Clinical Application of Exercise Stress Echocardiography in an Outpatient Pediatric Population

Background: Exercise stress echocardiography (ESE) is commonly employed in adults, but its applicability in pediatric populations remains to be clarified. Methods: A total of 309 consecutive children (C), with a mean age of 14.1 ± 2.6 years (range 6-17 years), underwent treadmill ESE starting in 2002. They were divided into two groups: Group I comprised 258 children, including 237 with symptoms related to exercise (such as chest pain, fatigue, lipothymia/syncope, or one aborted sudden death), 15 with electrocardiogram (ECG) abnormalities, and 6 with a positive ECG stress test showing ST changes. Group II consisted of 10 asymptomatic children whose parents requested routine screening, 11 with symptoms unrelated to exercise, 12 with a family history of sudden death, and 17 with known pathologies (including 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, and the remainder with various conditions, such as Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, and aortic switch operation). Regional wall motion abnormalities (RWMAs) and transvalvular or intraventricular (IVG) gradients were assessed using 2D and continuous-wave Doppler, respectively, in all cases. Results: The success rate was 100% (309/309). Stress-induced RWMAs were observed in two children. A significant IVG (>30 mmHg) was detected in 101 out of the 258 children (39%) in Group I, who presented with exercise-related symptoms, ECG abnormalities, or positive stress ECG. In Group I, the odds ratio (OR) of ESE reproducing the symptoms in children with IVG compared to those without IVG was 8.22 (95% CI: 4.84-13.99, p < 0.001). Conclusions: Treadmill ESE is both feasible and safe for pediatric populations. RWMAs demonstrated limited utility in our cohort of children, while IVG induced by exercise was frequently observed in symptomatic children.

Intraventricular gradients-When we have to "exercise" our minds: A case report

Increased intraventricular pressure gradients due to dynamic left ventricular outflow tract obstruction during exercise have long been known to cause different symptoms. Exercise stress echocardiography is fundamental in the diagnostic approach of symptoms presenting during exercise. We hypothesize on the possible pathophysiological mechanisms responsible for our patient's syncopal episodes.

Clinical Case 23—Adult-onset recurrent Kawasaki disease complicated by coronary aneurysms and recurrent acute myocardial infarction

Summary of case: A 67-year-old man presented to the emergency department (ED) with acute chest pain. He had the previous diagnosis of Kawasaki disease (KD) made when he was 51 years-old in a event of a acute myocardial infarction. Upon admission, his blood pressure was 100/70 mm Hg, heart rate was 55 beats/min, apyretic. Clinical examination was unremarkable. Electrocardiogram showed a synus rhythm without any ST-T alterations. An echocardiogram showed mildly decreased left ventricular function (LVEF) of 44% by the biplane Simpson method, with hypokinesia of anterolateral and inferolateral wall, and enlargement of the ascendent aorta and aorta root. Cardiac enzymes were elevated, troponin-I 10.5 ng/mL and NTproBNP of 832 ng/mL. The diagnosis of acute myocardial infarction without ST segment elevation was made. Cardiac catheterization revealed diffuse aneurysmal dilation of the left anterior descendent artery and right coronary artery. Circunflex artery was occluded in the mid segment. Thrombotic aspiration was made and a drug-eluting stent was implanted. The patient showed clinical improvement and was discharged 4 days later with ticagrelor and aspirin.

This case illustrates the importance to recognize adult-onset KD as part of the differential diagnosis of chest pain with ST-segment elevation in a adult, even if uncommon. Early recognition is fundamental, permitting correct treatment and prevention of potentially fatal coronary complications.

Poster No. 140 Major cardiovascular events in high cardiovascular risk patients submitted to non-cardiac surgery and its clinical determinants

Introduction

Pre-operative cardiovascular assessment of patients with high ischaemic risk is fundamental to give the best perioperative management. Morbi-mortality is mainly due to patient-related risk and surgery-related risk. However, the risk scores are very heterogeneous and derived from non-cardiac populations, making them less accurate.

Purpose

The study aims to characterize a cohort of patients with high ischemic risk who underwent non-cardiac surgery and to identify predictors of perioperative major adverse cardiovascular events (MACE) defined by urgent revascularization, myocardial infarction (MI) and/or cardiac death, thromboembolism and acute limb ischemia.

Methods

A single-center retrospective observational analysis between January 2015 and August 2022 evaluated 356 patients. Eligibility criteria included: patients with high cardiovascular risk with previous diagnosis of cardiac disease, planned to be submitted to high-risk non-cardiac surgery, and perioperative follow-up at our center.

Results

A total of 356 patients with high cardiovascular risk undergoing NCS were eligible in the cohort. Perioperative MACE occurred in 4.5% of the patients. Predictors of MACE during perioperative period were older age (P &lt; 0.001), chronic pulmonary disease (P = 0.031), coronary artery disease (CAD) (P = 0.011) and valvular heart disease (P = 0.039). Diabetes and hypertension exhibited a neutral impact in these patients.

Conclusions

These results highlight the increased thrombotic risk inherent to major surgery in patients with high risk cardiovascular disease. Older age, previous diagnosis of chronic pulmonary disease, coronary artery disease, and valvular heart disease are predictors of MACE in patients submitted to non-cardiac surgery, providing incremental value for predicting these events. More studies are needed to further caracterize this population.x

Poster No. 138 Thromboembolic and bleeding risks due to perioperative stop of antithrombotic treatment in non-cardiac surgery - a single center experience

Introduction

Discontinuation of antiplatelet therapy is essential for patients in the perioperative period submitted to high bleeding risk non-cardiac surgery (NCS). Similarly, oral anticoagulants should be interrupted before high risk surgical procedures, excluding patients with mechanical heart valves together with any thromboembolic risk factors. Interruption of this medication may increase thromboembolic events, however, their frequency still remains unclear.

Purpose

We aim to evaluate the thromboembolic and bleeding events due to perioperative cessation of antithrombotic treatment in non-cardiac surgery approach in the population in our center.

Methods

A single-center retrospective observational analysis between January 2015 and August 2022 evaluated 356 patients. Eligibility criteria included: interruption of antithrombotic or anticoagulant therapy, high cardiovascular risk with previous cardiovascular disease diagnosis, planned major non-cardiac surgery, and perioperative follow-up at our center.

Results

A total 356 patients undergoing NCS were eligible in the cohort: 91.2% of patients with high bleeding risk surgery and 94.5% with mild-moderate thrombotic risk.

All cause death occurred in 4 patients (1.1%), thrombotic events in 4 patients (1.1%) and major bleeding events in 11 patients (3.1%). Hemoglobin level (P = 0.004), duration of surgery (P &lt; 0.001) and age (P = 0.004) were significantly related to the risk of bleeding events. Mean duration of interruption of antithrombotic therapy was of 8 ± 2 days.

Conclusions

Although cessation of antithrombotic therapy, hemorrhagic events are more associated than thrombotic ones in patients with previous cardiac disease that underwent elective NCS. The factors with significant association with bleeding complications after NCS were age, hemoglobin level, and duration of surgery.

Exercise stress echocardiography: Where are we now?

Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.

Upright exercise stress echocardiography may unmask dynamic left ventricular obstruction also beyond hypertrophic cardiomyopathy

Background

Dynamic left ventricular outflow obstruction (LVOTO) during exercise stress echocardiography (ESE) is recommended in hypertrophic cardiomyopathy (HCM) to identify the obstructive phenotype.

Aim

To assess left ventricular outflow gradient (LVOTG) during ESE in different conditions.

Methods

In a single-group, prospective, observational study, we performed peak and/or post-treadmill ESE with systematic assessment of LVOTG in the orthostatic position by continuous-wave Doppler in 1333 subjects (837 males, mean age 38,2±20 ranging from 6 to 87 years) recruited over a period of twenty years, from 2001 to 2021. Peak LVOTG ≥30 mm Hg was considered abnormal for LVOTO during ESE. We enrolled 7 different populations: asymptomatic healthy controls (n=35); HCM (n=81); genotype-positive, phenotype negative asymptomatic HCM (n=6); patients with chest pain symptoms, suspected myocardial ischemia and either normal coronary arteries (INOCA, n=131,or with very low pre-test probability of coronary artery disease (probable INOCA, n=416) and; fatigue and suspected heart failure with preserved ejection fraction (HFpEF, n=206); amateur athletes with ischemia-like ECG changes during exercise-test or symptoms such as near syncope or chest pain or dizziness (n=457); aborted sudden death and with negative screening (n=1).

Results

Technical success rate of LVOTG assessment was 1333/1333 at rest and at peak stress (feasibility 100%). Imaging and analysis time were &lt;1 minute. LVOTG at rest was present in 25 pts (2.8%) of the overall population: 23 HCM, 1 INOCA, and 1 HFpEF. Overall prevalence during ESE was 432/1333 (32%). During ESE, LVOTO (see Figure 1 and 2) was 0% (0/35) in normals, 58% (47/81) in HCM (23 with obstruction at rest), 33% (2/6) in genotype-positive, phenotype negative HCM, 37% (33/131) in INOCA, 40% (135/416) in athletes and 1/1 in the patient with aborted sudden death on strenuous exercise.

Conclusion

LVOTO in orthostatic position is detectable during treadmill ESE in several cardiovascular conditions associated with symptoms such as dyspnea, chest pain or near syncope, and even in asymptomatic patients with genotype-positive, phenotype-negative HCM. The identification of the obstructive phenotype is easy to capture during ESE without any significant additional imaging and analysis burden and can be important also outside HCM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Usefulness of Routine Fractional Flow Reserve for Clinical Management of Coronary Artery Disease in Patients With Diabetes

Importance

Approximately one-third of patients considered for coronary revascularization have diabetes, which is a major determinant of clinical outcomes, often influencing the choice of the revascularization strategy. The usefulness of fractional flow reserve (FFR) to guide treatment in this population is understudied and has been questioned.

Objective

To evaluate the usefulness and rate of major adverse cardiovascular events (MACE) of integrating FFR in management decisions for patients with diabetes who undergo coronary angiography.

Design, Setting, and Participants

This cross-sectional study used data from the PRIME-FFR study derived from the merger of the POST-IT study (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease [March 2012-November 2013]) and R3F study (French Study of FFR Integrated Multicenter Registries Implementation of FFR in Routine Practice [October 2008-June 2010]), 2 prospective multicenter registries that shared a common design. A population of all-comers for whom angiography disclosed ambiguous lesions was analyzed for rates, patterns, and outcomes associated with management reclassification, including revascularization deferral, in patients with vs without diabetes. Data analysis was performed from June to August 2018.

Main Outcomes and Measures

Death from any cause, myocardial infarction, or unplanned revascularization (MACE) at 1 year.

Results

Among 1983 patients (1503 [77%] male; mean [SD] age, 65 [10] years), 701 had diabetes, and FFR was performed for 1.4 lesions per patient (58.2% of lesions in the left anterior descending artery; mean [SD] stenosis, 56% [11%]; mean [SD] FFR, 0.81 [0.01]). Reclassification by FFR was high and similar in patients with and without diabetes (41.2% vs 37.5%, P = .13), but reclassification from medical treatment to revascularization was more frequent in the former (142 of 342 [41.5%] vs 230 of 730 [31.5%], P = .001). There was no statistical difference between the 1-year rates of MACE in reclassified (9.7%) and nonreclassified patients (12.0%) (P = .37). Among patients with diabetes, FFR-based deferral identified patients with a lower risk of MACE at 12 months (25 of 296 [8.4%]) compared with those undergoing revascularization (47 of 257 [13.1%]) (P = .04), and the rate was of the same magnitude of the observed rate among deferred patients without diabetes (7.9%, P = .87). Status of insulin treatment had no association with outcomes. Patients (6.6% of the population) in whom FFR was disregarded had the highest MACE rates regardless of diabetes status.

Conclusions and Relevance

Routine integration of FFR for the management of coronary artery disease in patients with diabetes may be associated with a high rate of treatment reclassification. Management strategies guided by FFR, including revascularization deferral, may be useful for patients with diabetes.

Left Ventricular Noncompaction: A Rare Cause of Effort Angina Unveiled During Left Heart Catheterization

Effort angina is an under-appreciated presentation of left ventricular non-compaction that frequently leads to a late diagnosis. Cardiac ventriculography can assist in this diagnosis.

P859 Can we connect intraventricular exercise induced gradients to sudden cardiac death?

Background

Some publications, on exercise induced intraventricular gradients, admit the possibility they can be related to some cases of unexplained sudden cardiac death (SCD).

Clinical case

We present the case of a young male athlete (16 years) that after winning a triathlon competition has sudden cardiac death.

No cardiovascular risk factors.

No family history of SCD

A previous episode of dizziness, accompanied by nausea and vomiting related to intense training happens 6 months before.

In September 2018 about 30 minutes after winning a triathlon competition has SCD episode having been resuscitated on site by the competition physician having been defibrillated and transported to intensive care unit.

After discharge, cardiac MRI, Coronary AngioTC, complete genetic study for heart diseases, flecainid test, transthoracic echocardiogram, stress echocardiogram with hyperventilation and ergometrine. All have normal results (Figure)

During 24 hours Holter ECG isolated premature ventricular complexes were detected and during exercise stress echocardiography a significant intraventricular gradient without systolic anterior movement of mitral valve was detected (Figure).

The athlete was disqualified for sports practice, refuses CDI implantation and started bisoprolol 2,5 mg daily.

To the best of our knowledge this is the first case of association between SCD and exercise induced intraventricular gradient. This possible association should be studied in the future.

Abstract P859 Figure. Intraventricular gradient in SCD athlete

P794 Treadmill exercise stress echocardiography in children; our experience

Background

Exercise stress echocardiography (ESE) is routinely used in adults but its role in children (C) is less established

Purpose

To assess the feasibility and clinical value of ESE in outpatient children

Methods

We enrolled 309 consecutive C (mean age = 14,1 ± 2,6 years, range 6-17 yrs) who underwent treadmill ESE between 2002 and 2019: One group (Group I) of 258 C including: 237 with exercise related symptoms (chest pain and/or dyspnea and/ or lypotimia-syncope), 15 with resting ECG alterations, 6 with positive ECG stress test and other group of C (Group II) including: 10 asymptomatic for screening requested by parents, 11 with symptoms unrelated to exercise, 12 with antecedents of sudden death in the family, and 17 with known pathology - 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, 1 each with Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, aortic switch operation. Regional wall motion abnormalities (RWMA) by 2-D and continuous wave Doppler (transvalvular or transaortic or intraventricular (IVG) gradients were assessed in all.

Results

The success rate was 309/309 (100%). Only one complication (allowing asthma diagnosis by serendipity) occurred: a severe asthmatic crisis in one girl studied because of chest pain with exercise (with ESE negativity), Stress-induced RWMA occurred in 2 pts (one with HCM, the other with normal coronary arteries). A significant orthostatic exercise induced IVG (&gt; 30 mmHg) was present in 101 of the 258 C (39%) studied due to symptoms, ECG alterations or positive stress ECG.

In group II the C with induced IVG attained

greater heart rate (HR) 184 ± 12 vs 174 ± 16 (p &lt; 0,001); greater blood pressure (BP) 150 ± 19 mmHg vs 136 ± 23 mmHg (p &lt; 0,001). The OR to the reproduced symptoms that motivated the exam during the SE comparing the 101 C with IVG with the 158 without IVG was 8,22 (4,83-13,99) p &lt; 0,001 (95% CI).

Conclusions

Treadmill ESE is feasible and safe in young people. RWMA are of limited usefulness in our outpatient C group. Doppler often documents significant exercise induced IVG, occult at rest that associate with symptoms.

Abstract P794 Figure. ESE Induced IVG in a C with chest pain

P945 Should children, with exercise induced intra-ventricular gradients, be treated with beta blockers?

Background

In our experience, treadmill exercise echocardiography (SE) is feasible and safe in children (C). Regional wall motion abnormalities (RWMA) are of limited usefulness, but Doppler often - (in 39% from 258 previously studied C) - documents significant intraventricular gradients (IVG), occult at rest, and allowing to document a possible explanation for exercise related symptoms, or abnormal resting or stress-ECG findings.

Purpose - To assess the effect of ß blockers on the occurrence of IVG, in C, with symptoms or abnormal resting or stress-ECG findings.

Methods – We repeated SE in 66 of the 101 C – (with normal echocardiogram at rest) - that developed IVG on exertion, under treatment with ß blockers. These 66 C who repeated the SE under treatment with ß blockers are the study group. 15 (23%) of them were female and the mean age of the group was 14,6 ± 1,7 years old (11 to 17).

They all underwent SE with 2D and Doppler echocardiographic evaluation of, and during treatment with ß blockers.

Results

Mean IVG in those 66 C submitted to SE was 105 ± 38 mmHg in the first SE evaluation. In SE evaluation performed under ß blockers, 37 of them didn’t develop IVG and in 29 of them IVG was significantly reduced to a mean IVG of 58 ± 32 mmHg (p&lt; 0,0001). The mean heart rate attained at peak exercise was 178 ± 15 bpm in the first SE evaluation and 157 ± 9 bpm in the evaluation performed under treatment with ß blockers (p &lt; 0, 0001). 47 of these C reproduced clinical symptoms (that were indication to SE) of beta-blockers, and only 7 reproduced the symptoms under treatment with beta blockers (p&lt; 0,0001).

Conclusions

In C with symptoms, abnormal rest or exercise ECG on medical evaluation and IVG on exertion, treatment with oral ß blockers prevented the occurrence of IVG or significantly reduced its magnitude. These changes were associated to significant clinical improvement in 85 % of the symptomatic population.

Abstract P945 Figure. SE without and with beta-blockers

P236 Pinball game over

Introduction

Transthoracic echocardiogram (TTE) is recommended for the diagnosis of acute pulmonary embolism (PTE) only in unstable patients, as it lacks specificity and sensitivity in stable ones. However, the rare documentation of intracavitary thrombus confirms the diagnosis and is associated with right ventricular dysfunction and high mortality, up to 42%.

We report a 69year-old female patient with history of hypertension and obesity, presenting at the emergency department with hypothermia (35º C), cyanosis, tiredness and breathless to minimal efforts. At examination she had no measurable blood pressure, low peripheral perfusion, tachycardia, tachypneia and no other abnormalities. Arterial blood gases on 10L/min facemask showed an uncompensated metabolic acidosis with pCO2 27mmHg, HCO3 12mmol/L, hyperlactacidemia and hypoxemia (pO2 57mmHg). Lab results had leucocytosis and neutrophilia, CRP 30mg/L, serum creatinine 2.53mg/dL, K+ 5.1mmol/L and high sensitivity troponin I 305pg/ml. Chest X-ray showed enlargement of the right chambers with a nodular image next to the right hila.

Although sepsis complicating acute pneumonia was firstly assumed and intravenous antibiotics and fluids were rapidly started; persistent hypoxemia with hypocapnia and tachycardia lead to the suspicion of acute PTE and workup proceeded in that direction. A TTE was primarily done because of the renal injury, showing a dilated right ventricle with flattening of the interventricular septum and a large, long, mobile mass in the right atria, protruding to the right ventricle, consistent with a thrombus. As the patient was no more hemodynamic unstable, prompt anticoagulation with low molecular weight heparin (LMWH) was initiated. Lately performed thoracic angio-CT with no contrast showed mild dilation of pulmonary artery and scintigraphy confirmed extensive perfusion defects of the left lung, preserving only posterobasal segment, with normal ventilation.

Additional study revealed a deep venous thrombosis of left popliteal and right gemelar veins and a heterozygosity for two polymorphisms of methyltethahdrofolate reductase enzyme

C677T and A1298C, clinically relevant in the context of patient’s hyperhomocysteinemia.

The patient recovered initially, with compression stockings and anticoagulation. A follow-up TTE showed no remaining intracavitary mass and no signs of right side overload. In the day after, the patient evolved with sudden refractory hypotension and signs of hypoperfusion with cardiorespiratory collapse and death.

Conclusion

The incidence of intracardiac thrombus in the right chambers in a patient with PTE is low (3-23%) and probably underestimated by the absence of early echocardiography in all patients. This case highlights the lability of the clinical evolution of these patients, even tough disappearance of the right atrium thrombus, which is in line with their high early mortality.

Abstract P236 Figure. Imaging study

Patient-specific 3D printing simulation to guide complex coronary intervention

The field of three-dimensional printing applied to patient-specific simulation is evolving as a tool to enhance intervention results. We report the first case of a fully simulated percutaneous coronary intervention in a three-dimensional patient-specific model to guide treatment. An 85-year-old female presented with symptomatic in-stent restenosis in the ostial circumflex and was scheduled for percutaneous coronary intervention. Considering the complexity of the anatomy, patient setting and intervention technique, we elected to replicate the coronary anatomy using a three-dimensional model. In this way, we simulated the intervention procedure beforehand in the catheterization laboratory using standard materials. The procedure was guided by optical coherence tomography, with pre-dilatation of the lesion, implantation of a single drug-eluting stent in the ostial circumflex and kissing balloon inflation to the left anterior descending artery and circumflex. Procedural steps were replicated in the real patient's treatment, with remarkable parallelism in angiographic outcome and luminal gain at intracoronary imaging. In this proof-of-concept report, we show that patient-specific simulation is feasible to guide the treatment strategy of complex coronary artery disease. It enables the surgical team to plan and practice the procedure beforehand, and possibly predict complications and gain confidence.

Impact of Routine Fractional Flow Reserve on Management Decision and 1-Year Clinical Outcome of Patients With Acute Coronary Syndromes: PRIME-FFR (Insights From the POST-IT [Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease] and R3F [French FFR Registry] Integrated Multicenter Registries - Implementation of FFR [Fractional Flow Reserve] in Routine Practice)

BACKGROUND

Fractional flow reserve (FFR) is not firmly established as a guide to treatment in patients with acute coronary syndromes (ACS). Primary goals were to evaluate the impact of integrating FFR on management decisions and on clinical outcome of patients with ACS undergoing coronary angiography, as compared with patients with stable coronary artery disease.

METHODS AND RESULTS

R3F (French FFR Registry) and POST-IT (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease), sharing a common design, were pooled as PRIME-FFR (Insights From the POST-IT and R3F Integrated Multicenter Registries - Implementation of FFR in Routine Practice). Investigators prospectively defined management strategy based on angiography before performing FFR. Final decision after FFR and 1-year clinical outcome were recorded. From 1983 patients, in whom FFR was prospectively used to guide treatment, 533 sustained ACS (excluding acute ST-segment-elevation myocardial infarction). In ACS, FFR was performed in 1.4 lesions per patient, mostly in left anterior descending (58%), with a mean percent stenosis of 58±12% and a mean FFR of 0.82±0.09. In patients with ACS, reclassification by FFR was high and similar to those with non-ACS (38% versus 39%; P=NS). The pattern of reclassification was different, however, with less patients with ACS reclassified from revascularization to medical treatment compared with those with non-ACS (P=0.01). In ACS, 1-year outcome of patients reclassified based on FFR (FFR against angiography) was as good as that of nonreclassified patients (FFR concordant with angiography), with no difference in major cardiovascular event (8.0% versus 11.6%; P=0.20) or symptoms (92.3% versus 94.8% angina free; P=0.25). Moreover, FFR-based deferral to medical treatment was as safe in patients with ACS as in patients with non-ACS (major cardiovascular event, 8.0% versus 8.5%; P=0.83; revascularization, 3.8% versus 5.9%; P=0.24; and freedom from angina, 93.6% versus 90.2%; P=0.35). These findings were confirmed in ACS explored at the culprit lesion. In patients (6%) in whom the information derived from FFR was disregarded, a dire outcome was observed.

CONCLUSIONS

Routine integration of FFR into the decision-making process of ACS patients with obstructive coronary artery disease is associated with a high reclassification rate of treatment (38%). A management strategy guided by FFR, divergent from that suggested by angiography, including revascularization deferral, is safe in ACS.

Impact of Routine Fractional Flow Reserve Evaluation During Coronary Angiography on Management Strategy and Clinical Outcome

Background—

Penetration of fractional flow reserve (FFR) in clinical practice varies extensively, and the applicability of results from randomized trials is understudied. We describe the extent to which the information gained from routine FFR affects patient management strategy and clinical outcome.

Methods and Results—

Nonselected patients undergoing coronary angiography, in which at least 1 lesion was interrogated by FFR, were prospectively enrolled in a multicenter registry. FFR-driven change in management strategy (medical therapy, revascularization, or additional stress imaging) was assessed per-lesion and per-patient, and the agreement between final and initial strategies was recorded. Cardiovascular death, myocardial infarction, or unplanned revascularization (MACE) at 1 year was recorded. A total of 1293 lesions were evaluated in 918 patients (mean FFR, 0.81±0.1). Management plan changed in 406 patients (44.2%) and 584 lesions (45.2%). One-year MACE was 6.9%; patients in whom all lesions were deferred had a lower MACE rate (5.3%) than those with at least 1 lesion revascularized (7.3%) or left untreated despite FFR≤0.80 (13.6%; log-rank P =0.014). At the lesion level, deferral of those with an FFR≤0.80 was associated with a 3.1-fold increase in the hazard of cardiovascular death/myocardial infarction/target lesion revascularization ( P =0.012). Independent predictors of target lesion revascularization in the deferred lesions were proximal location of the lesion, B2/C type and FFR.

Conclusions—

Routine FFR assessment of coronary lesions safely changes management strategy in almost half of the cases. Also, it accurately identifies patients and lesions with a low likelihood of events, in which revascularization can be safely deferred, as opposed to those at high risk when ischemic lesions are left untreated, thus confirming results from randomized trials.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01835808.

Fractional flow reserve of non-culprit vessel post-myocardial infarction: is it reliable?

Background

Multi-vessel disease is frequent in patients presenting with myocardial infarction and have an important prognostic impact. The decision to proceed to revascularization in non-culprit vessels can be postponed until ischemia is proven in non-invasive stress tests. On the other hand, there is an increasing evidence to support the role of fractional flow reserve (FFR) in acute coronary syndrome setting.

Case presentation

We report a case in which a FFR-guided strategy for non-culprit vessels, 3 weeks after an ST-segment elevation myocardial infarction, was followed by a short-term sub-occlusion of the evaluated vessel.

Conclusion

The timing of the coronary microcirculation recovery post-myocardial infarction, avoiding a possible false negative FFR, and the diagnostic gaps between ischemia and plaque vulnerability are under discussion. An FFR-guided strategy in this setting should be interpreted with caution.

Mortality among a Cohort of Banana Plantation Workers in Costa Rica

The nematocide 1,2-dibromo-3-chloropropane (DBCP), widely used in Costa Rica during the late 1960s and 1970s, causes sterility in men and is a possible carcinogen. Mortality among a cohort of Costa Rican banana plantation workers was investigated. The cohort included 40,959 individuals who worked on banana plantations between 1972 and 1979. Employment records were linked with the Costa Rican Mortality Registry to determine outcomes through 1999. Standardized mortality ratios (SMRs) were calculated for all causes of death. Poisson regression was also used to calculate mortality risk estimates by duration of employment, but provided no additional insight. All-causes SMRs were 0.77 for men (95% CI 0.75-0.80) and 0.90 for women (95% CI 0.80-1.02) relative to national mortality rates. Mortality from septicemia was significantly higher than expected. Nonsignificant increases in mortality were also observed for testicular cancer, penile cancer, Hodgkin's disease, and Parkinson's disease in men, and for cervical cancer and lung cancer in women.

Five cases of transient left ventricular apical ballooning--the experience of a Portuguese center

Transient left ventricular apical dyskinesia (apical ballooning syndrome, ABS) is characterized by transient alterations in regional wall motion, involving the mid and apical segments of the left ventricle, as well as electrocardiographic alterations, mimicking ST-elevation acute myocardial infarction, in the absence of obstructive disease of the epicardial coronary arteries. In this article, we present a series of five cases of ABS and a theoretical review of the syndrome.

Parental occupational exposure to pesticides and the risk of childhood leukemia in Costa Rica

OBJECTIVES

Parental exposure to pesticides and the risk of leukemia in offspring were examined in a population-based case-control study in Costa Rica.

METHODS

All cases of childhood leukemia (N=334), in 1995-2000, were identified at the Cancer Registry and the Children's Hospital. Population controls (N=579) were drawn from the National Birth Registry. Interviews of parents were conducted using conventional and icon-based calendar forms. An exposure model was constructed for 25 pesticides in five time periods.

RESULTS

Mothers' exposures to any pesticides during the year before conception and during the first and second trimesters were associated with the risk [odds ratio (OR) 2.4, 95% confidence interval (95% CI) 1.0-5.9; OR 22, 95% CI 2.8-171.5; OR 4.5, 95% CI 1.4-14.7, respectively] and during anytime (OR 2.2, 95% CI 1.0-4.8). An association was found for fathers' exposures to any pesticides during the second trimester (OR 1.5, 95% CI 1.0-2.3). An increased risk with respect to organophosphates was found for mothers during the first trimester (OR 3.5, 95% CI 1.0-12.2) and for fathers during the year before conception and the first trimester (OR 1.5, 95% CI 1.0-2.2 and OR 1.6, 95% CI 1.0-2.6, respectively), and benzimidazoles during the first, second, and third trimesters of pregnancy (OR 2.2, 95% CI 1.0-4.4; OR 2.2, 95% CI 1.0-5.0; OR 2.2, 95% CI 1.0-5.2, respectively). There was a suggestion of an exposure-response gradient for fathers as regards picloram, benomyl, and paraquat. Age at diagnosis was positively associated with fathers' exposures and inversely associated with mothers' exposures.

CONCLUSIONS

The results suggest that parental exposure to certain pesticides may increase the risk of leukemia in offspring.

Transient left ventricular apical ballooning

We describe the case of an elderly woman patient referred for primary angioplasty for acute anterior myocardial infarction, which developed after intense emotional stress. The coronary angiogram was surprisingly normal, but left ventriculography showed severe apical dilatation and dyskinesia, confirmed by echocardiography. By this time we suspected a syndrome of transient apical ballooning without coronary stenosis, which mimics acute myocardial infarction. She underwent medical therapy and subsequent clinical evolution was favorable, with complete recovery of left ventricular systolic function. We discuss the clinical setting and the pathophysiologic mechanisms of this syndrome.

Left pulmonary artery evaluation through transesophageal echocardiography

INTRODUCTION

Transesophageal echocardiography (TEE) has become increasingly useful in the study of patients with suspected pulmonary thromboembolism.

OBJECTIVE

The aim of this study was to prospectively evaluate the usefulness of TEE in the study of the distal part of the left pulmonary artery (LPA) as well as the influence of this procedure on total echocardiographic exam duration.

METHODOLOGY

A prospective study in two groups of consecutive patients referred for TEE with a one- year interval between evaluation of Group A: 33 patients, 17 male, mean age 54 +/- 24 years, and Group B: 42 patients, 20 male, mean age 48 +/- 27 years (p = NS). The procedure was considered long when it took more than 3 min to evaluate the distal part of the LPA.

RESULTS

In group A we were able to visualize the distal part of the LPA in 24 patients (73%) without significant prolongation of total exam duration in 16 patients (48% of group A). In one of the patients with suspected pulmonary thromboembolism thrombi were only observed in the distal part of the LPA. In group B we were able to visualize the distal part of the LPA in 36 patients (86%) without significant prolongation of total exam duration in 26 patients (61% of group B).

CONCLUSIONS

1. Visualization of the distal part of the LPA was possible in more patients, and with TEE time prolongation in less patients, in group B. These differences can be accounted for by the training of the operator in this technique. 2. The importance of visualization of this part of the LPA in guiding treatment in the subset of patients with pulmonary thromboembolism confirms the usefulness of this specific procedure.

Coronary-subclavian steal syndrome. A case report

Coronary-subclavian steal is an unusual clinical syndrome after successful internal mammary-coronary artery bypass grafting. Proximal subclavian artery (SA) stenosis is present and atherosclerotic disease is the underlying pathophysiologic mechanism in the majority of cases. The authors report a case of a sixty-two-year old man with angina and ventricular fibrillation soon after myocardial revascularization with left internal mammary artery (LIMA) to left anterior descending coronary (LAD). Dobutamine stress echocardiography showed ischemia in the anterior myocardial territory with patent LIMA-LAD bypass in the angiographic evaluation. This procedure showed occlusion of the proximal SA with reversal of flow in the LIMA. The best therapeutic approach was discussed and a carotid-subclavian bypass was performed with restoration of antegrade blood flow and reversal of the clinical setting.

Myocardial infarction in a patient with congenital coronary anomaly

The authors describe the clinical case of a 38-year-old patient, with a history of smoking and hypercholesterolemia, who was admitted for non-Q wave acute myocardial infarction, and in whom coronary angiography revealed severe coronary disease and a congenital coronary anomaly. Unlike many congenital coronary anomalies that are manifested in ischemic disease, the nature of this patient's anomaly may have contributed to its benign clinical evolution, and influenced the therapeutic approach.

Thrombosis and endocarditis in prosthetic heart valves, a case report

The authors report the case of a 49-year-old female with a history of rheumatic valvular heart disease who underwent valve surgery in 1997, with implantation of St. Jude prosthetic valves in aortic and mitral position. She was asymptomatic until the end of July 2001, when she was admitted to Garcia de Orta Hospital emergency unit because of heart failure, fever and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. Blood cultures were negative. She started empiric antibiotic therapy and the clinical course stabilized in the first week. After ten days of medical therapy her symptoms became worse and TTE and TEE were repeated. TTE showed significant left ventricular-aortic gradient, suggesting aortic valve obstruction. Decreased left ventricular function was now present with hypokinesia in the anterior descending coronary artery territory. In the TEE, a large thrombotic process on the mitral prosthesis valve was seen, with a prosthesis disk blocked. There were similar findings in the aortic valve. Cardiac fluoroscopic images were obtained at the mitral and aortic position confirming the TEE report. The coronary angiogram was normal. Promptly transferred to a cardiac surgery center, the patient underwent aortic and mitral prosthetic valve replacement. The intraoperative findings were compatible with those from echocardiography and cardiac fluoroscopy.

Profile of HIV disease in an American border city

A previous study on patterns of migration of HIV-infected persons suggested that most patients in a rural setting in eastern Tennessee acquired their disease in an urban area, typically during a period of prolonged residence. Disease and disability were the most common reasons for returning to their hometown. We studied our urban, border-city HIV clinic population to see whether similar patterns of migration were discernible. Fifty-one of the 103 patients studied lived outside the El Paso/Juarez area when they contracted HIV infection. The major reason cited for returning home was a desire to return to family (25%). Those who returned and those who had never left showed no statistically significant difference in age, race, or risk factors. This study suggests that migration of HIV-infected patients back to their hometown does not appear to be an exclusively rural phenomenon.