Prevalence of myocardial scar in patients with cryptogenic cerebral ischemic events and patent foramen ovale.

OBJECTIVES: This study sought to evaluate the prevalence of subclinical myocardial infarctions with cardiovascular magnetic resonance imaging (CMRI) in patients with patent foramen ovale (PFO) after cryptogenic cerebral ischemic events. BACKGROUND: A thrombotic mass passing a PFO may embolize in cerebral but also in coronary arteries, resulting in both cerebral and myocardial ischemic events. CMRI with late gadolinium enhancement (LGE) analysis is the most sensitive imaging technique to detect small myocardial infarctions. METHODS: PFO patients (n = 74) with a first cryptogenic cerebral ischemic event without a clinical history for myocardial infarction underwent CMRI and coronary angiography. Right and left ventricular volumes and ejection fractions were measured by CMRI. LGE imaging was performed after administration of gadolinium-diethylenetriaminepentaacetic acid. The presence of atrial septal aneurysm (ASA) was evaluated by transesophageal echocardiography. RESULTS: LGE was detected in 8 of 74 (10.8%) patients. LGE pattern was transmural or subendocardial. Patients with LGE and those without did not differ in cardiovascular risk factors, type of ischemic event, presence of ASA, right and left ventricular volumes, and ejection fractions. LGE volume was small and comprised only 7.9 +/- 2.4% of left ventricular muscle mass. Coronary artery disease was ruled out in 7 of 8 patients with LGE. There was a trend towards a larger PFO size in patients with LGE compared with patients without LGE (13.2 +/- 4.1 mm vs. 16.0 +/- 2.8 mm, p = 0.06). CONCLUSIONS: Subclinical myocardial infarctions determined in CMRI were observed in 10.8% of patients with PFO after a first cryptogenic cerebral ischemic event. Our results strengthen the pathophysiologic role of a PFO with paradoxical embolism in patients with cryptogenic cerebral ischemic events.

Angiographic results of the cobalt chromium Vision and Mini-Vision stents.

BACKGROUND: Drug-eluting stents (DES) have been shown to reduce repeat revascularizations compared with their bare-metal stent (BMS) platforms. Modern BMS may be associated with better angiographic results compared with the older BMS platforms. In the Basel Stent Kosten Effektivitats Trial (BASKET), target vessel revascularization after six months was nonsignificantly different between DES and BMS with clinical follow-up. OBJECTIVES: To evaluate angiographic results of the cobalt chromium Vision and Mini-Vision stents (Abbott Vascular, USA). METHODS: A total of 247 consecutive patients with 293 de novo lesions in native coronary arteries were treated with cobalt chromium Vision (n=184; stent diameter 2.75 mm to 4.0 mm) or Mini-Vision stents (n=109; stent diameter 2.0 mm to 2.5 mm), and scheduled for six months of angiographic follow-up. The primary end point was in-stent late loss after six months. RESULTS: Acute coronary syndromes were present in 83.4% (n=206) of patients. The preinterventional reference diameter of Vision stents was 2.70+/-0.34 mm and for Mini-Vision stents, it was 2.13+/-0.27 mm (P<0.001). Clinical and angiographic follow-up was 98.0% and 51.2%, respectively. In the Vision group, in-stent late loss was 0.64+/-0.67 mm and the binary restenosis rate was 17.9%. In the Mini-Vision group, in-stent late loss was 0.82+/-0.71 mm and the restenosis rate was 45.4%. No difference in occurrence of restenosis within the segments proximal or distal to the stent was observed. The restenotic pattern was predominantly focal with a short length of 7.9+/-4.4 mm. CONCLUSIONS: The use of the cobalt chromium Vision stent for the treatment of de novo lesions was associated with a low late loss and binary angiographic restenosis rate.

Impact of percutaneous device implantation for closure of patent foramen ovale on valve insufficiencies.

BACKGROUND: In patients with percutaneous device implantation for closure of patent foramen ovale (PFO), a 10% incidence of new or worsened aortic regurgitation within 12 months has been reported with echocardiography. Cardiac magnetic resonance imaging is a powerful noninvasive tool to quantify volume and fraction of valve insufficiencies. We studied the acute and long-term impact of percutaneous device implantation for PFO closure on valve insufficiencies in cardiac magnetic resonance imaging. METHODS AND RESULTS: Sequential cardiac magnetic resonance imaging studies were performed in 102 patients with cryptogenic ischemic events. Cardiac magnetic resonance imaging was performed before PFO closure, the day after device implantation, and at 12 months of follow-up. There was no difference in volumetric and hemodynamic parameters before PFO closure compared with 12 months of follow-up. With a cutoff for relevant regurgitation fraction of 5%, there were no statistically significant differences in regurgitation fraction of the semilunar and atrioventricular valves. The median fraction of aortic valve insufficiency was 3.9% (interquartile range [IQR] 2.0% to 5.1%) before PFO closure, 5.4% (IQR 4.1% to 5.9%) after device implantation, and 4.3% (IQR 3.3% to 6.0%) at 12 months of follow-up. The size and type of the occluder had no impact on aortic valve insufficiency. Median regurgitation fraction for the pulmonary valve was 3.6% (IQR 2.4% to 6.7%) before intervention, 7.3% (IQR 5.1% to 8.2%) after occluder implantation and 5.8% (IQR 4.8% to 7.4%) at 12 months of follow-up. Values for the mitral valve were 3.1% (IQR 1.4% to 6.0%), 5.5% (IQR 3.5% to 7.3%), and 3.8% (IQR 1.5% to 7.9%) and for the tricuspid valve were 5.4% (IQR 0.1% to 8.8%), 5.8% (IQR 1.4% to 9.2%), and 6.0% (IQR 1.1% to 8.4%), respectively. CONCLUSIONS: Percutaneous PFO closure with device implantation has no impact on valve insufficiencies as determined by cardiac magnetic resonance imaging.

Carbon-coated stents in patients with acute coronary syndromes.

BACKGROUND: For patients with ST elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI), rapid restoration of coronary blood flow is the primary therapeutic goal. Because of the acute nature of this clinical presentation, bleeding risks may not be adequately evaluated, limiting the use of drug-eluting stents, since premature discontinuation of antiplatelet therapy strongly predicts stent thrombosis. We evaluated angiographic and clinical results of non-drug-eluting carbon-coated stents. METHODS: In this prospective observational study, angiographic and clinical 6-mo results of a carbon-coated stent for treatment of acute lesions in native coronary arteries were evaluated. Angiographic main outcome measures included in-stent late loss and binary restenosis rate. Major adverse cardiac events (MACEs) were defined as any death, Q-wave myocardial infarction (MI), and target lesion revascularization. RESULTS: We included 320 patients with STEMI (n = 205) or NSTEMI (n = 115) with 360 lesions. Reference vessel diameter was 2.93 +/- 0.53 mm and stented length 22.7 +/- 13.8 mm. Angiographic follow-up was available in 220 of 360 lesions (61%). In-stent late loss was 0.69 +/- 0.75 mm, with a binary restenosis rate of 19.1%. For the total segment late loss was 0.74 +/- 0.77 mm and binary restenosis rate 21.4%. Clinical follow-up for 97.4% of discharged patients was available. Hierarchical MACEs were death in 14 patients (4.4%), Q-wave MI in 3 patients (0.9%), and target lesion revascularization in 39 patients (12.2%). CONCLUSION: In this prospective, observational study, the use of a carbon-coated stent for treatment of lesions in patients with STEMI or NSTEMI was associated with a low late loss, translating into a low binary angiographic restenosis rate within a 6-mo follow-up.

Characterization of patients with acute chest pain using cardiac magnetic resonance imaging.

AIMS: The purpose of this study was to evaluate whether CMRI provides characteristic findings in patients with acute chest pain suffering from ST-elevation-myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), acute myocarditis or Tako-tsubo cardiomyopathy. PATIENTS AND METHODS: 230 consecutive patients with acute chest pain underwent cardiac catheterization followed by CMRI within median 5 days. Patients were classified to suffer from STEMI (n = 102), NSTEMI (n = 89), acute myocarditis (n = 27), or Tako-tsubo cardiomyopathy (n = 12) on the synopsis of all clinical data. Wall motion abnormalities, late enhancement (LE), persistent microvascular obstruction as well ventricular volumes and functions were assessed by CMRI. RESULTS: Right and left ventricular volumes were significantly different between the groups and values were highest in patients with acute myocarditis. Wall motion abnormalities were observed in 100% of STEMI, 75% of NSTEMI, 67% of acute myocarditis and 100% of Tako-tsubo patients. There was a characteristic pattern of abnormal wall motion focused on midventricular-apical segments in patients with Tako-tsubo cardiomyopathy, depending on the culprit vessel in patients with STEMI/NSTEMI and with a random distribution in patients with acute myocarditis. LE was mainly subendocardial or transmural in patients with STEMI (93.2%) or NSTEMI (62.9%). LE was diffuse, intramural or subepicardial in patients with acute myocarditis. No LE was observed in patients with Tako-tsubo cardiomyopathy. Persistent microvascular obstruction was only visualized in patients with STEMI (33%) or NSTEMI (6%). CONCLUSIONS: Cardiac magnetic resonance imaging provides characteristic patterns of LE, persistent microvascular obstruction and wall motion abnormalities that allow a differentiation between patients with acute chest pain from coronary and non-coronary origin.

Intracoronary application of abciximab in patients with ST-elevation myocardial infarction.

AIMS: Abciximab provides dose-dependent antiplatelet and anti-inflammatory properties. No specifically designed prospective studies have addressed the role of intracoronary bolus administration of abciximab in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: In a prospective observational study 633 STEMI patients were enrolled. After coronary angiography the filtered abciximab bolus with a concentration of 2,000 microg/mL was administered intracoronary by manual injection, followed by an intravenous infusion for 12 hours. Primary outcome measure was the cumulative rate of major adverse cardiac events (MACE) at 30 days defined as death, myocardial infarction or urgent target vessel revascularisation. Bleeding events were classified according to TIMI criteria. Patients with failed thrombolysis, cardiopulmonary resuscitation, cardiogenic shock, advanced age, or renal failure were assigned to group II; patients without those criteria were assigned to group I and compared to previous populations with intravenous bolus administration. There were no safety issues. In group I MACE occurred in 3.6% (N=16/451), major TIMI bleed in 2.0%. MACE and bleeding events were significantly less frequent in group I compared to group II (both p<0.0001). Significant predictors for MACE in multivariate statistics were assignment to group II (OR 11.69; 95%-CI 6.26-21.83; p<0.0001), post PCI TIMI 0-2 flow (OR 3.87; 95%-CI 2.02-7.44; p<0.0001) and female gender (OR 2.05; 95%-CI 1.15-3.65, p=0.014). CONCLUSIONS: The intracoronary administration of the abciximab bolus during PCI in STEMI patients is safe and associated with a low rate of MACE at 30 days.

Magnetic resonance imaging to assess acute changes in atrial and ventricular parameters after transcatheter closure of atrial septal defects.

PURPOSE: To evaluate acute changes in atrial and ventricular parameters by the use of cardiac magnetic resonance imaging (MRI) in patients with percutaneous transcatheter atrial septal defects (ASD) closure. MATERIALS AND METHODS: The study included 14 patients (six males and eight females, 45 +/- 18 years) with congenital ASD. Cardiac MRI (1.5T Philips Intera CV) was performed before and within 24 hours after transcatheter ASD closure. Right atrial (RA) and left atrial (LA) dimensions, as well as right (RV) and left (LV) ventricular end-diastolic (ED) volumes were determined. Atrial size was assessed by planimetry of the maximum RA and LA areas in a standard four-chamber view, and ventricular volumes were calculated according to a modified Simpson's rule in short-axis views. RESULTS: The mean RA decreased significantly from 27.6 +/- 6.4 cm(2) before closure to 24.4 +/- 5.6 cm(2) after the procedure (P = 0.0018), whereas the LA area did not change (24.1 +/- 4.7 cm(2) vs. 23.8 +/- 5.2 cm(2), P = 0.76). The RV volumes, volume index, and ejection fraction (EF) decreased significantly from 229 +/- 64 mL to 181 +/- 43 mL (P < 0.001, average reduction = 19% +/- 15%), from 126.0 +/- 37.2 mL/m(2) to 96.6 +/- 28.6 mL/m(2) (P < 0.0001) and from 64 +/- 5% to 58% +/- 7% (P = 0.01), respectively. The LV volumes and volume index remained unchanged (114 +/- 25 mL vs. 118 +/- 22 mL, P = 0.18, 63.5 +/- 13.5 mL/m(2) vs. 63.0 +/- 17.4 mL/m(2), P = 0.83). Left-right shunting decreased from 40% +/- 15% to 9% +/- 15% (P < 0.001). CONCLUSION: Cardiac MRI can reveal detailed information on acute changes in shunt fraction and ventricular dimensions after ASD closure. ASD closure by percutaneous transcatheter device implantation results within 24 hours in a significant reduction of shunt fraction, RA and RV sizes, and RV function, whereas LA and LV dimensions remain unchanged.

Assessment of myocardial perfusion for detection of coronary artery stenoses by steady-state, free-precession magnetic resonance first-pass imaging.

OBJECTIVE: To evaluate the diagnostic impact of magnetic resonance imaging (MRI) first-pass perfusion using steady-state, free-precession (SSFP) sequences with parallel imaging (SENSE) for detection of coronary stenoses. DESIGN: Prospective observational study. SETTING: University hospital, cardiac MRI and catheterisation laboratories. PATIENTS AND METHODS: 228 patients were examined with coronary angiography and MRI (1.5 T Intera CV). A three-slice, short-axis SSFP perfusion scan with a saturation prepulse was performed during infusion of adenosine and at rest followed by myocardial scar (late enhancement) imaging. Gadolinium-DTPA was given at 0.1 mmol/kg body weight. Perfusion images were visually assessed. Analysis for myocardial hypoperfusion was done according to patient group and according to vessel. RESULTS: Sensitivity, specificity and accuracy of MRI first-pass perfusion for detection of a coronary artery stenosis (>50% luminal narrowing) in the total patient group were 93.0%, 85.7%, 91.2% and for a significant lesion (>70% luminal narrowing) 96.1%, 72.0%, 88.2%, respectively. Based on 536 coronary artery territories without myocardial scar, the sensitivity of MRI perfusion analysis for detection of a significant lesion was for the left anterior descending artery 91.4%, for the circumflex artery 81.6% and for the right coronary artery 65.1% (p<0.001). CONCLUSIONS: MRI first-pass perfusion analysis using an SSFP sequence with three myocardial slices was a highly accurate diagnostic method for detection of coronary artery stenoses. This MRI technique can be included in daily practice and has the potential to guide the indication for invasive coronary angiography.

Prognostic role of myocardial tumor necrosis factor-alpha and terminal complement complex expression in patients with dilated cardiomyopathy.

BACKGROUND: In patients with dilated cardiomyopathy (DCM), elevated plasma levels of tumor necrosis factor-alpha (TNF-alpha) are associated with poor prognosis. The terminal complement complex (C5b-9) stimulates myocardial TNF-alpha expression. AIMS: To investigate whether myocardial TNF-alpha and C5b-9 expression correlate with clinical outcome in DCM. METHODS AND RESULTS: 71 patients with DCM underwent myocardial biopsy. Biopsies were analyzed for TNF-alpha, C5b-9, markers of inflammation and for viral genome. Patients were divided into three groups according to biopsy results: group A: no TNF-alpha and no C5b-9; group B: TNF-alpha or C5b-9; and group C: TNF-alpha and C5b-9. NYHA classification, ECG and echocardiography were documented. Patients received conventional treatment of heart failure and, in a few cases, additional treatment with interferon beta(1b) (virus positive) or prednisolone (inflammatory DCM). There were 13 patients (18%) in group A, 19 patients (27%) in group B, and 39 patients (55%) in group C. All groups had a similar and significant improvement in NYHA classification and echocardiographic parameters. TNF-alpha and C5b-9 did not significantly correlate with the presence of viral genome or with markers of inflammation. CONCLUSION: TNF-alpha and C5b-9 are widely distributed in the myocardium of DCM patients. Neither of the antigens correlates with clinical outcome. Myocardial TNF-alpha may not be a useful prognostic marker in DCM.

Myocardial perfusion reserve in cardiovascular magnetic resonance: Correlation to coronary microvascular dysfunction.

The present study examined the association of myocardial perfusion reserve index (MPRI) in cardiovascular magnetic resonance (CMR) with coronary microvascular dysfunction (CMD) and serum levels of markers of inflammation or endothelial activation. Twelve patients with typical angina pectoris without coronary artery disease were enrolled in this study, and CMR perfusion was analyzed using a steady-state-free-precession sequence with 3 short axis slices per heartbeat during first pass of 0.025 mmol Gadolinium-DTPA/kg body weight. The upslope of myocardial signal intensity curves was used to calculate MPRI. CMD was assessed by intracoronary Doppler flow measurement and biplane angiography. Both MPRI and CMD were assessed during endothelium-independent stimulation with intravenous adenosine and during endothelium-dependent stimulation with intracoronary infusion of acetylcholine. Serum values of soluble CD40 ligand (sCD40L), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), soluble intercellular adhesion molecule-1 (sICAM-1), and C-reactive protein (CRP) were measured. Impaired MPRI correlated significantly with a decrease in coronary blood flow reserve after both endothelium-dependent (p = 0.033) and endothelium-independent (p = 0.022) stimulation. Serum levels above the median of all normal ranged biomarkers sCD40L, TNF-alpha, IL-6, sICAM-1 and CRP were associated with an impaired MPRI for stimulation with adenosine as well as acetylcholine. In multivariable analyses, sCD40L (p < 0.001) and TNF-alpha (p = 0.011) were significantly associated with a decrease in MPRI on adenosine, as were TNF-alpha (p = 0.016) and sICAM-1 (p = 0.022) for a decrease in MPRI on acetylcholine. MPRI on adenosine significantly correlated with MPRI on acetylcholine (p < 0.001). Therefore, the present study demonstrates safety and feasibility of an intracoronary infusion of acetylcholine during CMR perfusion analysis, thus allowing direct assessment of endothelial dependent vasomotor function at the myocardial level by CMR. Furthermore, we show that an impaired myocardial perfusion reserved in CMR is associated with established biomarkers of early atherosclerosis and significantly correlated with CMD. CMR combined with adenosine could be proposed as a non-invasive tool to evaluate CMD.

Cardiac magnetic resonance imaging and transesophageal echocardiography in patients with transcatheter closure of patent foramen ovale.

OBJECTIVES: We studied the value of cardiac magnetic resonance imaging (CMRI) before and after closure of patent foramen ovale (PFO) in patients with cryptogenic ischemic events. BACKGROUND: Cardiac magnetic resonance imaging is a powerful noninvasive tool for detailed assessment of cardiac anatomy and function. The relevance of CMRI compared with transesophageal echocardiography (TEE) in patients undergoing transcatheter PFO closure has not been evaluated so far. METHODS: Contrast-enhanced CMRI and TEE were performed in 75 patients before and after PFO closure. Twelve months after PFO closure, both imaging techniques were repeated in 61 patients with contrast application. To determine provokable atrial right-to-left shunting in CMRI, we applied a contrast-enhanced perfusion imaging technique. Detection of atrial septal aneurysm (ASA) was achieved by means of a high-resolution cine imaging technique. RESULTS: Before PFO closure, ASA was seen with CMRI in 28 of 75 cases (37.3%), compared with 47 of 75 (62.7%) cases using TEE. There were a total of 211 CMRI studies with a corresponding TEE performed in 75 patients. No shunt was present in 107 of 211 studies with both techniques. Contrast-enhanced right-to-left shunting was detected by CMRI in 48 of 72 (66.6%) cases with moderate or severe shunts seen with TEE, but only in 6 of 32 (18.8%) studies with mild shunts with TEE. Anomalous venous returns were excluded in all patients. In two patients, coronary anomalies were seen. CONCLUSIONS: The present CMRI technique is inferior to TEE in detection of contrast-enhanced right-to-left shunting and identification of ASA.

Intracoronary beta-brachytherapy using a rhenium-188 filled balloon catheter in restenotic lesions of native coronary arteries and venous bypass grafts.

PURPOSE: We have previously demonstrated the efficacy of intracoronary beta-brachytherapy using a liquid (188)Re-filled balloon in a randomised trial including de novo lesions. Percutaneous coronary interventions in restenotic lesions and in stenoses of venous bypass grafts are characterised by a high recurrence rate for restenosis and re-interventions. Against this background, we wanted to assess the impact of intracoronary beta-brachytherapy using a liquid (188)Re-filled balloon in restenotic lesions in native coronary arteries and venous bypass grafts. METHODS: In 243 patients, beta-brachytherapy with 22.5 Gy was applied at a tissue depth of 0.5 mm. Patients were followed up angiographically after 6 months and clinically for 12 months. The primary clinical endpoint was the incidence of MACE (death, myocardial infarction, target vessel revascularisation). Secondary angiographic endpoints were late loss and binary restenosis rate in the total segment. RESULTS: All irradiation procedures were successfully performed. A total of 222 lesions were in native coronary arteries; 21 were bypass lesions. Mean irradiation length was 41.6+/-17.3 mm (range 20-150 mm) in native coronary arteries and 48.1+/-33.9 mm (range 30-180 mm) in bypass lesions; the reference diameter was 2.57+/-0.52 mm and 2.83+/-0.76 mm, respectively. There was no vessel thrombosis during antiplatelet therapy. Angiographic/clinical follow-up rate was 84%/100%. MACE rate was 17.6% in the native coronary artery group and 38.1% in the CABG group (p<0.03). Binary restenosis rate was 22.5% and 55.6% (p<0.01), and late loss was 0.38+/-0.72 mm and 1.33+/-1.11 mm (p<0.001), respectively. CONCLUSIONS: We conclude that intracoronary beta-brachytherapy with a liquid (188)Re-filled balloon using 22.5 Gy at a tissue depth of 0.5 mm in restenotic lesions is safe. It is associated with a low binary restenosis rate, resulting in a low occurrence rate of MACE within 12 months in restenotic lesions in native coronary arteries but not in vein grafts.

Repeat intracoronary beta-brachytherapy using a rhenium-188-filled balloon catheter for recurrent restenosis in patients who failed intracoronary radiation therapy.

BACKGROUND: Conventional percutaneous coronary intervention (PCI) in restenotic lesions after brachytherapy failure is associated with a high recurrence rate of restenoses and revascularizations. Intracoronary brachytherapy using a liquid rhenium-188-filled balloon in de novo or restenotic lesions safely and effectively reduced restenosis rates. We report clinical and angiographic data regarding the safety and efficacy of rhenium-188 brachytherapy in restenoses after brachytherapy failure. METHODS: Fourteen patients with restenosis after brachytherapy failure received rhenium-188 beta-brachytherapy. Follow-up was performed angiographically after 6 months and clinically after 12 months. Primary clinical endpoint was the incidence of major adverse cardiac events (MACE) defined as any death, myocardial infarction or repeat revascularization in the target vessel within 12 months. Secondary angiographic endpoints were the binary restenosis rate and late loss in the total segment including edge effects at 6 months. RESULTS: The prescribed dose of 22.5 Gy (n=12) or 30 Gy (n=2) was successfully delivered in all patients. In two lesions, a bare-metal stent was implanted. The mean length of the irradiated segment was 40.0+/-15.7 mm. The mean diameter of the irradiation balloon was 2.96+/-0.37 mm. Angiographic follow-up was done in 13 of 14 patients. There was no edge stenosis or coronary aneurysm. Within the total segment, late loss was 0.39+/-0.64 mm and late loss index was 0.18+/-0.40 with a binary restenosis rate of 23%. Twelve months' clinical follow-up was available in all patients, which showed a MACE rate of 7% due to one target lesion revascularization (TLR). CONCLUSIONS: Intracoronary beta-brachytherapy with a liquid rhenium-188-filled balloon in restenoses after intracoronary radiation therapy failure including 12 months combined antiplatelet therapy is safe with respect to vessel thrombosis, late coronary occlusion or aneurysm formation. With limited use of stenting, angiographic and clinical follow-up for repeat brachytherapy were favorable and it is associated with low restenosis and target vessel revascularization rate.

Myocardial biopsy findings and gadolinium enhanced cardiovascular magnetic resonance in dilated cardiomyopathy.

BACKGROUND: In some patients suffering from dilated cardiomyopathy (DCM) magnetic resonance imaging (MRI) shows late gadolinium enhancement with variable distribution. Myocardial biopsies in DCM reveal a chronic myocardial inflammatory process in almost 50% and myocardial persistence of adenoviral or enteroviral genome in about 15% of the patients. AIMS: We prospectively investigated whether the pattern of late gadolinium enhancement correlates with myocardial biopsy findings. METHODS AND RESULTS: 42 patients with DCM and 42 control subjects underwent contrast MRI. In the DCM group, endomyocardial biopsies were performed and evaluated for inflammation and viral genome. None of the control subjects showed late gadolinium enhancement whereas in 29 DCM patients (69%) gadolinium enhancement was detectable (p<0.001). 21 of the DCM patients (50%) showed midwall septal enhancement, 7 patients (17%) showed a patchy distribution of hyperenhancement and 1 patient (2%) showed enhancement typical for ischemic heart disease. In myocardial biopsy analysis, 2 patients (5%) showed persistence of viral genome, 18 patients (43%) showed inflammation and in 22 patients (52%) neither virus nor inflammation was detected. The pattern of late gadolinium enhancement and myocardial biopsy findings were not significantly correlated (p = 0.854). CONCLUSION: MRI as a non-invasive technique cannot replace myocardial biopsy for the differential diagnosis of DCM.

Myocardial biopsy based classification and treatment in patients with dilated cardiomyopathy.

BACKGROUND: We investigated whether myocardial biopsy analysis for inflammation and viruses correlates with outcome in dilated cardiomyopathy. METHODS: Myocardial biopsies of 82 patients were analyzed for HLAI, HLAII, CD54, CD2, CD68 and entero-/adenovirus. Ejection fraction was determined by left ventriculography. NYHA classification, electrocardiogram (ECG) and echocardiography were analyzed at first admission and for follow up. Patients were attributed to three groups: (A) no inflammation/no virus (B) inflammation/no virus (C) virus with/without inflammation. Patients not responding to conventional treatment of heart failure received interferon beta1b (group C) or prednisolone (group B). Median follow up was 7 months (group A), 11 months (group B) and 14.5 months (group C). RESULTS: Thirty nine patients (48%) belonged to group A, 33 patients (40%) to group B, 10 patients (12%) to group C. Only enterovirus was detected. Ejection fraction at admission was worse for group B compared to group A (p=0.003). Groups A and B improved for echocardiography and NYHA (p< or =0.001). Group C improved for echocardiography only (p=0.031). Group B showed a better outcome for echocardiography (p=0.014) and NYHA (p=0.023) than group A. CONCLUSIONS: Inflammatory cardiomyopathy shows the best outcome. Antiinflammatory or antiviral treatment may be an option in patients not responding to conventional therapy.

Sequelae of acute myocardial infarction regarding cardiac structure and function and their prognostic significance as assessed by magnetic resonance imaging.

AIMS: Because of its high spatial resolution and tissue contrast, magnetic resonance imaging (MRI) was used to assess cardiac structure and function in a large population of patients with acute myocardial infarction (AMI). METHODS AND RESULTS: One hundred and ten patients were studied by MRI 6.1 +/- 2.2 days after AMI. Infarct size (IS), persistent microvascular obstruction (PMO), left and right ventricular (LV/RV) volumes, and functions were measured. The same MRI measurements were repeated in 89 patients after a mean follow-up period of 225 +/- 92 days. IS was 11.9 +/- 7.3% of total LV muscle mass. PMO was detected in 51/110 (46.4%) patients and comprised 15.6 +/- 8.5% of IS and 2.8 +/- 2.3% of LV muscle mass. Papillary muscle infarct was seen in 26%, RV infarction in 16%, pericarditis in 40%, and pericardial effusion in 66% of the patients. During follow-up, there were 16 major adverse cardiac events (MACE) including seven deaths. IS, PMO, and amount of transmural infarction were predictive for LV adverse remodelling defined as > 20% increase in LV end-diastolic volume. Multivariable analysis revealed LV end-diastolic volume, LV ejection fraction, and PMO as significant predictors for the occurrence of MACE. CONCLUSION: MRI is a highly sensitive and reliable tool to detect morphologic and functional sequelae of AMI providing baseline MRI parameters with relevant predictive power for LV adverse remodelling and occurrence of MACE.

Re-angioplasty of in-stent restenosis versus balloon restenoses--a matched pair comparison.

BACKGROUND: Despite different biological mechanisms involved in the restenotic process of in-stent restenosis and restenosis after balloon angioplasty alone, the occurrence of a second restenosis has been reported in the same range. There are no data available comparing the outcome after re-angioplasty of such lesions. We analyzed in a matched pair comparison the clinical outcome and angiographic long-term result of patients with balloon angioplasty of a first in-stent restenosis versus patients with balloon re-angioplasty of a first balloon restenosis. METHODS: Both groups consisted of 74 lesions matched by treated vessel, lesion location differentiated in proximal and non-proximal, and angiographic appearance of coronary artery disease differentiated in singular stenosis, diffuse or mixed pattern. Clinical follow-up was 100%. Angiographic follow-up was 78.4% after median 174 days. RESULTS: Angiographic restenosis rate in matched pairs of patients (n=46/74) was significantly higher in the balloon restenosis group (41.3%, n=19/46) compared to the in-stent restenosis group (21.7%, n=10/46, p<0.042). There was no death or myocardial infarction. After clinical follow-up, target lesion revascularization rate was significantly lower in the in-stent restenosis group compared to the balloon restenosis group (12.1%, n=9/74 versus 27.0%, n=20/74; difference between groups 14.9%, 95% confidence interval 2.0-27.3%, p<0.023). Multivariate logistic regression analysis revealed as predictors for a second restenosis unstable angina pectoris, non-proximal lesion, restenosis after balloon angioplasty and the occurrence of the first restenosis within 90 days after initial intervention. CONCLUSION: Clinical and angiographic outcome after balloon angioplasty of a first in-stent restenosis was significantly better compared with balloon re-angioplasty of a first balloon restenosis.

Intracoronary beta-irradiation with a rhenium-188-filled balloon catheter: a randomized trial in patients with de novo and restenotic lesions.

BACKGROUND: Restenosis requiring reintervention is the main limitation of coronary angioplasty. Intracoronary irradiation reduces neointimal proliferation. We studied the efficacy of a self-centering liquid rhenium-188-filled balloon catheter for coronary beta-brachytherapy. METHODS AND RESULTS: After successful coronary angioplasty with or without stenting, 225 patients (71% de novo lesions) were randomly assigned to receive 22.5 Gy intravascular beta-irradiation in 0.5-mm tissue depth (n=113) or to receive no additional intervention (n=112). Clinical and procedural data did not differ between the groups except a higher rate of stenting in the control group (63%) compared with the rhenium-188 group (45%, P<0.02). After 6 months of follow-up, late loss was significantly lower in the irradiated group compared with the control group, both of the target lesion (0.11+/-0.54 versus 0.69+/-0.81 mm, P<0.0001) and of the total segment (0.22+/-0.67 versus 0.70+/-0.82 mm, P<0.0001). This was also evident in the subgroup of patients with de novo lesions and independent from stenting. Binary restenosis rates were significantly lower at the target lesion (6.3% versus 27.5%, P<0.0001) and of the total segment (12.6% versus 28.6%, P<0.007) after rhenium-188 brachytherapy compared with the control group. Target vessel revascularization rate was significantly lower in the rhenium-188 (6.3%) compared with the control group (19.8%, P=0.006). CONCLUSIONS: Intracoronary beta-brachytherapy with a rhenium-188 liquid-filled balloon is safe and efficiently reduces restenosis and revascularization rates after coronary angioplasty.

No effect of highly dosed nitric oxide donor molsidomine on the angiographic restenosis rate after percutaneous coronary angioplasty: a randomized, placebo controlled, double-blind trial.

BACKGROUND: Nitric oxide (NO) counteracts several mechanisms involved in the restenotic process after coronary angioplasty. NO mediates an antiproliferative effect on smooth muscle cells, inhibition of leukocyte-vessel wall interactions, and platelet aggregation and adhesion. Because these effects are mainly dose dependent, NO-releasing drugs have to be applied at a high dose to have an effect on restenotic mechanisms. OBJECTIVES: To study the effect of the NO donor molsidomine at a high dose of 8 mg tid on angiographic restenosis rate in a randomized, placebo controlled, double-blind trial. PATIENTS AND METHODS: One hundred and sixty-six patients with de novo stenosis were randomly assigned to molsidomine or placebo treatment for six months (83 patients each). The primary end point was the angiographic restenosis rate at six months. The secondary end points were major adverse cardiac events (MACE) including death, myocardial infarction and revascularization. Analyses were performed by intention to treat. RESULTS: There were no differences in clinical, procedural and angiographic data, including minimum lumen diameter and reference diameter. Provisional stenting was performed in 28% of patients receiving molsidomine and 25% of patients treated with placebo. All other patients were treated with standard balloon angioplasty. Reangiography rate was 89.3% (molsidomine 90 lesions, placebo 97 lesions). Restenosis rate (greater than 50% diameter stenosis) was not significantly different (molsidomine 25.6% and placebo 29.9%). Patients receiving molsidomine improved significantly more in their anginal class than patients receiving placebo (P<0.026). Occurrence of MACE did not significantly differ between both groups (molsidomine 26.8% and placebo 34.9%, P=0.26). CONCLUSION: Treatment with the NO donor molsidomine at a high dose of 8 mg tid for six months after coronary angioplasty has no effect on the angiographic restenosis rate. Due to the vasodilating effect of NO, the anginal status improves slightly more in patients receiving molsidomine.

Reduction of major adverse cardiac events with intracoronary compared with intravenous bolus application of abciximab in patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty.

BACKGROUND: In patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty, abciximab reduces major adverse cardiac events (MACE). Clinical trials have studied intravenous administration only. Intracoronary bolus application of abciximab causes very high local drug concentrations and may be more effective. We studied whether intracoronary bolus administration of abciximab is associated with a reduced MACE rate compared with the standard intravenous bolus application. METHODS AND RESULTS: We stratified 403 consecutive patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty according to the type of application of abciximab. A 20-mg bolus of abciximab was given intravenously in 109 patients and intracoronarily in 294 patients. There were no differences between the groups with regard to diabetes mellitus, cardiogenic shock, successful intervention, or preprocedural and postprocedural TIMI flow. At 30 days, the incidence of MACE (death, myocardial infarction, urgent revascularization) was significantly lower in the patients with intracoronary compared with intravenous administration of abciximab (10.2% versus 20.2%; P<0.008), which was independent from stenting in multivariate analysis. The effect was most pronounced in patients with preprocedural TIMI 0/1 flow (MACE: intracoronary 11.8% versus intravenous 27.5%, P<0.002; n=273). CONCLUSIONS: In patients with acute myocardial infarction or unstable angina undergoing emergency coronary angioplasty, intracoronary bolus application of abciximab is associated with a reduction of MACE compared with the standard intravenous bolus application of abciximab. Prospective, randomized trials are warranted to further assess intracoronary application of abciximab.