The aim of this study was to compare TIMI flow after administering intracoronary (IC) medications through various routes for the treatment of slow flow/no-reflow during primary PCI.
Two independent ...parallel cohorts of the patients who underwent primary PCI for STEMI and developed slow/no-reflow were recruited. Selection of cohort was based on the route of administration of IC medications as proximal or distal. Post administration TIMI follow was compared between the two cohorts.
A total of 100 patients were included in both, proximal and distal, cohort. Distribution of angiographic, clinical and demographic characteristics was not significant between the two cohorts except prevalence of hypertension, and diabetes mellitus. Frequency of hypertension, and diabetes mellitus were 45 % vs.70 %; p < 0.001 and 28 % vs. 44 %; p = 0.018 among patients in distal and proximal cohort respectively. Final TIMI III flow was achieved in significantly higher number of patients in distal cohort with the frequency of 88 % vs. 76 %; p = 0.027 as compared to proximal cohort.
Administration of IC medication via distal route is observed to be more effective for the treatment of slow flow/no-reflow during primary PCI. Distal route via export catheter or perforated balloon technique should be preferred wherever feasible.
•Administering medications distally at the lesion site produces more beneficial effects irrespective of the drugs used.•Encountering with no-reflow/slow flow in patients undergoing primary percutaneous coronary intervention appropriate management is crucial.•To achieve successful intervention, data suggest distal coronary administration of pharmacological agents using a catheters at the distal site.•Administration of IC medication via distal route is observed to be more effective for the treatment of slow flow/no-reflow during primary PCI.•Distal route via export catheter or perforated balloon technique should be preferred wherever feasible.
Degenerative aortic stenosis (AS) is the most common valvular disease in the western world with a prevalence expected to double within the next 50 years. International guidelines advocate the use of ...cardiovascular magnetic resonance (CMR) as an investigative tool, both to guide diagnosis and to direct optimal treatment. CMR is the reference standard for quantifying both left and right ventricular volumes and mass, which is essential to assess the impact of AS upon global cardiac function. Given the ability to image any structure in any plane, CMR offers many other diagnostic strengths including full visualisation of valvular morphology, direct planimetry of orifice area, the quantification of stenotic jets and in particular, accurate quantification of valvular regurgitation. In addition, CMR permits reliable and accurate measurements of the aortic root and arch which can be fundamental to appropriate patient management. There is a growing evidence base to indicate tissue characterisation using CMR provides prognostic information, both in asymptomatic AS patients and those undergoing intervention. Furthermore, a number of current clinical trials will likely raise the importance of CMR in routine patient management. This article will focus on the incremental value of CMR in the assessment of severe AS and the insights it offers following valve replacement.
Abstract
Aims
The main aim of this study was to characterize changes in the left ventricular (LV) blood flow kinetic energy (KE) using four-dimensional (4D) flow cardiovascular magnetic resonance ...imaging (CMR) in patients with myocardial infarction (MI) with/without LV thrombus (LVT).
Methods and results
This is a prospective cohort study of 108 subjects controls = 40, MI patients without LVT (LVT− = 36), and MI patients with LVT (LVT+ = 32). All underwent CMR including whole-heart 4D flow. LV blood flow KE wall calculated using the formula: KE=12 ρblood . Vvoxel . v2, where ρ = density, V = volume, v = velocity, and was indexed to LV end-diastolic volume. Patient with MI had significantly lower LV KE components than controls (P < 0.05). LVT+ and LVT− patients had comparable infarct size and apical regional wall motion score (P > 0.05). The relative drop in A-wave KE from mid-ventricle to apex and the proportion of in-plane KE were higher in patients with LVT+ compared with LVT− (87 ± 9% vs. 78 ± 14%, P = 0.02; 40 ± 5% vs. 36 ± 7%, P = 0.04, respectively). The time difference of peak E-wave KE demonstrated a significant rise between the two groups (LVT−: 38 ± 38 ms vs. LVT+: 62 ± 56 ms, P = 0.04). In logistic-regression, the relative drop in A-wave KE (beta = 11.5, P = 0.002) demonstrated the strongest association with LVT.
Conclusion
Patients with MI have reduced global LV flow KE. Additionally, MI patients with LVT have significantly reduced and delayed wash-in of the LV. The relative drop of distal intra-ventricular A-wave KE, which represents the distal late-diastolic wash-in of the LV, is most strongly associated with the presence of LVT.
Purpose of Review
Cardiogenic shock from decompensated heart failure is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) improves haemodynamics and reverses ...organ dysfunction in critically ill patients with cardiogenic shock. This paper summarises the main modalities of mechanical support and their physiological impact, practical considerations, advantages and disadvantages to facilitate a holistic approach in managing a potentially lethal pathology.
Recent Findings
To date, there remains a lack of large randomised controlled trials to support the use of any mechanical support strategy. Consequently, meta-analyses, registry data and expert consensus in the form of society guidelines are relied upon. Currently, randomised trials are in progress to assess the efficacy of a percutaneous assist device (Impella) and extracorporeal membrane oxygenation.
Summary
Mechanical support options are centred around the use of counter pulsation and percutaneous assist devices and the use of an extracorporeal pump and are hence varied in means of application, degree of haemodynamic benefit and potential complications. Regardless of future innovations, a timely multidisciplinary approach that incorporates both patient and institutional considerations will always be crucial to a successful outcome.
Symptomatic severe aortic stenosis (AS) is a class I indication for replacement in patients when left ventricular ejection fraction (LVEF) is preserved. However, symptom reporting is often equivocal ...and decision making can be challenging. We aimed to quantify myocardial deformation using cardiovascular magnetic resonance (CMR) in patients classified by symptom severity.
Forty-two patients with severe AS referred to heart valve clinic were studied using tagged CMR imaging. All had preserved LVEF. Patients were grouped by symptoms as either "none/mild" (n=21, NYHA class I, II) or "significant" (n=21, NYHA class III, IV, angina, syncope) but were comparable for age (72.8±5.4
. 71.0±6.8 years old, P=0.345), surgical risk (EuroSCORE II: 1.90±1.7
. 1.31±0.4, P=0.302) and haemodynamics (peak aortic gradient: 55.1±20.8
. 50.4±15.6, P=0.450). Thirteen controls matched in age and LVEF were also studied. LV circumferential strain was calculated using inTag
software and longitudinal strain using feature tracking analysis.
Compared to healthy controls, patients with severe AS had significantly worse longitudinal and circumferential strain, regardless of symptom status. Patients with "significant" symptoms had significantly worse peak longitudinal systolic strain rates (-83.352±24.802%/s
. -106.301±43.276%/s, P=0.048) than those with "no/mild" symptoms, with comparable peak longitudinal strain (PLS), peak circumferential strain and systolic and diastolic strain rates.
Patients with severe AS who have no or only mild symptoms exhibit comparable reduction in circumferential and longitudinal fibre function to those with significant symptoms, in whom AVR is clearly indicated. Given these findings of equivalent subclinical dysfunction, reportedly borderline symptoms should be handled cautiously to avoid potentially adverse delays in intervention.
BackgroundMicrovascular obstruction (MVO) and intramyocardial haemorrhage (IMH) are associated with adverse prognosis, independently of infarct size after reperfused ST-elevation myocardial ...infarction (STEMI). Mitral annular plane systolic excursion (MAPSE) is a well-established parameter of longitudinal function on echocardiography.ObjectiveWe aimed to investigate how acute MAPSE, assessed by a four-chamber cine-cardiovascular MR (CMR), is associated with MVO, IMH and convalescent left ventricular (LV) remodelling.Methods54 consecutive patients underwent CMR at 3T (Intera CV, Philips Healthcare, Best, The Netherlands) within 3 days of reperfused STEMI. Cine, T2-weighted, T2* and late gadolinium enhancement (LGE) imaging were performed. Infarct and MVO extent were measured from LGE images. The presence of IMH was investigated by combined analysis of T2w and T2* images. Averaged-MAPSE (medial-MAPSE+lateral-MAPSE/2) was calculated from 4-chamber cine imaging.Results44 patients completed the baseline scan and 38 patients completed 3-month scans. 26 (59%) patients had MVO and 25 (57%) patients had IMH. Presence of MVO and IMH were associated with lower averaged-MAPSE (11.7±0.4 mm vs 9.3±0.3 mm; p<0.001 and 11.8±0.4 mm vs 9.2±0.3 mm; p<0.001, respectively). IMH (β=−0.655, p<0.001) and MVO (β=−0.567, p<0.001) demonstrated a stronger correlation to MAPSE than other demographic and infarct characteristics. MAPSE ≤10.6 mm demonstrated 89% sensitivity and 72% specificity for the detection of MVO and 92% sensitivity and 74% specificity for IMH. LV remodelling in convalescence was not associated with MAPSE (AUC 0.62, 95% CI 0.44 to 0.77, p=0.22).ConclusionsPostreperfused STEMI, LV longitudinal function assessed by MAPSE can independently predict the presence of MVO and IMH.
Intramyocardial hemorrhage (IMH) identified by cardiovascular magnetic resonance (CMR) is an established prognostic marker following acute myocardial infarction (AMI). Detection of IMH by T2-weighted ...or T2 star CMR can be limited by long breath hold times and sensitivity to artefacts, especially at 3T. We compared the image quality and diagnostic ability of susceptibility-weighted magnetic resonance imaging (SW MRI) with T2-weighted and T2 star CMR to detect IMH at 3T.
Forty-nine patients (42 males; mean age 58 years, range 35-76) underwent 3T cardiovascular magnetic resonance (CMR) 2 days following re-perfused AMI. T2-weighted, T2 star and SW MRI images were obtained. Signal and contrast measurements were compared between the three methods and diagnostic accuracy of SW MRI was assessed against T2w images by 2 independent, blinded observers. Image quality was rated on a 4-point scale from 1 (unusable) to 4 (excellent).
Of 49 patients, IMH was detected in 20 (41%) by SW MRI, 21 (43%) by T2-weighted and 17 (34%) by T2 star imaging (p = ns). Compared to T2-weighted imaging, SW MRI had sensitivity of 93% and specificity of 86%. SW MRI had similar inter-observer reliability to T2-weighted imaging (κ = 0.90 and κ = 0.88 respectively); both had higher reliability than T2 star (κ = 0.53). Breath hold times were shorter for SW MRI (4 seconds vs. 16 seconds) with improved image quality rating (3.8 ± 0.4, 3.3 ± 1.0, 2.8 ± 1.1 respectively; p < 0.01).
SW MRI is an accurate and reproducible way to detect IMH at 3T. The technique offers considerably shorter breath hold times than T2-weighted and T2 star imaging, and higher image quality scores.
Background: Surgical aortic valve replacement (SAVR) remains first-line treatment for symptomatic severe aortic stenosis, whereas transcatheter aortic valve implantation (TAVI) is indicated in ...patients who are inoperable or considered too high-risk for surgery. Current focus is centred on differences in the impact of valve replacement upon cardiovascular function to guide patient selection and the development of novel prosthetic valves to improve outcomes. Cardiovascular Magnetic Resonance (CMR) imaging is the investigative modality of choice for such a purpose. Objectives: To compare the impact of SAVR and TAVI upon aortic stiffness, right ventricular function and myocardial strain, and to compare two vendor designs in the quantity of post-TAVI aortic regurgitation and reverse remodelling. Methods: A prospective study of patients with severe aortic stenosis under surveillance and subsequently requiring SAVR or TAVI, recruited between September 2009 and December 2015. A 1.5 Tesla CMR study was performed pre and 6 months post SAVR, and pre, immediately and 6 months post implantation of Medtronic CoreValve and Boston Lotus TAVI. Aortic distensibility (AD), pulse wave velocity (PWV), right ventricular (RV) volumes, myocardial strain and aortic regurgitation (AR) were quantified. Results: At 6 months, SAVR was associated with a significant worsening in PWV (6.38±4.47 vs. 11.01±5.75ms-1, p=0.001) and ascending AD (1.95±1.15 vs. 1.57±0.68x10-3mmHg-1, p=0.044), whereas no change was seen following TAVI. A significant reduction in RV ejection fraction (58±8 vs. 53±8%, p=0.005) was seen flowing SAVR, with no change following TAVI. A significant and comparable decline in LV torsion and twist was observed. Baseline circumferential strain was significantly associated with all-cause mortality (hazard ratio, 1.03; 1.01–1.05; p=0.009). Significantly less AR was seen immediately following Lotus than CoreValve TAVI (4.3±3.4 vs.11.7±8.4%, p=0.001) with equivalent degrees of reverse remodelling observed at 6 months. Conclusion: Compared with TAVI, SAVR is more detrimental upon aortic stiffness and right ventricular function at 6 months. CMR derived circumferential strain is associated with survival following SAVR and TAVI.
Background: Surgical aortic valve replacement (SAVR) remains first-line treatment for symptomatic severe aortic stenosis, whereas transcatheter aortic valve implantation (TAVI) is indicated in ...patients who are inoperable or considered too high-risk for surgery. Current focus is centred on differences in the impact of valve replacement upon cardiovascular function to guide patient selection and the development of novel prosthetic valves to improve outcomes. Cardiovascular Magnetic Resonance (CMR) imaging is the investigative modality of choice for such a purpose. Objectives: To compare the impact of SAVR and TAVI upon aortic stiffness, right ventricular function and myocardial strain, and to compare two vendor designs in the quantity of post-TAVI aortic regurgitation and reverse remodelling. Methods: A prospective study of patients with severe aortic stenosis under surveillance and subsequently requiring SAVR or TAVI, recruited between September 2009 and December 2015. A 1.5 Tesla CMR study was performed pre and 6 months post SAVR, and pre, immediately and 6 months post implantation of Medtronic CoreValve and Boston Lotus TAVI. Aortic distensibility (AD), pulse wave velocity (PWV), right ventricular (RV) volumes, myocardial strain and aortic regurgitation (AR) were quantified. Results: At 6 months, SAVR was associated with a significant worsening in PWV (6.38±4.47 vs. 11.01±5.75ms-1, p=0.001) and ascending AD (1.95±1.15 vs. 1.57±0.68x10-3mmHg-1, p=0.044), whereas no change was seen following TAVI. A significant reduction in RV ejection fraction (58±8 vs. 53±8%, p=0.005) was seen flowing SAVR, with no change following TAVI. A significant and comparable decline in LV torsion and twist was observed. Baseline circumferential strain was significantly associated with all-cause mortality (hazard ratio, 1.03; 1.01–1.05; p=0.009). Significantly less AR was seen immediately following Lotus than CoreValve TAVI (4.3±3.4 vs.11.7±8.4%, p=0.001) with equivalent degrees of reverse remodelling observed at 6 months. Conclusion: Compared with TAVI, SAVR is more detrimental upon aortic stiffness and right ventricular function at 6 months. CMR derived circumferential strain is associated with survival following SAVR and TAVI.
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