Usefulness of coronary fractional flow reserve measurements in guiding clinical decisions in intermediate or equivocal left main coronary stenoses.

The objectives of this study were to evaluate the usefulness of fractional flow reserve (FFR) measurements to guide the clinical decision in patients with intermediate left main coronary artery (LMCA) stenosis and to determine the predictors of major adverse cardiac events (MACE) -- cardiac death, myocardial infarction, coronary revascularization -- in such cases; 142 consecutive patients with intermediate LMCA stenosis (mean percent diameter stenosis 42 +/- 13%) were included. All patients underwent FFR measurement after intracoronary administration of adenosine at a dose > or =30 microg. The clinical decisions were based on FFR as follows: coronary revascularization was recommended if FFR was <0.

Severe valvular regurgitation and late prosthesis embolization after percutaneous aortic valve implantation.

We report the case of a 79-year-old man with low-flow, low-gradient aortic stenosis who underwent transapical aortic valve implantation. The deployment of a 26-mm Edwards SAPIEN valve (Edwards Lifesciences Inc, Irvine, CA) was complicated with the occurrence of severe central aortic regurgitation that was successfully treated with the implantation of a second valve ("valve-in-valve"). Postoperative progress was satisfactory but 2 days after the procedure he suddenly developed cardiogenic shock secondary to the migration of the aortic bioprothesis into the left ventricular outflow tract.

Feasibility and initial results of percutaneous aortic valve implantation including selection of the transfemoral or transapical approach in patients with severe aortic stenosis.

The purpose of this study was to evaluate the feasibility and initial results of a multidisciplinary percutaneous aortic valve implantation (PAVI) program including the transfemoral approach (TFA) and the transapical approach (TAA). This was a prospective registry including all patients with symptomatic severe aortic stenosis who were evaluated for PAVI and those who finally underwent the procedure. All patients were considered very high risk or nonsurgical candidates, and an algorithm based on prespecified criteria was used to determine the most appropriate approach (TFA vs TAA) for each patient.

Effects of exogenous metabolic substrate modulation on exercise-induced myocardial ischemia.

Background: The aim of the study is to compare the impact of intravenous glucose versus lipid versus saline on exercise-induced myocardial ischemia in patients with stable angina.

Methods: Twelve men with coronary artery disease and positive exercise tests performed a symptom-limited, modified Bruce electrocardiogram (ECG) exercise test at 3 sessions, 3 weeks apart. They randomly received, in double-blind design, at each session equal intravenous volumes of 10% glucose/insulin or Intralipid plus heparin or saline.

Clinical utility of C-reactive protein measured at admission, hospital discharge, and 1 month later to predict outcome in patients with acute coronary disease. The RISCA (recurrence and inflammation in the acute coronary syndromes) study.

Objectives: This study was designed to prospectively determine, in patients with an acute coronary syndrome, whether the inflammatory marker, C-reactive protein (CRP), measured at hospital admission, discharge, and 1 month later has incremental value to predict outcomes at 1 year.

Background: The clinical utility of CRP measurements in patients with acute coronary syndromes remains uncertain. Limitations of previous studies have been retrospective design and incomplete adjustment for readily available clinical prognosticators.

Delayed improvement in valve hemodynamic performance after percutaneous pulmonary valve implantation.

We report the case of a 21-year-old woman with a severely stenotic pulmonary homograft who underwent percutaneous pulmonary valve implantation, with no significant change in transvalvular gradient within the 24 hours after the procedure. Major improvement in hemodynamic valve performance of more than 60% decrease in transvalvular gradient and more than 30% increase in pulmonary valve area was observed 3 months after the procedure, showing that hemodynamic improvement can occur late after pulmonary valve implantation. An echocardiogram after 3 months should be done before concluding the procedure failed and that reintervention is necessary.

New concepts in valvular hemodynamics: implications for diagnosis and treatment of aortic stenosis.

Aortic valve stenosis (AS) is the third-most frequent heart disease after coronary artery disease and arterial hypertension, and it is associated with a high incidence of adverse outcomes. Recent data support the notion that AS is not an isolated disease uniquely limited to the valve. Indeed, AS is frequently associated with abnormalities of the systemic arterial system, and, in particular, with reduced arterial compliance, which may have important consequences for the pathophysiology and clinical outcome of this disease.

Predictors of aorto-saphenous vein bypass narrowing late after coronary artery bypass grafting.

The objective of this study was to evaluate the clinical and angiographic factors associated with significant saphenous vein graft (SVG) atherosclerosis progression at mid-term follow-up in a series of unselected coronary patients who had previously received a coronary artery bypass graft (CABG). A total of 123 SVGs from 86 patients who underwent cardiac catheterization twice, 15 +/- 12 months apart, were included in the study. None of the SVGs presented any > or =50% diameter stenosis (DS) lesion or underwent any intervention at baseline.

Comparison of surgical and transcatheter treatment for native coarctation of the aorta in patients > or = 1 year old. The Quebec Native Coarctation of the Aorta study.

Background: The objectives of this study were to compare, in the current era, the immediate results, complications, and midterm outcomes obtained by surgical repair versus transcatheter treatment of coarctation of the aorta (CoA).

Methods: The study was of retrospective nature and included 80 consecutive patients > or = 1 year old (mean age 12 +/- 10 years) treated for an isolated CoA in 4 university centers in Quebec between 1998 and 2004. Fifty patients underwent aortic angioplasty, with stent implantation in 19, and 30 had surgical repair.

Different thresholds of myocardial ischemia in ramp and standard bruce protocol exercise tests in patients with positive exercise stress tests and angiographically demonstrated coronary arterial narrowing.

Gradual instead of abrupt increases in workload favor a more physiologic response in terms of hemodynamic and gas exchange parameters. Therefore, we investigated whether myocardial ischemia is attenuated with a ramp compared with a standard Bruce exercise protocol in patients with coronary artery disease. We compared electrocardiographic ischemic parameters on the standard Bruce protocol treadmill and the individualized ergocycle ramp protocol in 18 men with coronary artery disease and a reproducible ischemic electrocardiographic exercise test.

Acute ischemic heart disease and interventional cardiology: a time for pause.

Background: A major change has occurred in the last few years in the therapeutic approach to patients presenting with all forms of acute coronary syndromes. Whether or not these patients present initially to tertiary cardiac care centers, they are now routinely referred for early coronary angiography and increasingly undergo percutaneous revascularization. This practice is driven primarily by the angiographic image and technical feasibility.

The ACE-DD genotype is associated with endothelial dysfunction in postmenopausal women.

Objective: To evaluate the effects of the angiotensin-converting enzyme (ACE) insertion/deletion (I/D), the angiotensinogen M235T and the angiotensin II type 1 receptor A1166C polymorphisms, and hormone therapy used on endothelial function in postmenopausal women without manifestation of coronary artery disease.

Design: Sixty-four postmenopausal women (42 hormone therapy users and 22 hormone therapy nonusers) without clinical manifestation of coronary artery disease were evaluated using external vascular ultrasonography to measure endothelium-dependent (hyperemic response, flow-mediated dilatation) and -independent (nitroglycerin) dilatation. Genotypes were determined by polymerase chain reaction amplification.

Usefulness of fractional flow reserve measurements to defer revascularization in patients with stable or unstable angina pectoris, non-ST-elevation and ST-elevation acute myocardial infarction, or atypical chest pain.

This study determined the safety of deferring coronary revascularization based on a fractional flow reserve (FFR) value > or = 0.75 in a series of consecutive unselected coronary patients with moderate coronary lesions, including patients with unstable angina, myocardial infarction (MI), and/or positive noninvasive test findings. The study included 201 consecutive coronary patients (mean age 62 +/- 10 years; 65% men) with 231 lesions evaluated by FFR measurement for which revascularization was deferred based on a FFR value > or = 0.

Does hormonal status influence the clinical presentation of acute coronary syndromes in women?

Background: Previous studies suggest that the clinical presentation of acute coronary syndromes (ACS) may differ between women and men. It is not known if different clinical presentations may be explained by hormonal status in women with ACS. Our objective was to compare the clinical presentation of ACS between premenopausal (PRE) women and post-menopausal women with hormone replacement therapy (HRT) and without (POST).

Impact of prolonged cyclooxygenase-2 inhibition on inflammatory markers and endothelial function in patients with ischemic heart disease and raised C-reactive protein: a randomized placebo-controlled study.

Background: The impact of cyclooxygenase (COX)-2 antagonist treatment on acute coronary risk is controversial. We investigated the effect of prolonged COX-2 inhibition on inflammatory profile and endothelial function in patients with ischemic heart disease and high serum C-reactive protein (CRP) values.

Methods And Results: In a double-blind study, 35 stable subjects on low-dose aspirin with > or =2 previous acute coronary events and 2 of 2 screening CRP values >2.

Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement.

Background: The prosthesis used for aortic valve replacement (AVR) can be too small in relation to body size, thus causing valve prosthesis-patient mismatch (PPM) and abnormally high transvalvular pressure gradients. This study examined if there is a relation between PPM and short-term mortality after operation.

Methods And Results: The indexed valve effective orifice area (EOA) was estimated for each type and size of prosthesis being implanted in 1266 consecutive patients and used to define PPM as not clinically significant if >0.

Left ventricular longitudinal shortening in patients with aortic stenosis: relationship with symptomatic status.

Background And Aim Of The Study: Symptomatic status in aortic stenosis is not always related to hemodynamic severity as estimated by the aortic valve effective orifice area (AVA), and other factors may be involved. It has been seen previously that, whilst ejection fraction is preserved, left ventricular (LV) longitudinal shortening may be selectively decreased in aortic stenosis, and hypothesized that this might be a marker of subendocardial ischemia as subendocardial myocardial fibers are oriented longitudinally. The present study examined the possible relationship between LV longitudinal shortening and symptoms in patients with aortic stenosis.

What induces the warm-up ischemia/angina phenomenon: exercise or myocardial ischemia?

Background: The relation of the warm-up ischemia phenomenon to the presence and intensity of initial myocardial ischemia is unclear. We sought to determine whether the warm-up ischemia phenomenon requires initial myocardial ischemia or can be induced by exercise without ischemia and whether there is a relation between the intensity of initial ischemia and the attenuation of ischemia on reexercise.

Methods And Results: Twelve subjects with exertional myocardial ischemia performed 2 exercise ECG tests (1 and 2) at a +/-10-minute interval on 3 occasions (A, B, C) 1 month apart.

Rescue therapy with methylene blue in systemic inflammatory response syndrome after cardiac surgery.

Severe unresponsive vasoplegia syndrome following cardiopulmonary bypass is rare. The authors report a case of severe vasoplegia, unresponsive to conventional treatment three days following cardiopulmonary bypass. A single intravenous bolus (2 mg/kg) of methylene blue was administered with normalization of the peripheral resistance.

Mitral annulus velocities by Doppler tissue imaging: practical implications with regard to preload alterations, sample position, and normal values.

Because it appears to be less affected by changes in preload, mitral annulus Doppler tissue imaging (DTI) has been proposed as an alternate mean of identifying pseudonormal patterns of left ventricular filling. We thus studied the practical implications of DTI in 40 patients classified according to the Canadian Consensus on Diastolic Function (9 control participants, 9 with impaired relaxation, and 22 pseudonormal participants). Using DTI, the early diastolic velocity (Ea) was the most reproducible parameter whereas the late diastolic velocity (Aa) and Ea/Aa ratio varied significantly.

Independent contribution of left ventricular ejection time to the mean gradient in aortic stenosis.

Background And Aims Of The Study: Transvalvular mean pressure gradients (MPG) are important in the evaluation of aortic stenosis, but surprisingly they often differ in patients having similar valve effective orifice area (EOA) and stroke volume (SV). The study aim was to determine if these differences could be explained by variations in left ventricular ejection time (LVET).

Methods: A pulse duplicator system with a constant SV of 75 ml and incremental increases of LVET from 250 to 450 ms was used to measure MPG by Doppler echocardiography in three fixed stenoses (0.

Hemodynamic performance at rest and during exercise after aortic valve replacement: comparison of pulmonary autografts versus aortic homografts.

Background: The Ross procedure and aortic homografts have both been shown to have superior hemodynamic performance after valve replacement, but there have been few comparisons.

Methods: Sequential Doppler echocardiograms were performed up to 5 years after aortic valve replacement in 132 patients with the Ross procedure and 111 patients with an aortic homograft (AH). Measurements included assessment of valvular regurgitation and calculations of valve effective orifice area (EOA) and mean transvalvular gradients; the same measurements were also performed at the level of the pulmonary homograft in the Ross patients as well as during maximum exercise in 20 Ross patients and 14 AH patients.