Predicting the need of aortic valve surgery in patients with chronic aortic regurgitation: a comparison between cardiovascular magnetic resonance imaging and transthoracic echocardiography

To compare the ability of cardiac magnetic resonance tomography (CMR) and transthoracic echocardiography (TTE) to predict the need for valve surgery in patients with chronic aortic regurgitation on a mid-term basis. 66 individuals underwent assessment of aortic regurgitation (AR) both in CMR and TTE between August 2012 and April 2017. The follow-up rate was 76% with a median of 5.1 years. Cox proportional hazards method was used to assess the association of the time-to-aortic-valve-surgery, including valve replacement and reconstruction, and imaging parameters. A direct comparison of most predictive CMR and echocardiographic parameters was performed by using nested-factor-models. Sixteen patients (32%) were treated with aortic valve surgery during follow-up. Aortic valve insufficiency parameters, both of echocardiography and CMR, showed good discriminative and predictive power regarding the need of valve surgery. Within all examined parameters AR gradation derived by CMR correlated best with outcome [χ² = 27.1; HR 12.2 (95% CI: 4.56, 36.8); (p < 0.0001)]. In direct comparison of both modalities, CMR assessment provided additive prognostic power beyond echocardiographic assessment of AR but not vice versa (improvement of χ² from 21.4 to 28.4; p = 0.008). Nested model analysis demonstrated an overall better correlation with outcome by using both modalities compared with using echo alone with the best improvement in the moderate to severe AR range with an echo grade II out of III and a regurgitation fraction of 32% in CMR. This study corroborates the capability of CMR in direct quantification of AR and its role for guiding further treatment decisions particularly in patients with moderate AR in echocardiography.

Coronary plaque volume and predictors for fast plaque progression assessed by serial coronary CT angiography-A single-center observational study

PURPOSE

The rationale of this study was to identify patients with fast progression of coronary plaque volume PV and characterize changes in PV and plaque components over time.

METHOD

Total PV (TPV) was measured in 350 patients undergoing serial coronary computed tomography angiography (median scan interval 3.6 years) using semi-automated software. Plaque morphology was assessed based on attenuation values and stratified into calcified, fibrous, fibrous-fatty and low-attenuation PV for volumetric measurements. Every plaque was additionally classified as either calcified, partially calcified or non-calcified.

RESULTS

In total, 812 and 955 plaques were detected in the first and second scan. Mean TPV increase was 20 % on a per-patient base (51.3 mm³ [interquartile range (IQR): 14.4, 126.7] vs. 61.6 mm³ [IQR: 16.7, 170.0]). TPV increase was driven by calcified PV (first scan: 7.6 mm³ [IQR: 0.2, 33.6] vs. second scan: 16.6 mm³ [IQR: 1.8, 62.1], p < 0.01). Forty-two patients showed fast progression of TPV, defined as >1.3 mm³ increase of TPV per month. Male sex (odds ratio 3.1, p = 0.02) and typical angina (odds ratio 3.95, p = 0.03) were identified as risk factors for fast TPV progression, while high-density lipoprotein cholesterol had a protective effect (odds ratio per 10 mg/dl increase of HDL cholesterol: 0.72, p < 0.01). Progression to >50 % stenosis at follow-up was observed in 34 of 327 (10.4 %) calcified plaques, in 13 of 401 (3.2 %) partially calcified plaques and 2 of 221 (0.9 %) non-calcified plaques (p < 0.01).

CONCLUSION

Fast plaque progression was observed in male patients and patients with typical angina. High HDL cholesterol showed a protective effect.

P1824Aortic wall shear stress in bicuspid aortic valve disease - 10-year follow-up

Introduction

Bicuspid aortic valve (BAV) disease leads to deviant complex helical flow patterns in the aorta - especially in the mid-ascending (AoA) part. In association with congenital BAV, aortic wall alterations such as aortic dilatation and dissection may occur. Among others, wall shear stress (WSS) could be one parameter to contribute to the prediction of the long-term outcome of patients with BAV. 4D-flow in cardiovascular magnetic resonance has been established as a valid method to estimate WSS.

Purpose

The aim of this study is to reevaluate WSS and comparing it to values generated in the same patient cohort with bicuspid aortic valve disease in 2008. No one of the above had aortic dilation in 2008 but proven helical flow pattern. The long term follow-up study might show changes in WSS over the period of ten years.

Methods

Ten complete 4D flow datasets of patients (age at follow-up: median 34.5 years; range 19–41 years) with bicuspid aortic valve disease without enlargement of the aorta were obtained in 2008 and reevaluated in 2018/2019 in the same patient collective. Mean WSS values were calculated with identical specific software tools. All data were analyzed by two experienced investigators.

Results

Aortic diameters at the level of the mid AoA did not change significantly in the 10-year period. The WSS values were lower in 2018 at all levels of the ascending aorta (Table 1). Indexed aortic diameters at the level of the mid ascending aorta did not change, median difference 0.06 cm/m2 (range −0.1 cm/m2 to 0.2 cm/m2; p=0.28), absolute values of indexed AoA diameters in 2018/2019 ranged from 1.27 cm/m2 to 2.2 cm/m2 (median 1.76 cm/m2).

Table 1 WSS magnitudinal [N/m2] 2008 (n=10) 2018 (n=10) Median difference p-value median range median range Level aortic bulb 0.95 0.80–1.46 0.42 0.34–0.82 −0.53 <0.01 Level mid ascending aorta 0.72 0.40–0.98 0.39 0.34–0.59 −0.33 <0.01 Level brachiocephalic trunc (BCT) 0.71 0.38–1.03 0.40 0.37–0.61 −0.31 <0.01

Conclusions

Indexed AoA diameters in BAV disease did not change significantly over a 10-year period. WSS of AoA was less compared to values generated in 2008. This might be explained by a slight alteration in hemodynamic flow patterns by the aging aorta, but not by changes of the aortic diameters. Possibly a drop of WSS in BAV could serve as a marker for a benign long term course.

Assessment of infarcted myocardium with real time myocardial contrast echocardiography: comparison with technetium-99m sestamibi single photon emission computed tomography

BACKGROUND

Little is known about the relation between the extent of microvascular damage and infarct size in patients after successful mechanical reperfusion of acute myocardial infarction.

OBJECTIVE

To compare the spatial extent of reduced myocardial signal between real time myocardial contrast echocardiography (MCE) and single photon emission computed tomography (SPECT) after successful mechanical reperfusion of acute myocardial infarction and to test the hypothesis that MCE can be used for clinical infarct size assessment.

METHODS

10 days after successful mechanical reperfusion of acute myocardial infarction, 117 patients underwent MCE (power pulse inversion technique, slow contrast bolus injection) and SPECT (technetium-99m sestamibi). Location and number of segments with normal myocardial signal intensity and with mild and severe reduction were registered and the concordance between the techniques was calculated.

RESULTS

Segmental concordance between MCE and SPECT was 83% (kappa = 0.64). On average, the difference in the number of segments with reduced myocardial signal intensity between MCE and SPECT did not exceed one segment (p < 0.001). Sensitivity and specificity of MCE for the detection of an abnormal segment on SPECT were 87% and 91%, respectively. Intraobserver and interobserver agreement were 94% (kappa = 0.84) and 92% (kappa = 0.83), respectively.

CONCLUSIONS

Real time MCE is a promising technique for infarct size assessment after successful mechanical reperfusion of acute myocardial infarction.

[Paracardiac infiltrate or Turkish sword?]

Four cases of the scimitar syndrome with typical radiologic findings are described. The cases demonstrate that when a curved density along the right paracardial border that descends toward the diaphragm is visible on the posteroanterior chest radiograph, the possibility of an anomalous connection of the pulmonary vein with the inferior vena cava should be considered. The anomaly can remain asymptomatic until adult life.

Coronary stenting plus platelet glycoprotein IIb/IIIa blockade compared with tissue plasminogen activator in acute myocardial infarction. Stent versus Thrombolysis for Occluded Coronary Arteries in Patients with Acute Myocardial Infarction Study Investigators

BACKGROUND

Prevention of myocardial damage is the main goal of all reperfusion therapies in patients with acute myocardial infarction. The relative efficacy of various reperfusion strategies is under intensive investigation. We assessed whether coronary stenting combined with the blockade of platelet glycoprotein IIb/IIIa receptors produces a greater degree of myocardial salvage than fibrinolysis with an accelerated infusion of alteplase, a tissue plasminogen activator, in patients with acute myocardial infarction.

METHODS

A total of 140 patients were enrolled in the randomized trial; 71 were assigned to receive a stent plus abciximab, and 69 to receive intravenous alteplase. The primary end point was the degree of myocardial salvage, determined by means of serial scintigraphic studies with technetium Tc 99m sestamibi. The secondary end point was a composite of death, reinfarction, and stroke within six months after randomization.

RESULTS

In the group that received a stent plus abciximab, the median size of the final infarct was 14.3 percent of the left ventricle (25th and 75th percentiles, 6.8 and 24.5 percent), as compared with a median of 19.4 percent (25th and 75th percentiles, 7.9 and 34.2 percent) in the alteplase group (P=0.02). This difference was due to the larger salvage index (the percentage of the left ventricle that was salvaged, divided by the percentage that was compromised by the initial perfusion defect) in the stent group: 0.57 (25th and 75th percentiles, 0.35 and 0.69), as compared with 0.26 (25th and 75th percentiles, 0.09 and 0.61; P<0.001). The cumulative incidence of death, reinfarction, or stroke at six months was lower in the stent group than in the alteplase group (8.5 vs. 23.2 percent. P=0.02; relative risk, 0.34; 95 percent confidence interval, 0.13 to 0.88).

CONCLUSIONS

In patients with acute myocardial infarction, coronary stenting plus abciximab leads to a greater degree of myocardial salvage and a better clinical outcome than does fibrinolysis with a tissue plasminogen activator.

Preoperative positron emission tomographic viability assessment and perioperative and postoperative risk in patients with advanced ischemic heart disease

OBJECTIVES

This study sought to investigate whether determination of tissue viability by means of positron emission tomography (PET) before coronary artery bypass graft surgery (CABG) affects clinical outcome with respect to both in-hospital mortality and 1-year survival rate.

BACKGROUND

Patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction are at higher risk for perioperative complications associated with CABG. Therefore, the selection of patients who will benefit from CABG is an important clinical issue.

METHODS

This study retrospectively evaluated 76 patients with advanced CAD and LV dysfunction (LV ejection fraction < or = 0.35) who were considered candidates for CABG. Thirty-five patients were selected for CABG on the basis of clinical presentation and angiographic data (group A), and 34 of 41 patients were selected according to extent of viable tissue determined by PET (group B) in addition to clinical presentation and angiographic data.

RESULTS

There were four in-hospital deaths (11.4%) in group A and none in group B (p = 0.04). After 12 months, the survival rate was 79% in group A and 97% in group B (p = 0.01). Postoperatively, group B patients had a less complicated recovery (p = 0.05). They required lower doses of catecholamines (p = 0.002) and demonstrated a significantly decreased incidence of low output syndrome (p = 0.05).

CONCLUSIONS

This retrospective data analysis suggests that selection of patients with impaired LV function on the basis of extent of viability supplementary to clinical and angiographic data may lead to postoperative recovery with a low early mortality and promising short-term survival. Therefore, viability studies permit selection of patients who are at low risk for serious perioperative complications.

Local epinephrine injection improves the therapeutic effect of Nd-YAG laser treatment of arterial peptic ulcer bleeding

Nd-YAG laser therapy has been shown to be effective in the treatment of gastrointestinal ulcer bleeding. However, a breakdown by bleeding severity shows that its benefit is doubtful in bleeds classified as Forrest Ia and IIa. In a prospective study, we therefore tested a new therapeutic approach combining epinephrine injection into the bleeding site, with subsequent laser coagulation. Thirty-two patients with Forrest Ia and IIa bleeding from gastric or small intestinal ulcers were compared with 51 own historical controls treated by laser coagulation alone. In the combined therapy group, a significantly higher rate of permanent hemostasis was achieved, and mortality and frequency of emergency surgery were significantly reduced. Furthermore bleeding recurred more rarely and only during the later course of the disease. Finally, following epinephrine injection fewer Forrest IIa ulcer bleeds were reactivated by laser treatment, and all of these bleeds were stopped by further laser coagulation. Overall, our results demonstrate a clear-cut therapeutic improvement when laser coagulation is preceded by local epinephrine injection.