Interobserver variability in assessing segmental function can be reduced by combining visual analysis of CMR cine sequences with corresponding parametric images of myocardial contraction.

OBJECTIVE: To evaluate if color-coded parametric images could help subjective visual analysis and improve interobserver agreement in the evaluation of segmental contraction (SC) in CMR. BACKGROUND: Routine evaluation of SC in CMR remains mostly based on visual analysis of cine loops and subsequent interobserver variability remains a potential drawback. MATERIALS AND METHODS: Three short axis cine loops were obtained in 33 subjects (18 myocardial infarction, 15 control), and 528 segments were analyzed. From each cine loop a single static parametric image resuming wall motion information was generated using Factor Analysis of Medical Image Sequences. Three readers (R1, R2, R3) scored left ventricular SC in 4 classes in 2 steps: visual assessment of cine loops alone and by combining cine loops with the corresponding parametric image. Reference segmental scores were obtained by consensus. Global contraction indexes were calculated in each step of the analysis. RESULTS: When parametric images were combined with cine loop assessment, interobserver agreement was enhanced for paired readers: R1-R2: kappa = 0.66 (combined analysis) vs. kappa = 0.60 (cine alone); R2-R3: kappa = 0.67 vs. kappa = 0.65; R3-R1: kappa = 0.71 vs. kappa = 0.67 and absolute agreement with consensus was higher for the 3 readers: R1: 91% vs. 85%; R2: 87% vs. 83% and R3: 94% vs. 89%. When considering global wall motion indexes, interobserver agreement was also enhanced: R1 vs. R2 : r = 0.91 vs. 0.85; R2 vs. R3: 0.95 vs. 0.91; R3 vs R1: 0.98 vs. 0.91. CONCLUSION: Adding a color-coded static parametric image to routine subjective visual assessment of SC reduces interobserver variability.

A case of recurrent transient left ventricular apical ballooning associated with atrial fibrillation.

We report the case of a post-menopausal female who presented two episodes of transient left ventricular apical ballooning associated with rapid atrial fibrillation within a four-month period. The clinical features of this phenomenon also known as Tako-tsubo mimic acute myocardial infarction and may be a form of catecholamine-induced neurogenic stunning. The case illustrates that typical ECG features could be masked by atrial fibrillation with rapid ventricular response.

[Cardiac MRI in the evaluation of ischemic cardiopathy]. / Avancées récentes en cardiologie: cardiopathie ischémique et IRM cardiaque.

It is now currently possible with MRI to study global and regional cardiac function using dynamic sequences, to follow up myocardial perfusion, or to directly visualize myocardial infarctions. This article details the use of these new techniques in the diagnosis of ischemic cardiopathy. At least three applications are ready to be used in clinical practice: determination of viability by MRI, ischemia detection by associating pharmacologic stress and finally evaluation of an ischemic cardiopathy as the possible cause of cardiac dysfunction. Future developments in the next few years could be the use of MRI for differential diagnosis of chest pain in the emergency department as well as non invasive coronary angiography.

Elective ostial left main stenting: a tailored approach.

Elective left main (LM) stenting is increasingly performed as a valuable alternative to coronary artery bypass grafting. Nevertheless, clinical data are limited to registries, and randomized trials have not been published. Intravascular ultrasound (IVUS) has been recognized as an accurate tool for assessing optimal stent deployment. We hereby report the usefulness of IVUS in defining the interventional strategy in four consecutive patients presenting with severe, symptomatic ostial LM disease, and this in the era of drug-eluting stents. The first two patients were treated by a short drug-eluting stent for a critical LM stenosis as IVUS demonstrated a reference diameter < 3.7 mm. The third patient had a larger reference diameter and was treated with conventional stenting with optimization of the result by IVUS. IVUS was particularly helpful in all patients to confirm accurate stent placement in relation to the LM ostium and bifurcation. In another patient, based on IVUS findings, surgery was preferred. This patient with diabetes as a risk factor presented with comparable angiographic features. IVUS, however, showed diffuse disease without any healthy reference segment in the LM. All stented patients are asymptomatic at 15 +/- 7 months follow-up with negative stress testing. The present observation indicates that IVUS is an essential tool for strategic selection and to optimize percutaneous coronary intervention for LM disease.

Percutaneous closure of patent foramen ovale: head-to-head comparison of two different devices.

Percutaneous closure of patent foramen ovale (PFO) has been proposed as the treatment of choice for young high-risk patients who suffered cryptogenic stroke and/or peripheral paradoxical embolism. We sought to compare prospectively two different devices used for percutaneous PFO closure.Prospective data were collected on 40 high risk patients (females: 38%, mean age : 44 +/- 11 years, interatrial septal aneurysm >10 mm: 68%) who underwent percutaneous PFO closure after cryptogenic stroke (n = 38) or peripheral paradoxical embolism (n = 2). Chronologically, 20 patients were first treated by a PFO-Star (Cardia, Burnsville, MI) device. Then, 20 other patients received a Starflex occluder (NMT, Boston, MA). The primary endpoint was complete PFO closure at 6 months as assessed by transthoracic contrast echocardiography. Secondary endpoints were major peri- or post procedural complications and clinical recurrence at 1 year follow-up.Baseline clinical and anatomical characteristics were comparable for both groups. Complete PFO closure was observed in 50% (PFO-Star) and 90% (Starflex) of patients (p=0.001) respectively. Major peri-procedural complications occurred in the PFO-star group only: right-sided device thrombus (1 patient) and aorto-right atrial fistula (1 patient). At 1 year follow-up, no clinical recurrence occurred.In conclusion, despite the absence of clinical recurrence in this high-risk population with presumed paradoxical embolism, complete PFO closure at 6 months follow-up was significantly related to the type of closure device used.

Confounding effects of heart rate on pulse wave velocity in paced patients with a low degree of atherosclerosis.

BACKGROUND: Pulse wave velocity (PWV), an index of arterial wall stiffness, is modulated by blood pressure (BP). Whether heart rate (HR) is also a modulator of PWV is controversial. Recent research involving mainly patients with high aortic PWV have found either no change or a positive correlation between the two. Given that PWV is increasingly being measured in cardiovascular studies, the relationship between HR and PWV should be known in patients with preserved arterial wall elasticity. OBJECTIVE: The aim of this study was to evaluate the importance of HR as a determinant of the variability in PWV in patients with a low degree of atherosclerosis. DESIGN AND METHODS: Fourteen patients (five female, nine male; aged 68 +/- 8 years) were evaluated post pacemaker implantation due to sick sinus or carotid hypersensitivity syndromes. Carotid-femoral PWV was measured at rest and during atrial pacing at 80, 90 and 100 bpm (paced HR). Arterial femoral blood flow (AFBF) was measured by echodoppler. RESULTS: PWV increased from 6.2 +/- 1.5 m/s (mean +/- SD) during resting sinus rhythm (HR 62 +/- 8 bpm; mean +/- SD) to 6.8 +/- 1.0, 7.0 +/- 0.9, and 7.6 +/- 1.1 m/s at pacing rates of 80, 90 and 100 bpm, respectively (P < 0.0001). Systolic (SBP) and mean blood pressure (MBP) remained constant at all HR levels, whereas AFBF increased in a linear fashion. CONCLUSIONS: These results demonstrate that even in patients with a low degree of atherosclerosis, HR is a potential modulator of carotid-femoral PWV.

Direct stenting with a combined intravascular ultrasound-coronary stent delivery platform: a feasibility trial.

IVUS is considered as the most accurate tool for the assessment of optimal stent deployment. Direct stenting has shown to be a safe, efficient, and resource-saving procedure in selected patients. In a prospective 1-month feasibility trial, a new combined IVUS-coronary stent delivery platform (Josonics Flex, Jomed, Helsingborn, Sweden) was evaluated during direct stenting in consecutive patients considered eligible for direct stenting. The feasibility endpoint was successful stent deployment without any clinical adverse event, while the efficacy endpoint was strategic adaptation according to standard IVUS criteria for optimal stent deployment at the intermediate phase (after a result considered angiographically optimal) and at the end of the intervention (after optimization according to IVUS standards). A total of 16 patients were successfully treated with this device without any major clinical complication. At the intermediate phase, optimal stent deployment was achieved in four patients only, while at the end only one patient had nonoptimal IVUS stent deployment. In particular, the minimal in-stent cross-section area increased from 6.3 +/- 1.2 to 8.3 +/- 2.5 mm(2). These preliminary data demonstrate the feasibility of direct stenting with a combined IVUS-stent catheter in selected patients and confirm the results from larger randomized trials on the impact of IVUS on strategic adaptations during coronary stent placement.