Late percutaneous coronary intervention for an occluded infarct-related artery in patients with preserved infarct zone viability: A pooled analysis of cardiovascular magnetic resonance studies

Background: The results of clinical trials assessing the effect of late opening of infarct-related artery (IRA) on left ventricular ejection fraction (LVEF) and size in stable patients are equivocal, which may be related to the fact that the presence of viability was not a requirement for randomization in these trials. The aim of the study was to assess the influence of late percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) vs. OMT alone on cardiac function and remodeling in patients presenting infarct zone with preserved viability on cardiovascular magnetic resonance (CMR).Methods: The analysis included pooled data of 43 patients from 3 randomized studies. All patients underwent CMR before randomization, but only in 1 previously unpublished study was preserved viability required for randomization to treatment. Follow-up CMR was performed after 6–12 months.Results: Late PCI with OMT led to improved LVEF (+5 ± 7% vs. –1 ± 6%, p = 0.005), decreased left ventricular end-systolic volume (–11 ± 19 mL vs. 12 ± 40 mL, p = 0.02) and a trend towards a decrease in end-diastolic volume (–7 ± 27 mL vs. 15 ± 47 mL, p = 0.07) in comparison to OMT alone. Increased LVEF and decreased left ventricular volumes were observed after the analysis was restricted to patients with left anterior descending artery (LAD) occlusion.Conclusions: In patients with the presence of infarct zone viability, OMT with late PCI for an occluded IRA (particularly LAD) is associated with improvement of left ventricular systolic function and size over OMT alone

The use of adenosine stress perfusion cardiac magnetic resonance in determining incomplete revascularization post-coronary artery bypass grafting and the importance of anterior septal vessels

Incomplete revascularization post-coronary artery bypass grafting (CABG) may occur in up to one quarter of patients,1 and meta-analyses suggest this is associated with poor outcomes.1,2 ESC guidelines now prioritize complete revascularization when deciding between CABG or percutaneous coronary intervention (PCI).3 Adenosine stress perfusion cardiac magnetic resonance (MR) is well suited to determine the burden and location of ischaemia over and above scar, which may guide further revascularization after CABG. In our magnetic resonance experience, patients may receive bypass grafts that inadvertently leave proximal branches of the main coronary arteries trapped between a distal bypassed stenosis, and a proximal native stenosis.This article is available via Open Access. Click on the Publisher URL to access.Publishe

Cardiac imaging to investigate suspected cardiac pain in the post-treadmill era

Symptomatic cardiovascular disease is one of the leading causes of hospital admissions in the UK; along with emergency attendances, over 100,000 patients are investigated using treadmill testing via rapid access chest pain clinics each year. With the introduction of new technologies, clinicians have a wide choice of investigations including nuclear perfusion scanning, dobutamine stress echocardiography, cardiac computed tomography and stress cardiac magnetic resonance imaging. These imaging modalities have their strengths and weaknesses, which depend not only on the pre-test likelihood of significant coronary artery disease but also the clinical characteristics of the patient. This article will review the differing imaging modalities, the patient experience, accuracy, prognostic data and future prospects for cardiac computed tomography and magnetic resonance imaging

Multimodality imaging in bland-White-Garland syndrome in an adult with a left dominant coronary artery system

Bland-White-Garland syndrome, also known as anomalous origin of the left coronary artery from the pulmonary artery, is a rare congenital disorder affecting around one in 300,000 live births. The majority of these present within the first year of life with 90% mortality rate if untreated and consequently is an extremely rare presentation in the adult. We present the first published case with a left dominant system in an adult presenting in their late 20s, illustrated by multimodality imaging

The relationship between the contralateral collateral supply and myocardial viability on cardiovascular magnetic resonance: can the angiogram predict functional recovery?

BACKGROUND: A collateral circulation which supplies a myocardial territory, subtended by a chronic total occlusion (CTO), may be observed at invasive coronary angiography. The prognostic and protective role of such collateralisation is well demonstrated suggesting that a good collateral circulation may be a predictor of myocardial viability, but current evidence is discrepant. The aim of this study is to assess the relationship between collateralisation from the contralateral epicardial vessels and myocardial viability by cardiovascular magnetic resonance (CMR). METHOD: Consecutive patients with CTO having had both CMR and invasive coronary angiography were retrospectively identified. The collateral circulation was graded with the Cohen and Rentrop classification. CMR images were graded per segment for wall motion (1: normal/hyperkinetic, 2: hypokinetic, 3: akinetic, or 4: dyskinetic) and wall motion score index (WMSI) was calculated. The segmental transmurality of late gadolinium enhancement was scored as 1 (0%), 2 (1-25%), 3 (26-50%), 4 (51-75%) and 5 (76-100%). RESULTS: A good collateral circulation was more likely to supply viable myocardium (p=0.01). There was no relationship between collateral circulation supply and wall motion score index (WMSI), however, increasing transmurality of LGE was significantly associated with higher mean WMSI representing increasing dysfunctional myocardium (p<0.001). CONCLUSION: The presence of collateral coronary circulation at angiography predicts the presence of viability on cardiovascular MRI, with a gradation of greater viability associated with improving Rentrop grade. A collateral circulation at angiography should, therefore, prompt more formal assessment of viability and consideration of revascularisation in order for the patient to obtain the associated functional and prognostic improvement

Safety and feasibility of dobutamine stress cardiac magnetic resonance for cardiovascular assessment prior to renal transplantation.

Current guidelines recommend cardiovascular risk assessment prior to renal transplantation. There is currently no evidence for the role of cardiovascular magnetic resonance (CMR) in this population, despite an established evidence base in the non-chronic kidney disease (CKD) population. Our aim is to determine the feasibility and safety of dobutamine stress CMR (DSCMR) imaging in the risk stratification of CKD patients awaiting renal transplantation