Pre-ejection mitral annular motion velocity responses to dobutamine infusion: a quantitative approach for assessment of myocardial viability

Dobutamine stress echocardiography [DSE] is widely used for detection of myocardial viability. The main limitation of DSE is its subjective interpretation. Assessment of mitral annular motion velocities with tissue Doppler imaging is a simple and quantitative measurement. To determine the relationship between myocardial viability and regional systolic mitral annular motion tissue Doppler velocities responses to dobutamine stress. Our study group included 42 patients with previous myocardial infarction referred for coronary angiography and revascularization. We did dobutamine stress tissue Doppler echocardiography [DSTDE] measuring velocities of pre-ejection wave [pre-Ej] and peak ejection wave [Ej] at rest and during low-dose dobutamine infusion. We did follow up echocardiography after 1 month. After exclusion of the normokinetic walls, we analyzed 196 walls. Using receiver operator characteristic ROC curves, the optimal cut-off value for viability assessment was an increase of 1.75cm/s in pre-ejection velocity during DSTDE [area under the curve 0.70, p<0.001]. On the other hand, the optimal cut-off value for viability assessment was an increase of 1.75cm/s in ejection velocity during DSTDE [area under the curve 0.613, p=0.01]. The sensitivity, specificity, and total accuracy of the DSTSE [pre-Ej] versus the gold standard for detection of myocardial viability were 66.15%, 67.94%, and 67.35%, respectively. The sensitivity, specificity, and total accuracy of the DTSE [Ej] were 56.92%, 64.12%, and 61.43%, respectively. There was a good correlation between the pre-Ej at 5 ug/kg/min dobutamine infusion and the pre-Ej after revascularization [r=0.64, p=0.01] while the correlation with the Ej was moderate [r=0.50, p=0.01]. Viable left ventricular myocardium could be identified easily and quantitatively with pre-ejection mitral annular velocity during dobutamine infusion. The pre-ejection wave during DSTDE showed greater sensitivity and specificity for the prediction of myocardial viability than the ejection wave

Multivessel coronary stenting versus bypass surgery in patients with multivessel coronary artery disease and normal left ventricular function immediate and six months follow up

The usual goal for CABG is complete revascularization, which may be associated with greater freedom from recurrent angina and better long-term survival. In selected patients with multivessel coronary artery disease and normal left ventricular function, intracoronary stenting may offer an effective alternative to coronary bypass surgery. was to compare the immediate and six months follow up of the results of percutaneous coronary intervention [PCI] and the conventional coronary bypass surgery [CABG] in symptomatic patients with multivessel coronary artery disease and normal left ventricular function. The study included 61 patients who were randomly selected and divided into two groups: group [1]: 33 patients who underwent CABG and group [2]: 28 patients who underwent percutaneous coronary intervention. Both groups were followed up immediately post procedures and for a period of six months after. Stress ECG was done for returning patients during the 6 months follow up. During the immediate post operative follow up, only one patient in group 1 [3%] and 19 patients in group 2 [67.6%] were free of complications [P<0.001] Postoperative angina, acute renal failure, need for inotropic support, blood transfusion and lung atelectasis were significantly higher in group [1] than group [2]. Coronary dissection was found only in the PCI group. Other complications found in both groups were of no statistical significance. Regarding the cost and hospitals stay, it was significantly higher and more in group [1] than group [2]. During the 6 months follow up of the symptoms and the level of activity, there was no statistically significant difference regarding the angina and positive stress test between both groups. There was no statistical difference between the two groups in the composite end points [exercise tolevance, incidence of angina and mortality] during the 6 months follow up after the operation. PCI is relatively safer procedure, less costly and with lower hospital stay than CAVG, but it should be done in the presence of surgical back up because it is not completely free of risk and disadvantages. CABG still will have its role in managing patients with complex lesions not amenable to catheter interventions

Guard wire use during percutaneous intervention of saphenous vein bypass grafts in non-MI patients is associated with a reduction of in-hospital and 30-day major adverse cardiac events- a small scale randomized study

Distal embolization is known to be an awful complication of vein graft intervention, especially so in old friable and degenerated vein grafts. Distal protection offers an attractive option to prevent embolization, and hence preserve the myocardium. Fifty- three patients [with chronic stable angina, unstable angina, or myocardial infarction [MI] with the cardiac enzymes back to normal] were randomized to two treatment modalities. Thirty-one patients were randomized to conventional angioplasty and/or stenting of vein grafts, as opposed to 22 patients who were randomized to distal protection utilizing the Guard Wire treatment. Major Adverse Cardiac Events [MACE] during index hospitalization and at thirty days were recorded for both groups. There was a 19.4% absolute [100% relative] reduction in the Major Adverse Cardiac Events [MACE] during index hospitalization [19.4% of the patients in the control group versus zero percent of the patients in the guard wire group, P= 0.032]. Major Adverse Cardiac Events [MACE] during the first 30 days following the index procedure were seen in 25.8% [n=8] of the patients in the control group, as opposed to zero percent of the patients in the control group [P= 0.009]. The results of the current study suggest that distal protection might be superior to the current conventional PTCA and/or stenting techniques when percutaneous treatment of saphenous vein grafts is to be attempted. Distal protection needs to be the "standard" procedure during SVG interventions, especially in light of the accumulating evidence of its superiority over stand-alone PTCA and stenting