Transcatheter aortic valve implantation and off-pump coronary artery bypass surgery: an effective hybrid procedure in selected patients.

OBJECTIVES: Simultaneous surgical off-pump coronary revascularization and transcatheter aortic valve implantation (TAVI) as a hybrid procedure may be a therapeutic option for patients with a TAVI indication who are not suitable for percutaneous coronary intervention and for patients who have an indication for combined surgical aortic valve implantation and coronary artery bypass grafting but present with a porcelain aorta. Early outcomes of these patients are analysed in this study. METHODS: From February 2011 to April 2017, hybrid TAVI/off-pump coronary artery bypass (OPCAB) was performed in 12 (60%) patients, hybrid TAVI/minimally invasive direct coronary artery bypass in 6 (30%) patients and staged TAVI/OPCAB in 2 (10%) patients. Endpoints of this study were 30-day mortality, device success and postoperative adverse events as defined by the updated Valve Academic Research Consortium (VARC-2). RESULTS: The median age at the time of surgery was 77 years [interquartile range (IQR), 70-81] with a median logistic EuroSCORE and Society of Thoracic Surgeons' Predicted Risk score of 16.1% (IQR, 9.3-28.1) and 3.9% (IQR, 2.2-5.6), respectively. The median Synergy between PCI with Taxus and Cardiac Surgery score was 16.5 (IQR, 9.8-22.8). TAVI implantation routes were transaortic in 9 (45%) patients, transapical and transfemoral in 5 (25%) patients each and trans-subclavian in 1 (5%) patient. Complete myocardial revascularization was achieved in 75% of patients. Device success rate was 100%. Paravalvular aortic regurgitation did not exceed mild in any patient. Stroke/transient ischaemic attack, vascular complications and myocardial infarction were not observed. Re-exploration for bleeding was required in 1 (5%) patient. Thirty-day mortality was 0%. CONCLUSIONS: Hybrid OPCAB/MIDCAB and TAVI prove to be a safe and effective alternative treatment option in selected higher risk patients.

First-in-man experience with a new 7F vascular closure device (EXOSEAL™): the 7F ECLIPSE study.

OBJECTIVE: This feasibility study examined safety and effectiveness of the new EXOSEAL™ Vascular Closure Device (VCD) designed to promote hemostasis and early ambulation after percutaneous procedures. BACKGROUND: Most VCDs currently approved by the United States FDA have been associated with significantly shorter time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to standard manual or mechanical compression, but their ease of use, patient comfort during deployment, and safety profiles are variable. METHODS: Patients underwent diagnostic or interventional procedures using 7F introducer sheaths. Primary safety endpoint was the 30-day combined rate of access-related complications and primary effectiveness endpoints were TTH and TTA. RESULTS: Sixty patients were enrolled prospectively (mean age 63.3 ± 11.3 year, 17% diabetics). Device and procedural success was achieved in 92% and 93%, respectively. Mean TTH and TTA was 3.2 ± 3.0 minutes and 3.0 ± 6.2 hours, respectively. No deaths or serious access-related adverse events occurred. A ≥6 cm access-site hematoma was the only adverse event, observed in 3 patients. CONCLUSIONS: Use of the 7F EXOSEAL™ VCD was associated with short TTH and TTA, as well as low rates of procedural and 30-day access-related complications.

Analysis of myocardial perfusion or myocardial function for detection of regional myocardial abnormalities. An echocardiographic multicenter comparison study using myocardial contrast echocardiography and 2D echocardiography.

BACKGROUND: Echocardiography based myocardial perfusion imaging and regional wall motion analysis are used for evaluation of coronary artery disease and regional myocardial abnormalities. AIM: This study sought to compare myocardial contrast echocardiography (MCE) and 2D echocardiography with regard to interobserver variability and detection of regional myocardial abnormalities. METHODS: In 70 patients evenly distributed between three ejection fraction groups based on biplane cineventriculography ( > 55%, 35-55%, < 35%), unenhanced and contrast enhanced 2D echocardiography and myocardial contrast echocardiography (MCE; SonoVue; Bracco) were performed. Regional wall motion and myocardial perfusion were assessed referring to a 16 segment model. Interobserver agreement (IOA) among 2 readers was determined within each imaging modality. To define a standard of truth for the presence of segmental myocardial disease an independent expert-panel decision was obtained based on clinical data, ECG, coronary angiography and blinded information from the imaging modalities. RESULTS: Regional wall motion assessment was possible in 98.1% of segments using contrast enhanced 2D echocardiography and in 87.2% using unenhanced 2D echocardiography (p < 0.001), while perfusion assessment was possible in 90.1% of segments (p < 0.001). IOA on presence of any regional wall motion abnormality expressed as Kappa coefficient was 0.71 (95% CI 0.53-0.89) for contrast enhanced echocardiography and 0.37 (95% CI 0.14-0.59) for unenhanced echocardiography. IOA on presence of any perfusion abnormality was 0.53 (95% CI 0.34-0.73). For MCE there was high IOA for the apical segments (kappa = 0.57) and lower IOA for the basal segments (kappa=0.14), while no such gradient was found for the IOA on wall motion abnormalities. Mean accuracy to detect expert-panel defined myocardial abnormalities was 80.6% for unenhanced echocardiography, 85.0% for contrast enhanced 2D echocardiography and 80.6% for MCE. CONCLUSIONS: MCE is inferior to contrast enhanced 2D echocardiography with regard to visibility of all LV segments and appears slightly inferior with regards to IOA, while both are superior to unenhanced 2D echocardiography. The methods demonstrated high accuracy in detection of panel defined regional myocardial abnormalities.

Adenosine myocardial contrast echo in intermediate severity coronary stenoses: a prospective two-center study.

BACKGROUND: We sought to evaluate the role of adenosine myocardial contrast echocardiography (MCE) for the determination of functional relevance of coronary stenoses with intermediate angiographic severity and compared the results to single photon imaging (SPECT). We hypothezised that sole assessment of myocardial blood volume changes during adenosine on MCE would indicate functional stensosis relevance when accompanied by increased myocardial oxygen consumption (MVO2). METHODS: Fifty-seven patients with >or=1 coronary stenosis underwent adenosine MCE (ultraharmonic imaging) and exercise SPECT. On MCE, myocardial blood volume was assessed and constant or increased myocardial opacification during adenosine coupled with increased MVO2 was defined as normal and decreased opacification as abnormal. RESULTS: Rate-pressure product significantly increased during adenosine in all patients due to reflex tachycardia following mild hypotension, indicative of increased MVO2. Concordance between MCE and SPECT for the detection of reversible myocardial perfusion defects was 89% (kappa = 0.83). Comparison of regions between rest and during adenosine as opposed to comparison to remote regions of the same stage was important for accurate assessment because concordance betweenn MCE and SPECT was less on separate assessment at rest (73%, kappa = 0.40) compared to stress (91%, kappa = 0.81, P < 0.05) mainly due to territories scored normal on SPECT and abnormal on MCE. CONCLUSIONS: Assessment of myocardial blood volume changes during adenosine using MCE can be used for the determination of the functional relevance of coronary stenoses of intermediate angiographic severity if MVO2 is increased during adenosine.

Analysis of regional left ventricular function by cineventriculography, cardiac magnetic resonance imaging, and unenhanced and contrast-enhanced echocardiography: a multicenter comparison of methods.

OBJECTIVES: To define the use of cineventriculography, cardiac magnetic resonance imaging (cMRI), and unenhanced and contrast-enhanced echocardiography for detection of left ventricular (LV) regional wall motion abnormalities (RWMA). BACKGROUND: Detection of RWMA is integral to the evaluation of LV function. METHODS: In 100 patients, cineventriculography and unenhanced and contrast-enhanced echocardiography were performed. Fifty-six of the patients underwent additional cMRI. RWMA were assessed referring to a 16-segment model for cMRI, unenhanced and contrast echocardiography. Cineventriculography was evaluated on a 7-segment model. Hypokinesia in one or more segments defined presence of RWMA. Interobserver agreement among three readers was determined within each imaging modality. Intermethod agreement between imaging modalities was analyzed. A standard of truth for the presence of RWMA was obtained by an independent expert panel decision (EPD) based on clinical data, electrocardiogram, coronary angiography, and blinded information from the imaging modalities. RESULTS: Sixty-seven patients were found to have an RWMA by EPD. Interobserver agreement expressed as kappa coefficient was 0.41 (range 0.37 to 0.44) for unenhanced echocardiography, 0.43 (range 0.29 to 0.79) for cMRT, 0.56 (range 0.44 to 0.70) for cineventriculography, and 0.77 (range 0.71 to 0.88) for contrast echocardiography. Contrast enhancement compared to unenhanced echocardiography improved agreement of echocardiography related to cMRI (kappa 0.46 vs. 0.29) and related to cineventriculography (kappa 0.59 vs. 0.28). Accuracy to detect EPD-defined RWMA was highest for contrast echocardiography, followed by cMRI, unenhanced echocardiography, and cineventriculography. CONCLUSIONS: Analysis of RWMA is characterized by considerable interobserver variability even using high-quality imaging modalities. Interobserver agreement on RWMA and accuracy to detect panel-defined RWMA is good using contrast echocardiography.

Correlation between ECG and myocardial perfusion after mechanical reperfusion of acute myocardial infarction.

UNLABELLED: The identification of viable myocardium after myocardial infarction (MI) carries major prognostic impact. Due to myocardial stunning early after successful mechanical reperfusion of acute myocardial infarction, analysis of myocardial perfusion but not of contractile function can be used to differentiate between necrotic and viable myocardium. Although being widely regarded as an indicator of infarct transmurality, the relation between post-infarct Q-wave formation and the amount of viable myocardium has not been studied. We hypothesized that there was a correlation between the extent of Q-wave formation and the extent of perfusion abnormalities on myocardial contrast echocardiography early after successful mechanical reperfusion of first acute myocardial infarction and that the extent of post-infarct Q-wave formation might therefore be used as a simple estimate of the amount of viable myocardium. METHODS AND RESULTS: 47 patients with first MI and treated by direct PCI were enrolled. Patients were divided into 3 groups according the presence and number of abnormal Q waves (group A-no abnormal Q wave; group B-< or =2 abnormal Q waves, group C-> or =3 abnormal Q waves). Left ventricular pump function was defined by ejection fraction (EF) on ventriculography and wall motion score index (WMSI) on echocardiography. Myocardial perfusion was defined by perfusion score index (PSI) on myocardial contrast echocardiography. Patients in group A had significantly better LV function than patients in other groups [EF 57+/-5 vs. 48+/-11% (group B) and 47+/-10% (group C); p<0.05], also WMSI was the best in this group [1.34+/-0.22 vs. 1.67+/-0.39 (group B) and 1.68+/-0.31 (group C); p<0.01]. Myocardial perfusion assessed by PSI was best in group A (1.2+/-0.3, p<0.05). With respect to PSI, there was a significant difference between group B and C (1.41+/-0.21 vs. 1.56+/-0.29; p<0.05), even though EF and WMSI did not differ in these groups. The amount of perfused segments with severe wall motion abnormality was higher in group B compared to group C (47% vs. 25%; p<0.05). CONCLUSION: In patients after successful mechanical reperfusion of first MI, the extent of Q-wave formation on ECG may be regarded as a corollary of the amount of myocardial microvascular damage and may, therefore, be used to estimate the amount of viable myocardium post-infarct.

Assessment of systolic left ventricular function: a multi-centre comparison of cineventriculography, cardiac magnetic resonance imaging, unenhanced and contrast-enhanced echocardiography.

AIMS: To assess the agreement of left ventricular ejection fraction (LVEF) determinations from unenhanced echocardiography, contrast-enhanced echocardiography, magnetic resonance imaging (MRI), and cineventriculography as well as the inter-observer agreement for each method. METHODS AND RESULTS: In 120 patients, with evenly distributed EF-groups (> 55, 35-55, < 35%), cineventriculography, unenhanced echocardiography with second harmonic imaging, and contrast echocardiography at low mechanical index with iv administration of SonoVue were performed. In addition, cardiac MRI at 1.5 T using a steady-state free precession sequence was performed in a subset of 55 patients. On-site, and two blinded off-site assessments were performed for unenhanced and contrast echocardiography, cineventriculography, and MRI according to pre-defined standards. Intra-class correlation coefficients (ICCs) were determined to assess inter-observer reliability between all three readers (i.e. one on-site and two off-site). EF was 56.2 +/- 18.3% by cineventriculography, 54.1 +/- 12.9% by MRI, 50.9 +/- 15.3% by unenhanced echocardiography, and 54.6 +/- 16.8% by contrast echocardiography. Correlation on EF between cineventriculography and echocardiography increased from 0.72 with unenhanced echocardiography to 0.83 with contrast echocardiography (P < 0.05). Similarly, correlation on EF between MRI and echocardiography increased from 0.60 with unenhanced echocardiography to 0.77 with contrast echocardiography (P < 0.05). The inter-observer reliability ICC was 0.91 (95% CI 0.88-0.94) in contrast echocardiography, followed by cardiac MRI (0.86; 95% CI 0.80-0.92), cineventriculography (0.80; 95% CI 0.74-0.85), and unenhanced echocardiography (0.79; 95% CI 0.74-0.85). CONCLUSIONS: Unenhanced echocardiography resulted in slight underestimation of EF and only moderate correlation compared with cineventriculography and MRI. Contrast echocardiography resulted in more accurate EF and significantly improved correlation with cineventriculography and MRI. Contrast echocardiography significantly improved inter-observer agreement on EF compared with unenhanced echocardiography. Inter-observer reliability on EF using contrast echocardiography reaches a level comparable to MRI and is better than those obtained by cineventriculography.

Incremental value of cardiac imaging in patients presenting to the emergency department with chest pain and without ST-segment elevation: a multicenter study.

BACKGROUND: We hypothesized that imaging of regional myocardial function (RF) and perfusion (PER) will add incremental value for both diagnosis and short-term prognosis to routine demographic, clinical, and electrocardiographic findings in patients presenting to the emergency department (ED) with chest pain and without ST-segment elevation on the electrocardiogram. METHODS: We compared contrast echocardiography (CE) with gated single-photon emission computed tomography (SPECT) for this purpose. Both CE and SPECT readings included separate and composite assessments of both RF and PER. Adverse events in the first 48 hours after ED presentation included acute myocardial infarction, emergent revascularization, and cardiac-related death. RESULTS: Concordance between CE and SPECT was 77% (73% to 82%) for all territories, with a higher concordance for the anterior wall of 84% (78% to 89%). Of the 203 patients recruited for the study, 38 (19%) had a cardiac event within 48 hours of ED presentation: 21 had acute myocardial infarction, 16 underwent an urgent revascularization procedure, and 1 died. In multivariate logistic regression models, the number of abnormal segments on CE and SPECT were significant predictors (P <.05) of cardiac events. The composite scores on CE provided 17% incremental information (P =.009, n = 203) and gated SPECT provided 23.5% additional information (P =.020, n = 163) for predicting cardiac events compared with routine demographic, clinical, and electrocardiographic variables. RF and composite evaluation was superior on SPECT compared with CE, whereas PER alone was not. CONCLUSIONS: Cardiac imaging of RF and PER at the time of ED presentation offers substantially greater diagnostic and prognostic information for early cardiac events in patients presenting to the ED with chest pain and no ST elevation than does the routine demographic, clinical, and electrocardiographic assessment.

Cardiac malignant tumor as a rare cause of acute myocardial infarction.

Acute myocardial infarction is predominantly caused by coronary artery atherosclerotic plaque rupture and subsequent occlusive thrombus formation. The recognition of less common causes of acute myocardial infarction is important because they may require a different treatment strategy. We report a patient with acute myocardial infarction without any angiographic evidence of coronary atherosclerosis and a left atrial mass detected on echocardiography. Therefore, coronary embolism from intracardiac thrombus or tumor was suspected. No additional manifestations of a potential tumor were found on thoracic, abdominal and cranial computed tomography. During subsequent cardiac surgery, a large tumor could be in toto resected and was diagnosed as a highly malignant leiomyosarcoma on histopathological evaluation.

[Detection of myocardial viability with venous contrast echocardiography immediately after reperfusion therapy in patients with acute myocardial infarction]. / Az életképes myocardium megítélése közvetlenül az akut myocardialis infarctus reperfúziós terápiája után végzett vénás myocardiális kontrasztultrahanggal.

INTRODUCTION: After reperfusion therapy of acute myocardial infarction not only the patency of infarct related artery (IRA) but uncompromised myocardial perfusion are essential for recovery of myocardial contractile function. AIM: The authors sought to evaluate the relation between the status of myocardial microvasculature early after successful mechanical reperfusion therapy of AMI and contractile function at rest two weeks later. METHODS: Sixty-three patients with first acute myocardial infarction underwent venous myocardial contrast echocardiography (VMCE) 3 hours after successful percutaneous coronary intervention. The myocardial contrast intensity of akinetic segments was evaluated according to a semiquantitative score (1 = normal; 2 = moderate contrast defect; 3 = serious contrast defect; 4 = no contrast at all). Two weeks later the resting contractile function of previously akinetic segments (n = 218) was re-evaluated. RESULTS: The semiquantitative contrast score was significantly different between differential functional groups observed after two weeks: normokinesia (1.21 +/- 0.47); hypokinesia (1.65 +/- 0.77); akinesia (2.75 +/- 0.85). Sensitivity and the specificity of semiquantitative venous myocardial contrast echocardiography for early prediction of functional recovery is 90% and 69%, respectively (chi 2 = 76.2; p < 0.001). The global wall motion score index improved in contrast positive patients (more than 50% of initial akinetic segments show score 1 or 2) (1.607 +/- 0.30 vs. 1.295 +/- 0.25; p < 0.001), but did not change in the contrast negative patients (1.702 +/- 0.38 vs. 1.603 +/- 0.33; p = NS). CONCLUSION: Functional recovery after AMI can be predicted with VMCE immediately after successful reopening of IRA. The post-PTCA contrast intensity of an infarcted segment is closely related to its subsequent functional status.