3D transesophageal echocardiography: A new imaging tool for assessment of mitral regurgitation and for guiding percutaneous edge-to-edge mitral valve repair.

Real time three dimensional transesophageal echocardiography (3D TEE) is probably the most powerful and convincing imaging method for understanding the complicated multiform morphology and for evaluating geometry, dynamics and function of degenerative and functional mitral valve (MV) regurgitation. Moreover, color Doppler 3D TEE has been valuable to identify the location of the regurgitant orifice and the severity of the mitral regurgitation. 3D TEE has been shown to be of enormous value in helping surgeons to perform MV repair. In addition, due to its ability to show a "panoramic" view of the "theater" where the procedure takes place, it has become an indispensable companion of 2D TEE during percutaneous edge-to-edge repair. A novel hybrid imaging modality where echocardiography is merged with fluoroscopy, may in the future further improve guidance of this and other complex percutaneous transcatheter interventions.

Echocardiographic-Fluoroscopic Fusion Imaging in Transseptal Puncture: A New Technology for an Old Procedure.

In an era of catheter-based structural heart disease and left-side electrophysiologic interventions, transseptal puncture (TSP) is probably the most common transcatheter procedure. Experienced interventional cardiologists and electrophysiologists may safely perform TSP using fluoroscopic guidance alone. However, at present TSP is usually the first step in complex percutaneous catheter-based structural heart disease procedures and necessitate a precise site-specific TSP. Thus, in these procedures most interventional cardiologists perform TSP under fluoroscopic and two- or three-dimensional transesophageal echocardiographic guidance. The EchoNavigator system may provide a solution by fusing fluoroscopic and transesophageal echocardiographic images. In this review, the authors describe advantages and limitations of this new imaging system in guiding TSP and suggest specific echocardiographic-fluoroscopic fusion imaging perspectives that may facilitate TSP, making it potentially easier and safer.

Baseline inflammatory status and long-term changes in renal function after percutaneous renal artery stenting: a prospective study.

OBJECTIVES: To investigate a possible independent predictive role of systemic inflammation markers on renal function after renal artery stenting. BACKGROUND: An elevated baseline serum creatinine has previously been shown to be the strongest predictor of improved renal function after percutaneous renal artery stenting. The inflammatory system is implicated in every stage of chronic kidney disease, and we hypothesized an additional value of markers of systemic inflammation in predicting response after renal artery stenting. METHODS: This single center, prospective study includes 62 consecutive patients with chronic kidney disease at stage ≥ 3 or resistant hypertension who underwent stent placement for 74 angiographically significant atherosclerotic renal lesions. Inflammatory markers, including serum C-reactive protein (CRP), erythrocyte sedimentation rate, and white blood cell count were determined prior to renal angioplasty and related to changes in renal function at follow-up. RESULTS: Six-month clinical follow up was completed in 57 patients. Overall, median serum creatinine concentration exhibited a non significant reduction from 1.40 mg/dl (quartiles: 1.20, 1.75 mg/dl) at baseline to 1.30 mg/dl (quartiles: 1.1, 1.55 mg/dl) at 6 months (p=0.17). Significant multivariate independent predictors of decreased creatinine included higher baseline serum creatinine levels (adjusted OR per quartile increment, 2.5 [1.3 to 4.7], p=0.004) and lower C-reactive protein levels (adjusted OR per quartile increment 0.39 [0.19 to 0.82], p=0.013). CONCLUSIONS: Patients with higher serum creatinine and lower CRP derive the most benefit from renal artery stenting.

Immediate evidence of the benefit of distal protection in vein graft intervention.

Percutaneous intervention carries a higher risk of distal embolization and fatal outcome in saphenous vein grafts (SVG) than in native coronary vessels. Most of these adverse clinical events, predominantly myocardial infarction and reduced antegrade flow (no reflow phenomenon), are due to distal embolization of atherothrombotic debris and distal microvascular occlusion. For this reason, in current interventional practice, the use of distal protection devices is mandatory. Our case report provides direct and dramatic evidence of the usefulness of a low-profile filter device in the setting of massively thrombotic SVG.

Quantitative Blush Evaluator accurately quantifies microvascular dysfunction in patients with ST-elevation myocardial infarction: comparison with cardiovascular magnetic resonance.

BACKGROUND: After ST-elevation myocardial infarction (STEMI), microvascular obstruction (MVO) can be assessed using semiquantitative angiographic "blush" scores subject to interoperator variability. Quantitative Blush Evaluator (QuBE) is a free computer-calculated algorithm that evaluates myocardial blush on a continuous scale with improved reproducibility. We aimed to compare QuBE with cardiovascular magnetic resonance (CMR) in detecting MVO and its severity. METHODS: Fifty-two STEMI treated with successful primary percutaneous coronary intervention were enrolled. Quantitative Blush Evaluator and electrocardiographic sum ST-segment resolution were blindly calculated. All patients underwent CMR 4 to 7 days after STEMI for assessment of infarct size (IS), myocardial salvage index, MVO (both as first-pass MVO and delayed-enhancement MVO [DE-MVO]), and presence of intramyocardial hemorrhage on T2-weighted sequences. RESULTS: Quantitative Blush Evaluator values were inversely related to IS (R = -0.4, P = .008), DE-MVO (R = -0.7, P < .001), and first-pass MVO (R = -0.4, P = .002) and positively related to myocardial salvage index (R = 0.4, P = .007). Moreover, patients with intramyocardial hemorrhage had significantly lower QuBE values (3.9, 3.5-8.0 vs 12.2, 8.2-16.0, P = .001) than those without. At receiver operating characteristic curve analysis, QuBE accounted for an area under the curve of 0.88 (95% CI 0.7-0.9, P = .001) for both DE-MVO and hemorrhage detection and performed significantly better than ST resolution. CONCLUSIONS: Quantitative Blush Evaluator score correlates with IS and microvascular dysfunction by CMR and can be considered as an accurate tool for the assessment of MVO in clinical practice. Quantitative Blush Evaluator is a useful quantitative angiographic technique for the assessment of myocardial reperfusion after STEMI.