Intracoronary Imaging for Assessment of Vascular Healing and Stent Follow-up in Bioresorbable Vascular Scaffolds.

Bioresorbable Vascular Scaffolds (BVS) are polymer-based materials implanted in the coronary arteries in order to treat atherosclerotic lesions, based on the concept that once the lesion has been treated, the material of the implanted stent will undergo a process of gradual resorption that will leave, in several years, the vessel wall smooth, free of any foreign material and with its vasomotion restored. However, after the first enthusiastic reports on the efficacy of BVSs, the recently published trials demonstrated disappointing results regarding long-term patency following BVS implantation, which were mainly attributed to technical deficiencies during the stenting procedure. Intracoronary imaging could play a crucial role for helping the operator to correctly implant a BVS into the coronary artery, as well as providing relevant information in the follow-up period. This review aims to summarize the role of intracoronary imaging in the follow-up of coronary stents, with a particular emphasis on the role of intravascular ultrasound and optical coherence tomography for procedural guidance during stent implantation and also for follow-up of bioabsorbable scaffolds.

Longitudinal, circumferential and radial systolic left ventricular function in patients with heart failure and preserved ejection fraction.

INTRODUCTION: Heart failure with preserved left ventricular ejection fraction (HFPEF) is an epidemiologically serious disease. Noninvasive diagnosis of HFPEF remains challenging. The current diagnosis is based on evidence of diastolic dysfunction, albeit systolic dysfunction is also present but not included in the diagnostic algorithm. The aim of this study was to analyze the longitudinal (long), circumferential (circ) and radial (rad) component of systolic left ventricular (LV) function in patients with exertional dyspnea of unexplained etiology and normal left ventricular ejection fraction (LVEF). METHODS: One hundred and twenty-two patients with exertional dyspnea of unexplained etiology and normal LVEF and 21 healthy controls, underwent echocardiography examination at rest and at the end of symptom-limited exercise. We analysed the longitudinal, circumferential and radial deformation of myocardium using two dimensional speckle tracking echocardiography in all subjects. RESULTS: Patients with exertional dyspnea and preserved LVEF were divided into group A1 (46 patients meeting the criteria for the diagnosis HFPEF) and group A2 (76 patients without HFPEF). Group A1 had significantly worse longitudinal and circumferential systolic LV function than group A2. Subjects in group A1 compared to group A2 showed significantly different strain rates during atrial contraction (SR A), circ and ratio of peak early trans-mitral flow velocity (E) and strain rate E wave (E / SR E) circ. Multivariate logistic regression analysis showed that the SR parameter A circ is an independent predictor of HFPEF (odds ratio 0.550, 95% confidence interval: 0.370 - 0.817, P value 0.003). CONCLUSION: Longitudinal and circumferential LV deformation was significantly more impaired in patients with HFPEF than in patients with exertional dyspnea without HFPEF. In patients with exertional dyspnea and normal LVEF, the value of SRA circ appears to be a significant and independent predictor of HFPEF. This parameter may, in the future complement the diagnostic algorithm for HFPEF.

Ventricular Septal Rupture - A Critical Condition as a Complication of Acute Myocardial Infarction.

Ventricular septal rupture is a potentially fatal complication of acute myocardial infarction. The key to management of this critical condition is an aggressive approach to haemodynamic stabilization and surgical closure of the rupture. Where there is a small rupture and the patient is in a haemodynamically stable condition, surgery can be delayed with the prospect of achieving better perioperative results. However, in unstable critically ill patients either immediate surgery or extracorporeal membranous oxygenation support and delayed surgery is indicated. In some patients, trans-catheter closure may be considered as an alternative to surgery.

Early outcomes of alcohol septal ablation for hypertrophic obstructive cardiomyopathy: a European multicenter and multinational study.

BACKGROUND: This study was designed to evaluate the outcomes of alcohol septal ablation (ASA) under multicenter and multinational conditions. METHODS: Data for 459 patients (age 57 ± 13 years) from nine European centers were prospectively collected and retrospectively analyzed. RESULTS: ASA led to a significant reduction in outflow gradient (PG) and dyspnea [median of PG from 88 (58-123) mm Hg to 21 (11-41) mm Hg; median of NYHA class from 3 (2-3) to 1 (1-2); P < 0.01]. The incidence of 3-month major adverse events (death, electrical cardioversion for tachyarrhythmias, resuscitation) and mortality was 2.8% and 0.7%, respectively. Permanent pacemakers for post-ASA complete heart block were implanted in 43 patients (9%). Multivariate analysis identified higher amount of alcohol (however, in generally low-dose procedures), higher baseline left ventricular ejection fraction and higher age as independent predictors of PG decrease ≥50%. CONCLUSIONS: The results of the first European multicenter and multinational study demonstrate that real-world early outcomes of ASA patients are better than was reported in observations from the first decade after ASA introduction.

Matrix metalloproteinase 13 genotype in rs640198 polymorphism is associated with severe coronary artery disease.

Atherosclerosis as a main etiopathogenetic source for coronary artery disease (CAD) development is intimately related to dynamic changes in the extracellular matrix (ECM). Elevated levels of MMP-13 have been observed in human atherosclerotic plaques which could also involve variability in MMP-13 gene. The aim of the study was to associate rs640198 polymorphism with CAD and/or with its severity. The study comprised 1071 consecutive patients with suspected or known coronary artery disease (CAD), confirmed by coronary angiography. Genotyping for the rs640198 polymorphism in MMP-13 gene was performed using Taqman® assay. The TT and TG genotypes of rs640198 polymorphism in MMP-13 gene confer the significantly increased risk of triple vessel disease compared to patients without atherosclerotic lesions in coronary arteries (odds ratio=1.64, Pcorr=0.05). Furthermore, an increased risk of having 5 and more stenoses (odds ratio=1.90, Pcorr=0.004) was observed in TT and TG carriers (sensitivity of 0.613 and a specificity of 0.544; power of the test is 0.87). T allele of MMP-13 intron polymorphism rs640198 is associated with the severity of coronary artery disease, represented by the number of affected arteries as well as by the number of stenoses confirmed by coronarography.

The role of exercise echocardiography in the diagnostics of heart failure with normal left ventricular ejection fraction.

AIMS: Few data are available on the exercise-induced abnormalities of myocardial function in patients with exertional dyspnoea and normal left ventricular ejection fraction (LV EF). The main aims of this study were to determine the prevalence of isolated exercise-induced heart failure with normal ejection fraction (HFNEF) and to assess whether disturbances in LV or right ventricular longitudinal systolic function are associated with the diagnosis of HFNEF. METHODS AND RESULTS: Eighty-four patients with exertional dyspnoea and normal LV EF and 14 healthy controls underwent spirometry, NT-proBNP plasma analysis, and exercise echocardiography. Doppler LV inflow and tissue mitral and tricuspid annular velocities were analysed at rest and immediately after the termination of exercise. Of the 30 patients with the evidence of HFNEF, 6 (20%) patients had only isolated exercise-induced HFNEF. When compared with the remaining patients, those with HFNEF had a significantly lower resting and exercise peak mitral annular systolic velocity (Sa) and the mitral annular velocity during atrial contraction, lower exercise peak mitral annular velocity at early diastole, and lower exercise peak systolic velocity of tricuspid annular motion. The multivariate logistic regression analysis including both parameters standardly defining HFNEF and the new Doppler variables potentially associated with the diagnosis of HFNEF revealed that NT-proBNP, LV mass index, left atrial volume index, and Sa significantly and independently predict the diagnosis of HFNEF. CONCLUSION: A significant proportion of patients require exercise to diagnose HFNEF. Sa appears to be a significant independent predictor of HFNEF, which may increase the diagnostic value of models utilizing the variables recommended by the European Society of Cardiology guidelines.

Decrease in acute coronary syndrome mortality in Pleven district: implementation of scientific evidence into everyday practice.

Cardiovascular mortality in Bulgaria has increased for the last 25 years, contrary to the rest of the EU countries. One of the reasons is high in-hospital mortality due to acute myocardial infarction. The Bulgarian Cardiac Institute has established a modern cardiac hospital with a catheterization laboratory (cathlab) in the Medical University in Pleven, which helps it decrease acute coronary syndrome (ACS) mortality, taking all the necessary steps according to the guidelines of the European Society of Cardiology (ESC).

The effect of short-term isometric muscle contraction and the Valsalva maneuver on systemic and pulmonary hemodynamics in patients with severe heart failure.

BACKGROUND: Chronic heart failure is characterized by high mortality, frequent hospitalization, and reduced quality of life. Patients with severe heart failure are often in very poor physical condition, they are unable to take part in the usual exercise programs, and therefore need an individual approach. HYPOTHESIS: To assess the systemic and pulmonary hemodynamic responses to maximum voluntary contraction of the lower extremity muscles (MVC-LEM) with persistent physiologic breathing, the Valsalva maneuver, and the combination of Valsalva with MVC-LEM. METHODS: Seventeen patients with severe heart failure (ejection fraction 20%) were exposed to 3 types of load for a period of 10 seconds: 1) MVC-LEM with persistent physiologic breathing, 2) the Valsalva maneuver, and 3) a combination of MVC-LEM with the Valsalva maneuver. During each measurement, a continuous, time-synchronized record was taken of the electrocardiogram, and the pulmonary and systemic blood pressures. RESULTS: There were slight changes in the heart rate and systemic blood pressure when comparing resting versus MVC-LEM values. There were much greater and significant changes (P < .01) in the systemic and pulmonary blood pressures when comparing resting versus the Valsalva maneuver or the combination of the MVC-LEM plus the Valsalva maneuver values. CONCLUSIONS: A short maximum voluntary contraction of the muscles of the lower extremities with persistent physiologic breathing did not have an abnormal effect on the systemic and pulmonary hemodynamics in patients with severe chronic heart failure. The Valsalva maneuver caused significantly higher hemodynamic changes in the systemic and pulmonary system with possible negative effects.

Intracoronary delivery of bone marrow cells to the acutely infarcted myocardium. Optimization of the delivery technique.

OBJECTIVES: Intracoronary cell transplantation during catheter balloon inflations may be associated with adverse events. We studied the effectiveness of an alternative transplantation technique--intracoronary cell infusion. METHODS: Fourteen pigs, which had survived acute myocardial infarction, were randomized into 2 treatment groups and 2 controls. Three days after infarction, 12 pigs underwent allogeneic intracoronary mononuclear bone marrow cell transplantation using either the standard technique (short-term cell injections during repeat balloon inflations, technique A, n = 6) or continuous intracoronary cell infusion without balloon inflations (technique B, n = 6). Implanted cells were stained with fluorescent dye. After transplantation, the pigs were euthanized and myocardial samples were analyzed by fluorescent microscopy. RESULTS: The mean numbers of fluorescently labeled bone marrow cells in the infarction border zone, in the infarction mid-area and in the center of myocardial infarction were 84, 72 and 55 using technique A, and 29, 57 and 46 using technique B, respectively. The mean cell retention in the infarction border zone of 84 cells for technique A and 29 cells for technique B differed significantly (p = 0.034, two-tailed t test). CONCLUSION: The continuous intracoronary cell infusion technique is a less efficient cell delivery technique as compared with the standard technique using repeat intracoronary balloon inflations.

Serial echocardiographic assessment of the left ventricular function after direct PCI.

BACKGROUND: Acute myocardial infarction (AMI) causes remodelling of the left ventricle (LV). Restoration of patency of an infarct-related artery by percutaneous coronary interventions (PCI) may prevent or inhibit cardiac remodelling. AIM: To assess LV contractility and function by serial echocardiographic examinations. METHODS: The study group consisted of 61 patients (47 males, mean age 60+/-10 years) with acute MI treated with direct PCI. Echocardiography was performed 6-8 days after PCI, and 1, 6 and 12 months thereafter. RESULTS: LV ejection fraction increased significantly at the end of the first month in comparison with the baseline examination whereas EF values obtained after 6 months and after 1 year were not significantly different. Wall motion score index showed a significant improvement after one month, whereas it did not show any further improvement when measured after 6 or 12 months after AMI. The baseline LV end-diastolic diameter was 49+/-6 mm and did not change after one or 6 months, whereas it increased significantly 12 months after AMI. The baseline LV end-systolic diameter was 37+/-5 mm. At the one-month and six-month examinations it was similar to the baseline values but increased significantly to 38+/-6 mm after one year. CONCLUSIONS: These results confirm the beneficial effects of PCI-induced infarct-related artery patency on LV remodelling after AMI.