Prognostic value of adenosine stress cardiovascular magnetic resonance in patients with low-risk chest pain

<p>Abstract</p> <p>Background</p> <p>Approximately 5% of patients with an acute coronary syndrome are discharged from the emergency room with an erroneous diagnosis of non-cardiac chest pain. Highly accurate non-invasive stress imaging is valuable for assessment of low-risk chest pain patients to prevent these errors. Adenosine stress cardiovascular magnetic resonance (AS-CMR) is an imaging modality with increasing application. The goal of this study was to evaluate the negative prognostic value of AS-CMR among low-risk acute chest pain patients.</p> <p>Methods</p> <p>We studied 103 patients, mean 56.7 ± 12.3 years of age, with chest pain and no electrocardiographic evidence of ischemia and negative cardiac biomarkers of necrosis, who were admitted to the Cardiac Decision Unit of our institution. All patients underwent AS-CMR. A negative AS-CMR was defined as absence of all the following: regional wall motion abnormalities at rest; perfusion defects during stress (adenosine) and rest; and myocardial scar on late gadolinium enhancement images. The patients were followed for a mean of 277 (range 161-462) days. The primary end point was defined as the combination of cardiac death, nonfatal acute myocardial infarction, re-hospitalization for chest pain, obstructive coronary artery disease (>50% coronary stenosis on invasive angiography) and coronary revascularization.</p> <p>Results</p> <p>In 14 patients (13.6%), AS-CMR was positive. The remaining 89 patients (86.4%), who had negative AS-CMR, were discharged. No patient with negative AS-CMR reached the primary end-point during follow-up. The negative predictive value of AS-CMR was 100%.</p> <p>Conclusion</p> <p>AS-CMR holds promise as a useful tool to rule out significant coronary artery disease in patients with low-risk chest pain. Patients with negative AS-CMR have an excellent short and mid-term prognosis.</p

Is left ventricular dysfunction reversed after treatment of active acromegaly?

It has been suggested that control of GH and IGF excess can arrest the progression of cardiovascular abnormalities and normalize cardiac performance. The aim of the present study was to investigate the reversibility of acromegalic cardiomyopathy in patients with active and inactive disease and to evaluate the effect of the inactivity of the disease on left ventricular (LV) diastolic dysfunction, irrespective of the applied treatment. The patient population consisted of 55 patients who were studied in the active and/or inactive phase. A complete M-mode, two-dimensional and color-flow Doppler echocardiographic examination was performed. LV mass index and posterior wall index were significantly lower in patients with inactive acromegaly compared to those with active disease (P &lt; 0.03 respectively). Diastolic dysfunction was improved in patients with inactive compared to those with active disease (E/A ratio P &lt; 0.009). IGF was positively correlated with LV mass index (r = 0.28, P &lt; 0.02). Multivariate linear regression analysis showed that in active patients the E/A ratio was independently related to age (β = -0.674, P &lt; 0.001) and GH (β = 0.282, P &lt; 0.03), whereas in inactive patients none of the parameters were related significantly with the E/A ratio. In a subgroup of 15 patients who were studied in both the active and inactive phase of the disease, the reduction in GH levels was correlated positively with the reduction in LV mass index (r = 0.89, P &lt; 0.0001) and negatively with the improvement in E/A ratio (r = -0.74, P &lt; 0.001). In conclusion, the results of the present study indicate an improvement of left ventricular diastolic function and a significant improvement of cardiac hypertrophy in patients with inactive acromegaly and normal systolic cardiac function compared to those with active disease. © 2010 Springer Science+Business Media, LLC

Real-time three-dimensional echocardiography in evaluating Libman-Sacks vegetations

Libman-Sacks endocarditis, characterized by sterile fibrofibrinous vegetations that have the potential to develop anywhere on the endocardial surface, was originally reported in 1924. The mitral valve is most commonly affected, followed by the aortic valve, whereas tricuspid and pulmonary valves are seldom involved. Libman-Sacks vegetations can be found in similar to 1 of 10 patients with systemic lupus erythematosus by transoesophageal echocardiography (TTE), and they are variably associated with lupus duration, disease activity, anticardiolipin antibodies, and antiphospholipid syndrome manifestations. The capability to perform real-time 3D (RT3D) imaging in the evaluation of Libman-Sacks vegetation size may strengthen the already established role of transthoracic echocardiogram and TTE. The exact estimation of vegetation size may influence therapeutic interventions. Therefore, we are trying to highlight the role of RT3D echocardiography in assessing vegetation size in a patient with Libman-Sacks endocarditis

Effect of pacing mode and pacing site on torsional and strain parameters and on coronary flow

Background: Right ventricular apical pacing may induce detrimental effects on left ventricular function and coronary flow. In this study, the effects of pacing site and mode on cardiac mechanics and coronary blood flow were evaluated. Methods: This prospective study included 25 patients who received dual-chamber pacemakers with the ventricular lead placed in the right ventricular apex and presented in sinus rhythm (SR) at their regularly scheduled visits at the pacemaker clinic. Patients underwent complete transthoracic echocardiographic examinations while in SR, followed by noninvasive Doppler assessment of coronary flow in the left anterior descending coronary artery (LAD) and speckle-tracking echocardiography of short-axis planes in SR, atrial pacing (AAI-P), atrioventricular (dual-chamber) pacing (DDD-P), and ventricular pacing (VVI-P). Results: Rotation of the base was significantly decreased with VVI-P compared with AAI-P. Left ventricular twist decreased significantly with DDD-P compared with AAI-P. Circumferential strain of the base significantly decreased with DDD-P and VVI-P compared with SR. The velocity-time integral of diastolic flow in the LAD decreased significantly with DDD-P compared with SR (10.7 ± 2.2 vs 10.2 ± 2.2 vs 8.9 ± 1.6 vs 8.7 ± 2.6 cm in SR and with AAI-P, DDD-P, and VVI-P, respectively, P = .003). Basal rotation and time from onset of the QRS complex to peak basal rotation as a percentage of systole were independently associated with the velocity-time integral of diastolic flow in the LAD during SR and the three pacing modes. Conclusions: Acute right ventricular apical pacing showed a detrimental effect on left ventricular twist and basal mechanics, with the latter being independently associated with decreased LAD diastolic flow velocity parameters. Copyright 2015 by the American Society of Echocardiography

Atrioventricular node modification in patients with chronic atrial fibrillation - Role of morphology of RR interval variation

Background-This study evaluates the role of RR interval distribution pattern as an outcome predictor of radiofrequency (RF) modification of atrioventricular (AV) node in chronic atrial fibrillation (AF) and attempts to elucidate the likely mechanism of rate control. Methods and Results-Sixty-five patients with chronic AF underwent AV node modification. The RR interval distribution pattern was derived from 24-hour ECC recordings obtained before and after the procedure. The preablation pattern was bimodal (B) in 36 patients (55%) and unimodal (U) in 29 patients (45%). After the modification procedure, the B pattern shifted to U (78%) or became modified B (22%). The mean number of RF pulses delivered and the fluoroscopy time were n=8+/-5 and 24+/-11 minutes. respectively, in patients with B pattern versus n=18+/-7 and 45+/-17 minutes in patients with U pattern (P&lt;0.001 for both). The location of successful ablation was posteroseptal and lower midseptal in 26 patients (81%) with B pattern versus 2 (13%) with U pattern (P&lt;0.001). Mean and maximal ventricular rates and heart rate at peak exercise were reduced after the procedure in both groups (P&lt;0.001 for all). Long-term success rate, AV block incidence, and pacemaker implantation rate were 89%, 0%, and 8%, respectively, in patients with B pattern versus 52% (P&lt;0.001), 21% (P=0.006), and 48% (P&lt;0.001) in patients with U pattern. Conclusions-RF modification of the AV node is expected to be more effective, safe, and expeditious in patients with chronic AF and B RR interval distribution pattern. Posterior atrionodal input ablation may be the prevailing mechanism of rate control in these patients, whereas U-pattern patients may benefit from partial injury to the AV node

Effect of early changes in functional geometry of left ventricular contraction on the development of ventricular fibrillation during acute myocardial ischaemia. An experimental study

Objective: The early appearance of ventricular fibrillation (VF) following acute myocardial infarction (MI) is associated with adrenergic effects and electrical interactions although some early &quot; mechanical&quot; changes may also occur. The aim of the present experimental study was to examine whether early changes in the functional geometry of left ventricular (LV) contraction may be associated with ventricular arrhythmias occurring during the first 120. min of MI. Methods: In 11 swine left anterior descending (LAD) coronary artery ligation was performed. Aortic flow, LV end-diastolic pressure (LVEDP), LV long and short axis lengths were measured and their fractional shortening (FS) was calculated before and during the initial 120. min period of MI. Results: LV long axis FS and aortic flow decreased (p&lt; 0.001) whereas LVEDP increased (p&lt; 0.01) in all 11 animals within 30. min following LAD ligation. LV long and short axis lengths and LV short axis FS did not change significantly. VF occurred in 5 of the 11 animals within this 30. min period. LV short axis FS decreased (p&lt; 0.05) in all 5 animals prior to VF and increased (p&lt; 0.05) in all 6 animals without VF. In 3 of the 6 animals that had no VF during the initial 30. min VF occurred later. Similarly, LV short axis FS decreased prior to VF in all those 3 animals. LV short axis FS did not decrease in any of the remaining 3 swine without VF during the same period of time. Conclusion: Early changes in the functional geometry of LV contraction, in the form of a reduction of LV short axis FS, are associated with a greater incidence of VF in experimental acute MI. © 2010 Elsevier Ireland Ltd

Osteoprotegerin is a significant prognostic factor for overall survival in patients with primary systemic amyloidosis independent of the Mayo staging

Bone metabolism has not been systematically studied in primary (AL) amyloidosis. Thus we prospectively evaluated bone remodeling indices in 102 patients with newly diagnosed AL amyloidosis, 35 healthy controls, 35 newly diagnosed myeloma and 40 monoclonal gammopathy of undetermined significance patients. Bone resorption markers (C-telopeptide of type-1 collagen, N-telopeptide of type-1 collagen) and osteoclast regulators (soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteoprotegerin (OPG)) were increased in AL patients compared with controls (P&lt;0.01), but bone formation was unaffected. Myeloma patients had increased bone resorption and decreased bone formation compared with AL patients, while sRANKL/OPG ratio was markedly decreased in AL, due to elevated OPG in AL (P&lt;0.001). OPG correlated with N-terminal pro-brain natriuretic peptide (P&lt;0.001) and was higher in patients with cardiac involvement (P = 0.028) and advanced Mayo stage (P = 0.001). OPG levels above the upper value of healthy controls was associated with shorter survival (34 versus 91 months; P = 0.026), while AL patients with OPG levels in the top quartile had very short survival (12 versus 58 months; P = 0.024). In Mayo stage 1 disease, OPG identified patients with poor survival (12 versus 460 months; P = 0.012). We conclude that increased OPG in AL is not only a compensation to osteoclast activation but may also reflect early cardiac damage and may identify patients at increased risk of death within those with earlier Mayo stage

Acute Haemodynamic and Echocardiographic Effects of Multiple Configurations of Left Ventricular Pacing Sites in Acute Myocardial Infarction: Experimental Study

Background Left ventricular (LV) pacing is unsuccessful in a significant number of patients, mainly due to sub-optimal LV pacing location. Nevertheless, data about the impact of different pacing sites on LV function in ischaemic myocardium are scarce. The purpose of this study was to investigate the effect of combinations of alternative LV pacing sites on LV mechanics after experimental acute anterior myocardial infarction (AMI), in order to define the optimal configuration. Methods Atrioventricular epicardial pacing at alternative pacing sites was performed in 16 healthy pigs simultaneously, after experimental AMI. Standard right ventricular (RV) apical pacing was combined with: i) LV apex lateral wall; ii) LV basal posterior wall; iii) LV basal anterior wall, and; iv) LV basal anterior wall + LV basal posterior wall. Moreover the pacing configurations of, v) LV basal posterior wall + LV apex lateral wall; vi) LV basal posterior wall + LV basal anterior wall, and; vii) LV basal anterior wall + LV apex lateral wall were also investigated. Haemodynamic parameters, together with classic and novel echocardiographic indices were used, to evaluate the effect of each pacing combination. A speckle tracking technique using EchoPAC software was used. Results After AMI, the pacing combination of LV apex lateral wall and LV basal posterior wall had the most favourable effect on LV function, leading to similar haemodynamic and torsional effects with sinus rhythm (all variables p&gt;0.05). Conclusions In pig hearts after AMI, the combination of pacing LV apex lateral wall and LV basal posterior wall managed to maintain the LV function at a level comparable to the sinus rhythm. © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ