Stress cardiac MRI for the evaluation of CCS patients in a real-world tertiary care center

Background

The MR INFORM trial demonstrated that myocardial perfusion Magnetic Resonance Imaging (MRI) is non-inferior to Invasive Coronary Angiography (ICA) with measurement of Fractional Flow Reserve (FFR) in guiding the management of patients with stable coronary artery disease with respect to major adverse cardiac events, despite a reduced rate of revascularized patients. We sought to evaluate if a MRI-based strategy performed well also in patients with Chronic Coronary Syndrome (CCS) with intermediate coronary plaques observed by Coronary Computed Tomography Angiography (CCTA).

Methods

At our tertiary care center, patients with suspicion of CCS at intermediate risk first underwent CCTA. Subsequently, those showing intermediate coronary plaques underwent dipyridamole stress cardiac MRI. Revascularization was recommended for patients showing ischemia in at least two consecutive left ventricular segments or 6% of the myocardium. ICA and instantaneous FFR was performed in all of these patients, in order to confirm the indication for revascularization. The endpoint was a composite of death, non-fatal myocardial infarction, and target-vessel revascularization within 1 year.

Results

55 patients at intermediate risk underwent CCTA. 15 patients with no or only minimal plaques (stenosis <30%) and those with obstructive plaques (stenosis >70%) were excluded. 40 patients showed intermediate plaques (30–70% stenosis): 102 plaques total were classified as: non calcified n=9 (9%), calcified n=48 (47%), and mixed n=45 (44%). These patients underwent stress MRI, on the basis of which n=12 (30%) patients met criteria to recommend revascularization, whereas n=28 (70%) did not. The indication for revascularization was confirmed by ICA plus iFFR in 10 patients, and excluded in 2 (sensitivity = 100%, 95% CI 69%-100%; specificity = 93%, 95% CI 78%-99%; NPV = 100%, 95% CI 88%-100%; PPV = 83%, 95% CI 57%-95%; accuracy = 95%, 95% CI 83%-99%). Revascularization was obtained through PCI in 9 patients and through CABG in the remaining patient. All patients, regardless of revascularization, received optimal medical therapy (OMT), including high-dose statins. Throughout a 1-year follow-up, the composite endpoint occurred in only 1 patient belonging to the revascularized group, who was admitted to our hospital for NSTEMI. No adverse events were observed among the negative-MRI patients and the positive-MRI not-revascularized patients. All patients remained free from angina.

Conclusions

According to current European guidelines, in our tertiary care center patients with CCS at intermediate risk first underwent CCTA. A stress MRI-based strategy for the evaluation of intermediate plaques led us to refine the selection of patients needing coronary revascularization. No events occurred in patients with negative MRI, highlighting the accuracy of CCTA plus stress MRI strategy in these patients. In all patients, OMT may have contributed to freedom from angina.

Funding Acknowledgement

Type of funding sources: None.

Stenting after optimal lesion debulking (sold) registry. Angiographic and clinical outcome

BACKGROUND

Coronary stenting has reduced restenosis in focal de novo lesions, but its impact has been less pronounced in complex lesion subsets. Preliminary data suggest a role for plaque burden in promoting intimal hyperplasia after stent implantation. The aim of this study was to test the hypothesis that plaque removal with directional atherectomy before stent implantation may lower the intensity of late neointimal hyperplasia, reducing the incidence of in-stent restenosis.

METHODS AND RESULTS

Seventy-one patients with 90 lesions underwent directional atherectomy before coronary stenting. Intravascular ultrasound-guided stenting was performed in 73 lesions (81%). Clinical success was achieved in 96% of patients. Procedural complications were as follows: emergency bypass surgery in 1 patient (1.4%), who died 2 weeks later; Q-wave myocardial infarction in 2 patients (2.8%); and non-Q-wave myocardial infarction in 8 patients (11.3%). None of the patients had stent thrombosis at follow-up. Angiographic follow-up was performed in 89% of eligible patients at 5.7+/-1.7 months. Loss index was 0.33 (95% CI, 0.26 to 0.40), and angiographic restenosis was 11% (95% CI, 5% to 20%). Clinical follow-up was performed in all patients at 18+/-3 months. Target lesion revascularization was 7% (95% CI, 3% to 14%).

CONCLUSIONS

Directional atherectomy followed by coronary stenting could be performed with good clinical success rate. Also, these data point to a possible reduction in angiographic restenosis and a significant reduction in the need for repeated coronary interventions. Therefore, a randomized clinical trial seems appropriate to test the validity of this approach.

[Tardive pseudo-ischemic presentation of cardiac rhabdomyoma]

Rhabdomyoma (RBD) is the commonest cardiac tumour in early childhood. This tumour, which is asymptomatic in most patients, is often associated with tuberous sclerosis, a multisystem disease that involves mainly the central nervous system. RBD, which is generally considered a hamartoma rather than true tumour, often regresses spontaneously by age of 2. We present the case of a 19 year-old male affected with an RBD diagnosed through transthoracic and transesophageal echocardiography and nuclear magnetic resonance imaging, and characterized by late cardiac manifestations, including intermittent left bundle branch block and a pseudo-ischemic electrocardiographic pattern. These findings may depend on the anterobasal septal localization of the RBD.

[Role of a "bystander" concealed accessory pathway in the response to verapamil and flecainide treatment in a patient with nodal reentry tachycardia]

The possibility of multiple accessory atrioventricular pathways as that of multiple atrioventricular "nodal" pathways represents a relatively usual finding in patients suffering from supraventricular reciprocating tachycardias; the occurrence of both double atrioventricular nodal and concealed accessory pathways in the same patient, on the contrary, is far less common, and is usually an unsuspected condition prior to an electrophysiologic endocavitary study. The authors describe a patient suffering from paroxysmal tachycardias of both types, which have been clearly demonstrated by a transesophageal electrophysiological study. The report shows the different effects of two drugs, verapamil and flecainide, on these reciprocating circuits. Flecainide showed an immediate effectiveness in this condition, while verapamil, although very effective for the "nodal" reciprocating tachycardia, might worsen the accessory reentrant one, and cause a "jump" from the first to the second form.