Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?

OBJECTIVES: We wished to assess the profile and outcomes of patients with ventricular septal rupture (VSR) in the setting of cardiogenic shock (CS) complicating acute myocardial infarction (MI). BACKGROUND: Cardiogenic shock is often seen with VSR complicating acute MI. Despite surgical therapy, mortality in such patients is high. METHODS: We analyzed 939 patients enrolled in the SHOCK Trial Registry of CS in acute infarction, comparing 55 patients whose shock was associated with VSR with 884 patients who had predominant left ventricular failure. RESULTS: Rupture occurred a median 16 h after infarction. Patients with VSR tended to be older (p = 0.053), were more often female (p = 0.002) and less often had previous infarction (p < 0.001), diabetes mellitus (p = 0.015) or smoking history (p = 0.033). They also underwent right-heart catheterization, intra-aortic balloon pumping and bypass surgery significantly more often. Although patients with rupture had less severe coronary disease, their in-hospital mortality was higher (87% vs. 61%, p < 0.001). Surgical repair was performed in 31 patients with rupture (21 had concomitant bypass surgery); 6 (19%) survived. Of the 24 patients managed medically, only 1 survived. CONCLUSIONS: There is a high in-hospital mortality rate when CS develops as a result of VSR. Ventricular septal rupture may occur early after infarction, and women and the elderly may be more susceptible. Although the prognosis is poor, surgery remains the best therapeutic option in this setting.

Assessment of coronary arterial restenosis with phase-contrast magnetic resonance imaging measurements of coronary flow reserve.

BACKGROUND: After successful percutaneous coronary arterial revascularization, 25% to 60% of subjects have restenosis, a recurrent coronary arterial narrowing at the site of the intervention. At present, restenosis is usually detected invasively with contrast coronary angiography. This study was performed to determine if phase-contrast MRI (PC-MRI) could be used to detect restenosis noninvasively in patients with recurrent chest pain after percutaneous revascularization. METHODS AND RESULTS: Seventeen patients (15 men, 2 women, age 36 to 77 years) with recurrent chest pain >3 months after successful percutaneous intervention underwent PC-MRI measurements of coronary artery flow reserve followed by assessments of stenosis severity with computer-assisted quantitative coronary angiography. The intervention was performed in the left anterior descending coronary artery in 15 patients, one of its diagonal branches in 2 patients, and the right coronary artery in 1 patient. A PC-MRI coronary flow reserve value /=70% and >/=50%, respectively. CONCLUSIONS: Assessments of coronary flow reserve with PC-MRI can be used to identify flow-limiting stenoses (luminal diameter narrowings >70%) in patients with recurrent chest pain in the months after a successful percutaneous intervention.

Rotational atherectomy.

Rotational atherectomy is used most often to treat stenoses that are calcified, located at an arterial ostium or at the site of a bifurcation, or resulting from in-stent restenosis. The atherectomy device debulks soft and calcified plaque while minimizing injury to adjacent normal arterial segments. In a randomized comparison with excimer laser and balloon angioplasty, rotational atherectomy achieved a statistically higher procedural success rate without an increased incidence of major complications. Patients with lesions that were more complex derived the greatest benefit from rotational atherectomy. To date, rotational atherectomy usually is performed in conjunction with a) the intracoronary infusion of a "cocktail" containing verapamil, heparin, and nitroglycerin; b) the intravenous infusion of a glycoprotein IIb/IIIa receptor antagonist, such as abciximab; c) a stepped burr approach, leading to a burr:artery ratio of 0.8; d) burr rotations <30 seconds in duration; e) avoidance of burr deceleration; and f) low-pressure balloon angioplasty. Under these circumstances, it has a procedural success rate of 98% and a major complication rate of <2%.

Percutaneous mitral balloon valvuloplasty.

Almost all mitral stenosis (MS) is rheumatic in etiology. The patient with MS who is symptomatic despite medical therapy should undergo percutaneous mitral balloon valvuloplasty or mitral valvular surgery (commissurotomy or replacement). The choice of procedure is determined by patient preference and the echocardiographic morphologic features of the valvular and subvalvular apparati. With balloon valvuloplasty, the rate of success is > 90%. At institutions where operators are experienced with balloon valvuloplasty and open surgical commissurotomy, their acute and long-term results are comparable. Balloon valvuloplasty occasionally is associated with complications, including death in 0 to 1%, moderate or severe valvular regurgitation in 3 to 5%, and systemic embolization in 1 to 3%.

Late revascularization reduces mortality in survivors of myocardial infarction.

In survivors of acute myocardial infarction, the restoration of antegrade flow in the infarct-related coronary artery may improve prognosis by a mechanism that is independent of its influence on left ventricular systolic performance. Furthermore, survival may be improved even when antegrade flow is restored days or even weeks after the acute event. In several retrospective studies of survivors of infarction, we and others have shown a) that long-term survival is substantially better in those with-as opposed to those without-antegrade flow in the infarct-related coronary artery, and b) that the mechanical restoration of flow in an occluded infarct-related artery (accomplished with balloon angioplasty or bypass grafting) markedly improves long-term survival. The late restoration of antegrade flow in the infarct-related artery appears to render the so-called border zone of infarction less electrically unstable, thereby reducing the likelihood of ventricular tachyarrhythmias and sudden death.

Thrombolysis versus primary percutaneous transluminal coronary angioplasty for acute myocardial infarction.

For the patient with acute myocardial infarction (MI), both primary percutaneous transluminal coronary angioplasty (PTCA) and intravenous thrombolytic therapy are effective in restoring antegrade coronary blood flow, improving left ventricular systolic function, and reducing mortality. Primary PTCA is effective when performed quickly by experienced operators. It is the preferred therapy in the patient a) with a contraindication to thrombolytic therapy, b) aged 70 years or older, and c) in whom thrombolytic therapy is likely to be ineffective (ie, the patient with cardiogenic shock). Thrombolytic therapy is widely available and can be given quickly and easily. As a result, it remains the treatment of choice for most patients with acute MI. The goal of therapy for the patient with acute MI is the rapid and sustained restoration of coronary blood flow. For the individual patient, the better therapy-primary PTCA or thrombolytic therapy-is the one that can be given more safely and expeditiously.

Aggressive versus conservative therapy in unstable angina.

In patients with unstable angina, non-Q-wave, and Q-wave myocardial infarction, atherosclerotic plaque rupture leads to a variable amount of platelet adhesion and aggregation, vasoconstriction, and partially or totally occlusive thrombus formation. This article focuses on the role of aggressive (routine angiography and revascularization) versus conservative (maximal medical therapy, with catheterization and revascularization reserved for those with spontaneous or provable ischemia) management of the patient with unstable angina.

Visualization and functional assessment of proximal and middle left anterior descending coronary stenoses in humans with magnetic resonance imaging.

BACKGROUND: Coronary artery bypass grafting improves survival in patients with >70% luminal diameter narrowing of the 3 major epicardial coronary arteries, particularly if there is involvement of the proximal portion of the left anterior descending (LAD) coronary artery. Measurement of coronary flow reserve can be used to identify functionally important luminal narrowing of the LAD artery. Although magnetic resonance imaging (MRI) has been used to visualize coronary arteries and to measure flow reserve noninvasively, the utility of MRI for detecting significant LAD stenoses is unknown. METHODS AND RESULTS: Thirty subjects (23 men, 7 women, age 36 to 77 years) underwent MRI visualization of the left main and LAD coronary arteries as well as measurement of flow in the proximal, middle, or distal LAD both at rest and after intravenous adenosine (140 microgram/kg per minute). Immediately thereafter, contrast coronary angiography and when feasible, intracoronary Doppler assessments of coronary flow reserve, were performed. There was a statistically significant correlation between MRI assessments of coronary flow reserve and (a) assessments of coronary arterial stenosis severity by quantitative coronary angiography and (b) invasive measurements of coronary flow reserve (P<0.0001 for both). In comparison to computer-assisted quantitative coronary angiography, the sensitivity and specificity of MRI for identifying a stenosis >70% in the distal left main or proximal/middle LAD arteries was 100% and 83%, respectively. CONCLUSIONS: Noninvasive MRI measures of coronary flow reserve correlated well with similar measures obtained with the use of intracoronary Doppler flow wires and predicted significant coronary stenoses (>70%) with a high degree of sensitivity and specificity. MRI-based measurement of coronary flow reserve may prove useful for identification of patients likely to obtain a survival benefit from coronary artery bypass grafting.

Predictive value of prominent right atrial V waves in assessing the presence and severity of tricuspid regurgitation.

Neither "prominent" right atrial V waves nor an elevated mean right atrial pressure reliably predicts the presence of moderate or severe tricuspid regurgitation. On the other hand, the absence of prominent right atrial V waves and an elevated mean right atrial pressure are relatively specific for the absence of moderate or severe tricuspid regurgitation.