment of left ventricular dyssynchrony in heart failure patients regarding underlying etiology and QRS duration

Left ventricular [LV] dyssynchrony is a prevalent feature in heart failure [HF] patients. The current study aimed to evaluate the prevalence of inter and intraventricular dyssynchrony in HF patients with regard to the QRS duration and etiology. The available data on the tissue Doppler imaging [TDI] of 230 patients with refractory HF were analyzed. The patients were divided into three groups according to the QRS duration: QRS duration < 120 ms; 120-150 ms; and >/= 150 ms and the patients were re-categorized into two subgroups depending on the underlying etiology: ischemic cardiomyopathy [ICM] or dilated cardiomyopathy [DCM]. The time-to-peak myocardial sustained systolic velocity [Ts] in six basal and six middle segments of the LV was measured manually using the velocity curves from TDI. LV dyssynchrony was defined as interventricular mechanical delay >/= 40 ms and tissue Doppler velocity all segments delay >/= 105 ms; standard deviation [SD] of all segments >/= 34.4 ms; basal segments delay >/= 78 ms; SD of basal segments >/= 34.5 ms; and opposing wall delay >/= 65 ms. After adjustment for the possible confounders, interventricular dyssynchrony was more prevalent in the patients with QRS duration >/= 150 ms than in those with QRS duration 120-150 ms and < 120 ms. The patients with DCM also had a higher percentage of interventricular dyssynchrony than those with ICM in the wide QRS groups. Turning to the intraventricular dyssynchrony indices, the patients with QRS duration >/= 150 ms and 120-150 ms revealed a significantly greater delay between Ts at the basal and all segments than did those with QRS duration < 120 ms, while etiology did not influence the frequency of these indices in each QRS group. The prevalence of both inter and intraventricular dyssynchrony indices was greater in the patients with wide QRS than in those with narrow QRS duration. The underlying etiology may affect the frequency of interventricular but not intraventricular dyssynchrony indices

Transcatheter closure of patent ductus arteriosus: initial study on echocardiographic estimation of device size

Transcatheter occlusion of the patent ductus arteriosus [PDA] is a minimally invasive treatment. The appropriate device size is chosen based on the angiographic measurement of the PDA. The current study aimed to assess the relationship between the transthoracic echocardiographic [TTE] measurements of the PDA prior to the occlusion procedure and the actual size of the deployed device. We reviewed the available records of 7 patients [2 male] who underwent the procedure at our institution [mean age: 21 +/- 12.7years, range: 7 to 46years]. PDA closure was performed successfully using the Amplatzer Duct Occluder [n = 5] and its Chinese copycat, Cardi-O-Fix Occluder [n =2]. The TTE measurement of the aortic end diameter of the PDA showed a good linear regression correlation with the size of the implanted duct occluder [duct occluder size = 0.543 + [0.941 x TTE measured diameter], R = 0.907; p value

Measurement of atrial septal defect size: a comparative study between transesophageal echocardiography and balloon occlusive diameter method

Transcatheter closure of atrial septal defect secundum [ASD-II] has become an alternative method for surgery. We sought to compare the two-dimensional transesophageal echocardiography [TEE] method for measuring atrial septal defect with balloon occlusive diameter [BOD] in transcatheter ASD-II closure. A total of 39 patients [71.1% female, mean age: 35.31 +/- 15.37 years] who underwent successful transcatheter closure of ASD-II between November 2005 and July 2008 were enrolled in this study. Transthoracic echocardiography [TTE] and TEE were performed to select suitable cases for device closure and measure the defect size before the procedure, and BOD measurement was performed during catheterization via TEE. The final size of the selected device was usually either equal to or 1-2 mm larger than the BOD of the defect. The mean defect size obtained by TEE and BOD was 18.50 +/- 5.08 mm and 22.86 +/- 4.76 mm, respectively. The mean difference between the values of ASD size obtained by TEE and BOD was 4.36 +/- 2.93 mm. In comparison with BOD, TEE underestimated the defect size in 94.9%, but TEE value being equal to BOD was observed in 5.1%. There was a good linear correlation between the two measurements: BOD=0.773 ASD size by TEE+8.562; r2=67.9.1%. A negative correlation was found between TEE sizing and the difference between BOD and TEE values [r=-0.394, p value=0.013]. In this study, BOD was larger than ASD size obtained by two-dimensional TEE. However, TEE maximal defect sizing correlates with BOD and may provide credible information in device size selection for transcatheter ASD closure

Quadricuspid aortic valve diagnosed by transesophageal echocardiography: a case report

Quadricuspid aortic valve [QAV] is an uncommon congenital anomaly which was an incidental finding during surgery or autopsy in the past. We present the case of a 44-year-old woman with moderately severe aortic regurgitation due to unequal cusp size QAV diagnosed via transesophageal echocardiography. Due to echocardiographic imaging improvement, the diagnosis of QAV is now easier and earlier than the past

Cor triatriatum: preoperative diagnosis and successful surgical correction in a four-year-old girl

Cor triatriatum is defined as a membrane within the left atrium, which might lead to restricted pulmonary venous return. Diagnosis is usually achieved by echocardiography in early infancy. Therapy of choice is the excision of the membrane. Herein, successful correction of cor triatriatum in a 4-year-old girl is presented, and the clinical features, echocardiographic findings, and the surgical treatment are discussed

Impact of isolated coronary artery bypass grafting on non-organic tricuspid regurgitation severity

Moderate non-organic tricuspid regurgitation [TR] concomitant with coronary artery disease is not uncommon, Whether or not TR improves after pure coronary artery bypass grafting [CABG], however, is unclear. The aim of this study was to evaluate the effect of isolated CABG on moderate non-organic TR. This study recruited 50 patients [40% female, mean age: 65.38 +/- 8.01 years, mean left ventricular ejection fraction [LVEF]: 45.74 +/- 13.05%] with moderate non-organic TR who underwent isolated CABG. TR severity before and after CABG was compared. Pulmonary arterial systolic pressure [PAPs] > 30mmHg and LVEF < 50% were considered elevated PAPs [EPAPs] and LV systolic dysfunction, respectively. Presence of Q-wave in leads II, III, and aVF was considered inferior myocardial infarction [inf. MI]. Pre-operatively, 81.5% of the patients had EPAPs, 16% right ventricle [RV] dilation, and 50% left ventricle [LV] and 16% RV systolic dysfunction. TR severity improved in 64% after CABG, whereas it remained unchanged or even worsened in others [P value < 0.001]. Patients with inf. MI showed no improvement in TR, while patients without inf. MI had significant TR regression after CABG [P value= 0.050]. Improvement of TR severity after CABG was not related to pre-operative RV size and function, LV systolic function, or PAPs reduction. Although TR severity decreased remarkably after isolated CABG, a considerable number of the patients had no TR regression. In addition, only absence of inf. MI was significantly correlated to TR improvement after CABG. Further prospective studies with long-term follow-up needed to determine the other factors predicting TR regression after isolated CABG

Transesophageal echocardiographic characteristics of secundum-type atrial-septal defect in adult patients

Given the dearth of data in the existing literature on the size and morphologic variability of secundum-type atrial-septal defect [ASD-II] in adult patients, we aimed to address this issue in a series of consecutive adult patients evaluated by transesophagesal echocardiography [TEE]. A total of 50 patients [68.0% female] with isolated ASD-II underwent TEE for the evaluation of the defect. The morphological characteristics of eh defect were evaluated, and the largest defect size was measured. The ASD rim was divided into 6 sectors: the superior-anterior, superior-posterior; superior, inferior-anterior, inferior-posterior, and inferior. The minimal length of the defect rims was determined. Mean age at the time of evaluation was 33.62 +/- 14.48 years. Mean defect diameter in the all the study patients was 20.80 +/- 8.17 mm. Thirteenmorphological variations were detected. Deficiency of one rim was detected in 14 [28%] patients, two in 16 [32%], three in 2 [4%], and four in 2 [4%]. Deficiency of the superior anterior rim was found din 24% of the patients [gamma= 0.558, P value < 0.001]. Forty-eight [96%] patients emerged for defect closure: 22 [46.2%] suitable for percutaneous closure and 26 [53.8%] for surgical closure. Two patients with small defects were recommended for medical treatment and follow-up. ASD-II is larger and more morphologically variable in adults than in children. Based on the findings of the present and previous studies and given the advantages of percutaneous treatment, it is advisable to make a decision on ASD-II closure as soon as possible before it outgrows the transcatheter closure suitability criteria

Assessment of myocardial viability: selection of patients for viability study and revascularization

The aim of this article is to review the application of current imaging techniques used for the detection of viable myocardium. Each technique is discussed briefly, and the more commonly used techniques are compared. The imaging techniques reviewed herein are dobutamine stress echocardiography, single photon emission tomography, magnetic resonance imaging, positron emission tomography with F-18 fluorodeoxyglucose, and recently introduced tissue Doppler imaging. The estimation of the amount of viable myocardium that could predict a better outcome after revascularization being a challenging issue, the present article also reviews a variety of cut-off points suggested by different investigators as adequate viable myocardium for revascularization and presents a summary of clinical, angiographical, and echocardiographic findings that could assist in selecting patients for viability study

Comparison of short-term clinical outcome of non-ST elevation versus ST elevation myocardial infarction

Studies on the prognosis of ST elevation myocardial infarction [STEMI] versus non-ST elevation myocardial infarction [non-STEMI] have shown different results. The present study was designed to compare the early outcome and left ventricular systolic function of patients with ST and non-ST elevation myocardial infarction. The patients' information was derived from 10,065 consecutive patients hospitalized in Tehran Heart Center with acute MI [2007 patients with STEMI and 8058 with non-STEMI]. The baseline clinical characteristics, post-MI complications, left ventricular systolic functions, and 30-day mortality rates were compared. A history of current cigarette smoking, opium addiction, and brain stroke was more frequent in the STEMI patients, whereas hyperlipidemia, hypertension, and obesity were found more in the non-STEMI group. Ejection fraction was higher in the non-STEMI patients than that in the STEMI group, and anterior wall infarction was detected more frequently in the STEMI cases. A history of coronary artery bypass grafting and also percutaneous coronary intervention was observed more in the non-STEMI group. Amongst the in-hospital complications, ventricular arrhythmias [1.4 vs. 0.5, P<0.001] and pulmonary edema [0.4 vs. 0.1, P=0.002] were more prevalent in the STEMI cases. The 30-day mortality rate in the STEMI group was higher than that in the non-STEMI group [5.5 vs. 2.4, P<0.001]. Early mortality in both groups was dependant on advanced age, diabetes mellitus, post-MI bradycardia, and atrioventricular block. Also, female gender and pulmonary edema in the STEMI group and family history of MI in the non-STEMI patients could predict 30-day mortality. There were several differences in the baseline characteristics and early outcome between the two types of STEMI and non-STEMI. The 30-day mortality rate was higher in the STEMI group than that in the non-STEMI group

Discrete subvalvular aortic stenosis: severity of aortic regurgitation and rate of recurrence at midterm follow-up after surgery

Discrete subaortic stenosis [DSS] is a progressive condition. Controversy still rumbles on as to whether the subaortic membrane causes aortic regurgitation [AR] and whether membrane resection reduces AR severity. We investigated the association between the left ventricular outflow tract peak gradient [LVOT-PG] and AR severity preoperatively and changes in AR severity and obstruction recurrence after surgery in DSS patients. Twenty patients were evaluated before and after surgery for DSS [mean follow-up time: 13.60 +/- 9.61 months]. The patients were evaluated via transthoracic echocardiography and transesophageal echocardiography, if necessary. The cut-off point for surgery was LVOT-PG ?50 mmHg or the presence of progressive AR. The mean age of the patients was 28.55 +/- 15.23 years, and 35% of them were male. LVOT-PG decreased from a mean of 80.83 +/- 42.72 mmHg preoperatively to 19.14 +/- 14.03 mmHg postoperatively and to 25.47 +/- 16.10 at follow-up. AR was identified in 15 [75%] patients preoperatively: mild in 8 [40%] and moderate in 7 [35%]. The postoperative change in AR severity was insignificant. The correlation between preoperative LVOT-PG and the incidence and severity of preoperative AR was not significant. AR severity had no correlation with age. Membrane recurrence occurred in 25% of the patients. Our results indicated no relationship between AR severity and LVOT-PG and the patient's age. Patient selection for surgery can, therefore, be carried out on the basis of LVOT-PG or AR severity separately. Subaortic resection may reduce AR severity in some patients, but this reduction is not significant. Future studies are required to elucidate whether or not the presence of the AR is an indication for surgery

Coronary artery bypass surgery versus medical treatment in patients with low ejection fraction and coronary artery disease

We compared the outcomes in patients with a low ejection fraction [EF] and multivessel coronary artery disease [CAD] who either underwent coronary artery bypass grafting [CABG] or received medical treatment [MT] after a viability study via dobutamine stress echocardiography [DSE]. We considered patients with CAD and left ventricular ejection fraction [LVEF] 25% [100% vs. 40%, p < 0.05]. The patients with CAD and a low EF had the same survival rate after both CABG and MT at mid-term follow-up. Long-term follow-up is needed to show the survival benefit of CABG in such patients with an acceptable extent of viable myocardium

Significant improvement in severely stunned left ventricle after percutaneous coronary intervention

This is a case of severely stunned left ventricle which occurred after a non-ST elevation myocardial infarction in a 76-year-old woman who was a known case of three-vessel disease. Her symptoms and cardiac function responded well to revascularization

Repair versus replacement for ischemic mitral regurgitation

This study was undertaken to compare the outcome in patients with moderate to severe ischemic mitral regurgitation [IMR] undergoing coronary artery bypass grafting [CABG] with either mitral valve repair or mitral valve replacement. Between March 2002 and February 2005, 49 consecutive patients [mean age: 62.84 +/- 8.42 years; mean EuroSCORE: 10.03 +/- 3.12] with coronary artery disease and moderate to severe IMR underwent CABG plus mitral valve replacement or mitral valve repair. The patients with annulus dilatation were more likely to undergo repair. The mean follow-up period was 18.89 +/- 2.1 months. 40.8% of the patients underwent CABG plus mitral valve replacement, and 59.2% had CABG concomitant with mitral valve repair. The total rate of mortality in our population was 14.9% [7 patients] including 10.3% [3 patients] early mortalities; all the deceased patients were in the repair group. Both groups had a similar EuroSCORE, but more patients in the repair group had a recent episode of unstable angina [65.5% vs. 35.0%, respectively; P=0.035] and diabetes mellitus [44.8% vs. 10.0%, respectively; P=0.009]. After the follow-up period, in the repair group, 11.5% had no features of Mitral regurgitation [MR]; while 50% had mild MR, 23.1% moderate MR, 11.5% moderately severe MR, and 3.8% severe MR. Overall, 68.9% had no or mild MR, which we defined as successful repair, and 31.1% had moderate to severe MR. Success of repair and mortality were not statistically related to preoperative ejection fraction [39.2 +/- 7.8% vs. 32.5 +/- 8.5%; P=0.057]. Early mortality was higher in the repair group than that in the replacement group, but this may have been due to the higher frequency of diabetes mellitus and unstable angina in the former group. Future studies are required to determine the benefit of repair versus replacement concomitant with CABG in IMR patients