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Background: Identification of viable but dysfunctional myocardium after myocardial infarction is important for management, including the decision for revascularization. Assessment of infarct transmurality (TRM) by late contrast enhancement on magnetic resonance imaging (MRI) is frequently used for this task but has several limitations, particularly its availability. The goal of this study was to compare the value of several simple echocardiographic parameters measured at rest at the bedside for the identification of three degrees of infarct TRM, with contrast-enhanced MRI as the gold standard. Methods: In a prospective, single-center study, 41 patients (33 men; mean age, 62 +/- 10 years; 32 with ST-segment elevation infarctions) underwent resting echocardiography and contrast-enhanced MRI < 5 days after infarction. Wall motion score, preejection velocity by tissue Doppler, and longitudinal, circumferential, and radial peak systolic strain by speckle-tracking-based strain imaging were assessed, and the findings were compared with infarct TRM stratified by contrast-enhanced MRI (no scar, 0% TRM; nontransmural scar, 1%-50% TRM; and transmural scar, 51%-100% TRM). Results: Four hundred segments showed no scar, 125 showed nontransmural scar, and 213 showed transmural scar on contrast-enhanced MRI. The sensitivity and specificity of visual wall motion scoring to detect any scar versus no scar were 71% and 81%, respectively, similar to values for circumferential strain (sensitivity and specificity both 81% with a cutoff of -14.5%). Longitudinal and radial strain performed less well, and the presence of preejection velocity performed distinctly worse (45% and 90%, respectively). The sensitivity and specificity for identifying nontransmural versus transmural infarction was better for circumferential strain (78% and 75%, respectively, with a cutoff of -10.5%) than for the other strain types, preejection velocity (52% and 67%, respectively), or visual wall motion scoring (5

BACKGROUND: Predictors of long-term outcome after ST-elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA) are incompletely understood, including the influence of successful coronary reperfusion. METHODS: We analysed clinical and procedural data as well as 1-year outcome of 72 consecutive patients who underwent primary coronary intervention (PCI) after witnessed OHCA and STEMI and compared the results with 695 patients with STEMI and PCI, but without OHCA. Neurological recovery after OHCA was assessed using the Cerebral Performance Category (CPC) scale. RESULTS: PCI was successful in 83.3% after OHCA vs. 84.3% in the non-OHCA group (p=0.87). One-year mortality was 34.7% vs. 9.5% (p<0.001). 58.3% of the OHCA-patients showed complete neurological recovery (CPC 1) or moderate neurological disability (CPC 2). Another 6.9% showed severe cerebral disability (CPC 3) or permanent vegetative status (CPC 4). Delay from collapse until start of Advanced Cardiopulmonary Life Support (ACLS) was shorter for survivors with CPC status ≤2 (median 1min, range 0-11min) compared to non-survivors or survivors with CPC status >2 (median 8min, range 0-13min), p<0.0001. Age-adjusted multivariate analysis identified 'unsuccessful PCI', 'vasopressors on admission' and 'start of ACLS after >6min' as independent predictors of negative long-term outcome (death or CPC >2). CONCLUSIONS: Mortality is high in patients with STEMI complicated by OHCA - even though PCI was performed with the same success rate as in patients without OHCA. The majority of survivors had favourable neurological outcomes at 1year, especially if advanced life support had been started within ≤6min and PCI was successful.

BackgroundRecently, mild therapeutic hypothermia (MTH) has been integrated into the European resuscitation guidelines to improve outcomes after out-of-hospital cardiac arrest (OHCA). Data on long-term results are limited, especially in patients with acute ST-elevation myocardial infarction (STEMI). HypothesisInvasive MTH influences long-term prognosis after OHCA due to STEMI. MethodsWe analyzed 48 patients who underwent emergency coronary angiography for STEMI after witnessed OHCA. In 24 consecutive patients, MTH was performed via intravascular cooling (CoolGard System, 34 degrees C maintained for 24 hours) after initialization by rapid infusion of cold saline. Clinical, procedural, and mortality data were compared to 24 historical controls. Neurological recovery was assessed using the Cerebral Performance Category score (CPC) at 30-day and 1-year follow-up. ResultsMedian time delay until arrival of emergency medical service was 6 minutes (MTH group) vs 6.5 minutes (controls) (P=0.16). Initial rhythm was ventricular fibrillation in 75% vs 66.7% (P=0.75). There were no differences regarding baseline characteristics, angiographic findings, and success of cardiac catheterization procedures. MTH was not associated with a higher frequency of bleeding complications or of pneumonia. Thirty-day mortality was 33.3% in both groups. One-year mortality was 37.5% (MTH group) vs 50% (controls) (P=0.56). At 1 year, favorable neurological outcome (CPC 2) was significantly more frequent in the MTH group (58.3% vs 20.8%, P=0.017). Multivariate analysis identified MTH as independent predictor of favorable neurological outcome (P<0.02, odds ratio: 12.73). ConclusionsMTH via intravascular cooling improves neurological long-term prognosis after OHCA due to STEMI and is safe in clinical practice.

Objectives The study sought to compare echocardiographic with invasive hemodynamic data in patients with "paradoxic" aortic stenosis and in patients with conventionally defined severe aortic stenosis. Background Controversy exists whether low gradient severe aortic stenosis despite preserved ejection fraction ("paradoxic" aortic stenosis; aortic valve area <1 cm(2), mean gradient <40 mm Hg, ejection fraction >50%), which has been mainly diagnosed by echocardiography (echo), may be largely due to mistakes in echocardiographic measurements. Methods We compared echocardiographic and invasive hemodynamic data from 58 patients (43% male, mean age 77 +/- 5 years) with "paradoxic" aortic stenosis. Data of 22 patients (45% male, mean age 73 +/- 7 years) with conventionally defined severe aortic stenosis area (aortic valve area <= 1 cm(2), mean gradient >40 mm Hg, ejection fraction >= 50%) were also analyzed. Results In patients with "paradoxic" aortic stenosis, orifice area by echo (0.80 +/- 0.15 cm(2)) and catheterization showed modest agreement, whether stroke volume was measured by oxymetry (0.69 +/- 0.16 cm(2), bias 0.14 +/- 0.17 cm(2)), or by thermodilution (0.85 +/- 0.19 cm(2), bias -0.03 +/- 0.19 cm(2)). Mean systolic gradients were very similar (32 +/- 7 mm Hg vs. 31 +/- 6 mm Hg; bias -0.08 +/- 7.8 mm Hg). In comparison, in patients with conventionally defined severe aortic stenosis, orifice area by echo was 0.72 +/- 0.17 cm(2) and by catheterization 0.51 +/- 0.15 cm(2) (oxymetry) and 0.68 +/- 0.21 cm(2) (thermodilution), respectively, and mean systolic gradient 51 +/- 10 mm Hg and 55 +/- 8 mm Hg, respectively. Ejection fractions did not differ significantly in both groups. Ascending aortic diameter was significantly smaller in the "paradoxic" aortic stenosis group than in patients with conventionally defined severe aortic stenosis (28 +/- 5 mm vs. 31 +/- 5 mm), and energy loss index was significantly larger (0.51 +/- 0.12 cm(2)/m(2) vs. 0.42 +/- 0

Refers to: Neelakantan Saikrishnan, Ajit P. Yoganathan, Gautam Kumar; Diagnosis of “Paradoxical” Low-Gradient Aortic Stenosis Patients; Journal of the American College of Cardiology, Volume 62, Issue 24, 17 December 2013, Pages 2345-2346

Aims Regional myocardial function may change differently in different pathology. Speckle tracking echocardiography (STE) was applied to evaluate longitudinal, radial, and circumferential function in patients with aortic stenosis (AS) before, within 1 week, and 6 months after aortic valve replacement (AVR). Methods and results In 40 consecutive patients with severe AS, we acquired apical four-, three-, and two-chamber views and standard short-axis view pre- and post-AVR and after 6 months. Longitudinal, radial, and circumferential (LS, RS, and CS) were calculated by commercial STE software. Further, we analysed diastolic myocardial function by measuring E/e′ ratio. With AVR, valve area increased and remained stable at 6 months follow-up. Left ventricular mass was unchanged 1 week after AVR (270 ± 58 g vs. 267 ± 58 g, n.s.) but decreased significantly during the next 6 months (219 ± 50 g, P < 0.05). Left ventricular ejection fraction remained unchanged. Strain values did not change significantly within 1 week after AVR but increased significantly after 6 months (LS by 16%, RS by 21%, and CS by 28% of baseline values). E/e′ ratio was highly augmented before AVR (26.1 ± 12.5) and decreased significantly 6 months after AVR (15.9 ± 5.9). Conclusion Myocardial function significantly recovers after replacing the stenosed aortic valve. However, there is a considerable difference between the response of longitudinal, radial, and circumferential function. Our data suggest that echocardiographic assessment of regional function is feasible and of potential clinical importance.

Recent data have suggested a relation among long-term endurance sport practice, left atrial remodeling, and atrial fibrillation. We investigated the influence of an increased vagal tone, represented by the early repolarization (ER) pattern, on diastolic function and left atrial size in professional soccer players. Fifty-four consecutive athletes underwent electrocardiography, echocardiography, and exercise testing as part of their preparticipation screening. Athletes were divided into 2 groups according to presence or absence of an ER pattern, defined as a ST-segment elevation at the J-point (STE) ≥0.1 mm in 2 leads. For linear comparisons average STE was calculated. Mean age was 24 ± 4 years. Twenty-five athletes (46%) showed an ER pattern. Athletes with an ER pattern had a significant lower heart rate (54 ± 9 vs 62 ± 11 beats/min, p = 0.024), an increased E/e′ ratio (6.1 ± 1.2 vs 5.1 ± 1.0, p = 0.002), and larger volumes of the left atrium (25.6 ± 7.3 vs 21.8 ± 5.0 ml/m2, p = 0.031) compared to athletes without an ER pattern. There were no significant differences concerning maximum workload, left ventricular dimensions, and systolic function. Univariate regression analysis revealed significant correlations among age, STE, and left atrial volume. In a stepwise multivariate regression analysis age, STE and e′ contributed independently to left atrial size (r = 0.659, p <0.001). In conclusion, athletes with an ER pattern had an increased E/e′ ratio, reflecting a higher left atrial filling pressure, contributing to left atrial remodeling over time.

BACKGROUND: A higher mortality risk for women with acute ST-elevation myocardial infarction (STEMI) has been a common finding in the past, even after acute percutaneous coronary intervention (PCI). We set out to analyze whether there are gender differences in real-world contemporary treatment and outcomes of STEMI. PATIENTS AND METHODS: A retrospective analysis of all consecutive patients with STEMI and acute coronary angiography with the intention of performing a PCI at our center 6/1999-6/2006 was carried out (n = 566). Data were examined for gender-specific differences regarding patients' characteristics, referral patterns, timing of acute symptoms, angiographic findings, procedural details, and adverse events at 30 days after PCI. RESULTS: Women (n = 161) were on average 8 years older than men (n = 405), had higher co-morbidity, were more often transported to the hospital by ambulance and presented less often to the emergency room on their own (4.2% vs. 12.6% in men, P = 0.02). The pre-hospital delay from symptom onset to admission was significantly longer for women (median 185 vs. 135 min, P < 0.02). There was no gender difference in time from admission to PCI (median 46 min vs. 48 min, P = 0.42). Both genders received PCI with similar frequency (88.8% vs. 92.4%, P = 0.19), with similar success rates (83.2% vs. 85.3%, P = 0.68). Thirty-day overall mortality for women was not significantly higher than for men (8.7% vs. 7.2%, P = 0.6). Re-infarction or stroke within 30 days were rare for both genders without gender-specific differences whereas bleeding necessitating blood replacement was significantly more frequent in women (16.8% vs. 5.9%, P < 0.001). In multivariate analysis, female gender was not independently associated with a higher risk of 30-day mortality (OR 0.964, P = 0.93). CONCLUSIONS: Women underwent PCI therapy for STEMI with the same frequency and the same angiographic success as men. Despite their more advanced age and the higher prevalence o

BACKGROUND: Data on contemporary real-world outcomes of interventional revascularization in patients > or = 75 y of age with ST elevation infarction (STEMI) are limited. METHODS: We analyzed all 504 consecutive patients who underwent angiography for acute STEMI between 1999 and 2005 at our center, and followed them up over one year. Outcomes in patients > or = 75 y of age were compared with younger patients. RESULTS: Patients > or = 75 y of age (n = 115) were majority females (55% versus 21%, p < 0.001), more cases of diabetes (42% versus 27%, p = 0.004), hypertension (78% versus 65%, p = 0.03) and a history of coronary events (25% versus 15%, p = 0.002). Younger patients were more often smokers (63% versus 30%, p < 0.001). After coronary angiography patients > or = 75 y of age underwent less frequent intervention (PCI; 84% versus 93%, p = 0.01). However, if PCI was performed, technical success rates were similar to younger patients (84% versus 86%). The 30-d mortality was 13% versus 6.4% (p = 0.03), but after successful PCI, the 30-d mortality rate was not significantly higher in old patients (7.4% versus 3.9%, p = 0.23). Bleeding complications were very low in both age groups if the radial access route was chosen. Multivariate predictors of 30-d mortality were cardiogenic shock/survived cardiac arrest, ejection fraction < 30%, conservative treatment or unsuccessful PCI (OR 3.01), renal insufficiency, diabetes, and age. One-y mortality was higher in the elderly (24.3% versus 9.9%, p < 0.001). Among 30-d-survivors, only multivessel disease and age were multivariate predictors of 1-y mortality. CONCLUSION: Patients > or = 75 y of age benefit from PCI in STEMI, and failed or unattempted PCI worsens prognosis in the old as well as in younger patients.

We compared the measurements of the aortic valve area (AVA) using dual-source computed tomography (DSCT) in patients with mid to severe aortic stenosis to measurements using transthoracic echocardiography (TTE) and invasive hemodynamic assessment. A total of 50 patients (mean age 73 ± 10 years) with suspected aortic stenosis were included. The computed tomographic data were acquired using DSCT with standardized scan parameters (2 × 64 × 0.6 mm collimation, 330-ms rotation, 120-kV tube voltage, 560 mA/rot tube current). After injection of 35 ml contrast agent (flow rate 5 ml/s), a targeted volume data set, ranging from the top of the leaflets to the infundibulum, was acquired. Ten cross-sectional data sets (slice thickness 1 mm, no overlap, increment 0.6 mm) were reconstructed during systole in 5% increments of the R-R interval. The AVA determined in systole by planimetry was compared to the calculated AVA values using the continuity equation on TTE and the Gorlin formula on catheterization. DSCT allowed the planimetry of the AVA in all patients. The mean AVA using DSCT was 1.16 ± 0.47 cm2 compared to a mean AVA of 1.04 ± 0.45 cm2 using TTE and 1.06 ± 0.45 cm2 using catheterization, with a significant correlation between DSCT/TTE (r = 0.93, p <0.001) and DSCT/cardiac catheterization (r = 0.97, p <0.001). However, DSCT demonstrated a slight, but significant, overestimation of the AVA compared to TTE (+0.12 ± 0.17 cm) and catheterization (+0.10 ± 0.12 cm2). In conclusion, DSCT permits one to assess the AVA with a high-image quality and diagnostic accuracy compared to TTE and invasive determination.