Search

Hyper-trabeculation or non-compaction in the left ventricle of the myocardium (LVNC) is a recently classified form of cardiomyopathy. Several methods have been proposed to quantify the trabeculae accurately in the left ventricle, but there is no general agreement in the medical community to use a particular approach. In the previous work, we proposed DL-LVTQ, a deep-learning approach for left ventricular trabecular quantification based on a U-Net CNN architecture. In this work, we have extended and adapted DL-LVTQ to cope with patients with different particularities and cardiomyopathies. Patient images were taken from different scanners and hospitals. We have modified and adapted the U-Net convolutional neural network to account for the different particularities of a heterogeneous group of patients with multiple cardiomyopathies and inherited cardiomyopathies. The inclusion of new groups of patients has increased the accuracy, specificity and Kappa values while maintaining the sensitivity of the proposed method. Therefore, a better-prepared diagnosis tool is ready for various cardiomyopathies with different characteristics. Cardiologists have considered that 98.9% of the evaluated outputs are verified clinically for diagnosis. Therefore, the high precision to segment the different cardiac structures allows us to make a robust diagnostic system objective and faster, decreasing human error and time spent. [ABSTRACT FROM AUTHOR]

Accurate diagnosis of Left Ventricular Noncompaction Cardiomyopathy (LVNC) is critical for proper patient treatment but remains challenging. This work improves LVNC detection by improving left ventricle segmentation in cardiac MR images. Trabeculated left ventricle indicates LVNC, but automatic segmentation is difficult. We present techniques to improve segmentation and evaluate their impact on LVNC diagnosis. Three main methods are introduced: (1) using full 800 × 800 MR images rather than 512 × 512; (2) a clustering algorithm to eliminate neural network hallucinations; (3) advanced network architectures including Attention U-Net, MSA-UNet, and U-Net++.Experiments utilize cardiac MR datasets from three different hospitals. U-Net++ achieves the best segmentation performance using 800 × 800 images, and it improves the mean segmentation Dice score by 0.02 over the baseline U-Net, the clustering algorithm improves the mean Dice score by 0.06 on the images it affected, and the U-Net++ provides an additional 0.02 mean Dice score over the baseline U-Net. For LVNC diagnosis, U-Net++ achieves 0.896 accuracy, 0.907 precision, and 0.912 F1-score outperforming the baseline U-Net. Proposed techniques enhance LVNC detection, but differences between hospitals reveal problems in improving generalization. This work provides validated methods for precise LVNC diagnosis.

Background and Objective: Left ventricular non-compaction (LVNC) is an uncommon cardiomyopathy characterised by a thick and spongy left ventricle wall caused by the high presence of trabeculae (hyper-trabeculation). Recently, the percentage of the trabecular volume to the total volume of the external wall of the left ventricle (VT%) has been proposed to diagnose this illness., Methods: This paper presents the use of a deep learning-based method to measure the (VT%) value and diagnose this rare cardiomyopathy. The population used in this research was composed of 277 patients suffering from hypertrophic cardiomyopathy. 134 patients only suffered hypertrophic cardiomyopathy, and 143 also suffered left ventricular non-compaction. Our deep learning solution is based on a 2D U-Net. This artificial neural network (ANN) was trained on short-axis magnetic resonance imaging to segment the left ventricle's internal cavity, external wall, and trabecular tissue. 5-fold cross-validation was performed to ensure the robustness of the results. The Dice coefficient of the three classes was computed as a measure of the precision of the segmentation. Based on this segmentation, the percentage of the trabecular volume (VT%) was computed. Two specialist cardiologists rated the segmentation produced by the neural network for 25 patients to evaluate the clinical validity of the outputs. The computed VT% was used to automatically diagnose the 277 patients depending on whether or not a given threshold was exceeded. A receiver operating characteristic analysis was also performed., Results: According to the cross-validation results, the average and standard deviation of the Dice coefficient for the internal cavity, external wall, and trabeculae were 0.96±0.00, 0.89±0.00, and 0.84±0.00, respectively. The cardiologists rated 99.5% of the evaluated segmentations as clinically valid for diagnosis, outperforming existing automatic traditional tools. The area under the ROC curve was 0.94 (95% confidence interval, 0.91-0.96). The accuracy, sensitivity, and specificity values of diagnosis using a threshold of 25% were 0.87, 0.93, and 0.80, respectively., Conclusions: The U-Net neural network can achieve excellent results in the delineation of different cardiac structures of short-axis cardiac MRI. The high-quality segmentation allows for the correct measurement of left ventricular hyper-trabeculation and a definitive diagnosis of LVNC illness. Using this kind of solution could lead to more objective and faster analysis, reducing human error and time spent by cardiologists., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Left ventricular noncompaction (LVNC) is a heterogeneous entity with uncertain prognosis., Objectives: This study sought to develop and validate a prediction model of major adverse cardiovascular events (MACE) and to identify LVNC cases without events during long-term follow-up., Methods: This is a retrospective longitudinal multicenter cohort study of consecutive patients fulfilling LVNC criteria by echocardiography or cardiovascular magnetic resonance. MACE were defined as heart failure (HF), ventricular arrhythmias (VAs), systemic embolisms, or all-cause mortality., Results: A total of 585 patients were included (45 ± 20 years of age, 57% male). LV ejection fraction (LVEF) was 48% ± 17%, and 18% presented late gadolinium enhancement (LGE). After a median follow-up of 5.1 years, MACE occurred in 223 (38%) patients: HF in 110 (19%), VAs in 87 (15%), systemic embolisms in 18 (3%), and 34 (6%) died. LVEF was the main variable independently associated with MACE (P < 0.05). LGE was associated with HF and VAs in patients with LVEF >35% (P < 0.05). A prediction model of MACE was developed using Cox regression, composed by age, sex, electrocardiography, cardiovascular risk factors, LVEF, and family aggregation. C-index was 0.72 (95% confidence interval: 0.67-0.75) in the derivation cohort and 0.72 (95% confidence interval: 0.71-0.73) in an external validation cohort. Patients with no electrocardiogram abnormalities, LVEF ≥50%, no LGE, and negative family screening presented no MACE at follow-up., Conclusions: LVNC is associated with an increased risk of heart failure and ventricular arrhythmias. LVEF is the variable most strongly associated with MACE; however, LGE confers additional risk in patients without severe systolic dysfunction. A risk prediction model is developed and validated to guide management., Competing Interests: Funding Support and Author Disclosures The project was partially funded by a grant from the Catalan Society of Cardiology (Barcelona, Spain). Hospital Universitario Virgen de la Arrixaca (Murcia, Spain) was supported by a grant from the Foundation Marató TV3 (218/C/2015) (Barcelona, Spain). Hospital Universitario y Politécnico La Fe (Valencia, Spain) was partially supported by Fondo Europeo de Desarrollo Regional (“Unión Europea, Una forma de hacer Europa”) (Madrid, Spain) and the Instituto de Salud Carlos III (La Fe Biobank PT17/0015/0043) (Madrid, Spain). Dr Guala was supported by funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I) (Madrid, Spain). Dr La Mura was supported by a research grant from the Cardiopath PhD program (Naples, Italy). Prof de la Pompa was supported by grants PID2019-104776RB-I00 and CB16/11/00399 (CIBER CV) from the Spanish Ministry of Science, Innovation and Universities. Dr Bayes-Genis was supported by grants from CIBER Cardiovascular (CB16/11/00403 and 16/11/00420) (Madrid, Spain) and AdvanceCat 2014-2020 (Barcelona, Spain); and has received advisory board and lecture fees from Novartis, Boehringer Ingelheim, Vifor, Roche Diagnostics, and Critical Diagnostics. Dr Pontone has received speaker honorarium and/or institutional research grants from GE Healthcare, Bracco, Boehringer Ingelheim, and HeartFlow. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Left ventricular non-compaction (LVNC) is defined by an increase of trabeculations in left ventricular (LV) endomyocardium. Although LVNC can be in isolation, an increase in hypertrabeculation often accompanies genetic cardiomyopathies. Current methods for quantification of LV trabeculae have limitations. Several improvements are proposed and implemented to enhance a software tool to quantify the trabeculae degree in the LV myocardium in an accurate and automatic way for a population of patients with genetic cardiomyopathies (QLVTHCI). The software tool is developed and evaluated for a population of 59 patients (470 end-diastole cardiac magnetic resonance images). This tool produces volumes of the compact sector and the trabecular area, the proportion between these volumes, and the left ventricular and trabeculated masses. Substantial enhancements are obtained over the manual process performed by cardiologists, so saving important diagnosis time. The parallelization of the detection of the external layer is proposed to ensure real-time processing of a patient, obtaining speed-ups from 7.5 to 1500 with regard to QLVTHCI and the manual process used traditionally by cardiologists. Comparing the method proposed with the fractal proposal to differentiate LVNC and non-LVNC patients among 27 subjects with previously diagnosed cardiomyopathies, QLVTHCI presents a full diagnostic accuracy, while the fractal criteria achieve 78%. Moreover, QLTVHCI can be installed and integrated in hospitals on request, whereas the high cost of the license of the fractal method per year of this tool has prevented reproducibility by other medical centers.

Introduction and Objectives: Mutations in MYBPC3 are the cause of hypertrophic cardiomyopathy (HCM). Although most lead to a truncating protein, the severity of the phenotype differs. We describe the clinical phenotype of a novel MYBPC3 mutation, p.Pro108Alafs*9, present in 13 families from southern Spain and compare it with the most prevalent MYBPC3 mutation in this region (c.2308+1 G>A)., Methods: We studied 107 relatives of 13 index cases diagnosed as HCM carriers of the p.Pro108Alafs*9 mutation. Pedigree analysis, clinical evaluation, and genotyping were performed., Results: A total of 54 carriers of p.Pro108Alafs*9 were identified, of whom 39 had HCM. There were 5 cases of sudden death in the 13 families. Disease penetrance was greater as age increased and HCM patients were more frequently male and developed disease earlier than female patients. The phenotype was similar in p.Pro108Alafs*9 and in c.2308+1 G>A, but differences were found in several risk factors and in survival. There was a trend toward a higher left ventricular mass in p.Pro108Alafs*9 vs c.2308+1G>A. Cardiac magnetic resonance revealed a similar extent and pattern of fibrosis., Conclusions: The p.Pro108Alafs*9 mutation is associated with HCM, high penetrance, and disease onset in middle age., (Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Left ventricular outflow tract (LVOT) measurement is a critical step in the quantification of aortic valve area. The assumption of a circular morphology of the LVOT may induce some errors. The aim of this study was to assess the three-dimensional (3D) morphology of the LVOT and its impact on grading aortic stenosis severity., Methods: Fifty-eight patients with aortic stenosis were studied retrospectively. LVOT dimensions were measured using 3D transesophageal echocardiography at three levels: at the hinge points (HP) of the aortic valve and at 4 and 8 mm proximal to the annular plane. Results were compared with standard two-dimensional echocardiographic measurements., Results: Three-dimensional transesophageal echocardiography showed a funnel shape that was more circular at the HP and more elliptical at 4 and 8 mm proximal to the annular plane (circularity index = 0.92 vs 0.83 vs 0.76, P < .001). Cross-sectional area was smaller at the HP and larger at 4 and 8 mm from the annular plane (3.6 vs 3.9 vs 4.1 cm 2 , P = .001). The best correlation between two-dimensional and 3D transesophageal echocardiographic dimensions was at the HP (intraclass correlation coefficient = 0.75; 95% CI, 0.59-0.86). When the HP approach was selected, there was a reduction in the percentage of patients with low flow (from 41% to 29%)., Conclusions: A large portion of patients with aortic stenosis have funnel-shaped and elliptical LVOTs, a morphology that is more pronounced in the region farther from the annular plane. Two-dimensional LVOT measurement closer to the annular plane has the best correlation with 3D measurements. Measurement of the LVOT closer to the annular plane should be encouraged to reduce measurement errors., (Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Aims: To assess the feasibility and reliability of aortic valve area (AVA) planimetry by means of three-dimensional transesophageal echocardiography (3DTEE) as compared with the transthoracic echocardiogram (TTE) calculation of AVA, to determine the systematic deviations between measurements, and to describe the distribution of mean systolic in relation with 3DTEE anatomical AVA., Methods and Results: Three hundred seven patients with aortic valve stenosis (AVS) underwent both TTE and 3DTEE for AVA measurement by means of the continuity equation and direct anatomical planimetry, respectively. AVA planimetry was achieved in 282 (91.9%) of patients. Severity of the aortic valve calcification was independently associated with a poorer performance of planimetry. Intraclass correlation coefficient yielded a 0.848 (95% CI: 0.807-0.879) value. 3DTEE rendered a mild constant underestimation of AVA in comparison with TTE. Severe aortic stenosis according to the area criterion (<1 cm(2) ) despite mean systolic gradient below 40 mm Hg was detected in 37.6% of the study population, and in 33.7% of the subset of patients with preserved left ventricular ejection fraction., Conclusions: Reliability of AVA planimetry by 3DTEE in comparison with the calculation by TTE is good, but 3DTEE underestimates slightly the measurement. Feasibility of the technique is good but independently affected by valvular calcification. Inconsistent classification of AVS severity as graded by AVA or mean systolic gradient is observed in the overall population and in patients with preserved systolic function., (© 2014, Wiley Periodicals, Inc.)

Background: Paravalvular aortic regurgitation after transcatheter aortic valve implantation is associated with a hemodynamic deterioration and a poor outcome. We aim to determine the early hemodynamic effect of paravalvular aortic regurgitation in relation with the change in the left ventricle filling pattern and to assess their clinical outcome., Material and Methods: Eighty-two consecutive patients referred for transcatheter aortic valve implantation were included. Patients were classified according to the change in the left ventricular filling pattern, and significant paravalvular aortic regurgitation (grade ≥ 2) was reported. Follow-up and incidence of death and hospitalization for heart failure were reported., Results: Sixteen patients (19·5%) presented a worsening of left ventricular filling pattern. The incidence of significant paravalvular aortic regurgitation was higher in the group with a worsening of left ventricular filling pattern (56·3% vs. 19·7%; P = 0·009). In the multivariate analysis, the only variable significantly associated with the worsening of left ventricular filling pattern was the significant paravalvular aortic regurgitation (OR 4·84; 95% CI 1·23 - 19·1; P = 0·024). During the follow-up (642·5 days), there was a higher incidence of the endpoint of death or hospitalization for heart failure in the group with a worsening of left ventricular filling pattern (62·5% vs. 31·8%; P = 0·042) and a lower event-free survival rate (long rank test = 0·013)., Conclusions: The presence of a significant paravalvular aortic regurgitation is associated with a worsening in parameters of diastolic function. This finding should alert the cardiologist as patients with a worsening of left ventricular filling pattern present a higher incidence of paravalvular aortic regurgitation and a less favourable outcome., (© 2014 Stichting European Society for Clinical Investigation Journal Foundation.)

Aims: Risk stratification for sudden death in arrhythmogenic right ventricular cardiomyopathy (ARVC) is challenging in clinical practice. We lack recommendations for the risk stratification of exclusive left-sided phenotypes. The aim of this study was to investigate genotype-phenotype correlations in patients carrying a novel DSP c.1339C>T, and to review the literature on the clinical expression and the outcomes in patients with DSP truncating mutations., Methods and Results: Genetic screening of the DSP gene was performed in 47 consecutive patients with a phenotype of either an ARVC (n = 24) or an idiopathic dilated cardiomyopathy (DCM), who presented with ventricular arrhythmias or a family history of sudden death (n = 23) (aged 40 ± 19 years, 62% males). Three unrelated probands with DCM were found to be carriers of a novel mutation (c.1339C>T). Cascade family screening led to the identification of 15 relatives who are carriers. Penetrance in c.1339C>T carriers was 83%. Sustained ventricular tachycardia was the first clinical manifestation in six patients and nine patients were diagnosed with left ventricular impairment (two had overt severe disease and seven had a mild dysfunction). Cardiac magnetic resonance revealed left ventricular involvement in nine cases and biventricular disease in three patients. Extensive fibrotic patterns in six and non-compaction phenotype in five patients were the hallmark in imaging., Conclusion: DSP c.1339C>T is associated with an aggressive clinical phenotype of left-dominant arrhythmogenic cardiomyopathy and left ventricular non-compaction. Truncating mutations in desmoplakin are consistently associated with aggressive phenotypes and must be considered as a risk factor of sudden death. Since ventricular tachycardia occurs even in the absence of severe systolic dysfunction, an implantable cardioverter-defibrillator should be indicated promptly., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Introduction and Objectives: Low-gradient severe aortic stenosis with preserved ejection fraction is a controversial entity. Misclassification of valvulopathy severity could explain the inconsistencies reported in the prognosis of these patients. Planimetry of the aortic area using three-dimensional transesophageal echocardiography could clear up these doubts. The objectives were to assess the agreement between measurements of the valvular aortic area by continuity equation in transthoracic echocardiography and that obtained through planimetry with three-dimensional transesophageal echocardiography in low-gradient severe aortic stenosis patients., Methods: Cross-sectional descriptive study of consecutive patients referred due to severe aortic stenosis. Patients underwent transthoracic echocardiography and three-dimensional transesophageal echocardiography. Paradoxical low-gradient severe aortic stenosis was defined by the presence in the transthoracic echocardiography of aortic valve area<1 cm(2), mean ventricular gradient<40 mmHg, and ejection fraction ≥ 50%. Concordance between the two techniques was evaluated., Results: Of 212 consecutive severe aortic stenosis patients evaluated, 63 cases (29.7%) fulfilled the paradoxical low-gradient inclusion criteria. We obtained three-dimensional aortic valve planimetry in 61 (96.8%) of those patients. In 52 patients (85.2%), aortic valve area by transesophageal echocardiography was <1 cm(2). The intraclass correlation coefficient between the two methods was 0.505 (95% confidence interval, 0.290-0.671; P<.001)., Conclusions: Paradoxical low-gradient severe aortic stenosis is an actual entity, confirmed in 85% of cases evaluated by three-dimensional transesophageal echocardiography., (Copyright © 2012 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Genetically transmitted cardiomyopathies can affect several members in a family. Identification of high-risk patients could lead to a preventive treatment. We report the results of a 5-year experience of a dedicated clinic. Family screening was offered to 493 consecutive unrelated patients; 2,328 subjects (40 +/- 19 years old, 52% men) were evaluated (mean 4.4 relatives/family). Electrocardiography and echocardiography were performed in all cases; additional tests were indicated depending on the disease. Familial study was recommended because of a proband with hypertrophic cardiomyopathy (HC) in 57%, idiopathic dilated cardiomyopathy (IDC) in 14%, arrhythmogenic right ventricular cardiomyopathy (ARVC) in 2%, left ventricular noncompaction in 2%, Brugada syndrome (BS) in 15%, long QT syndrome (LQTS) in 3%, and other conditions in 6%. Familial disease was confirmed in 164 (39%); 43% with HC, 47% with IDC, 25% with ARVC, 33% with left ventricular noncompaction, 28% with BS, and 30% with LQTS. Two hundred twenty-two (44 +/- 20 years old, 60% men) affected relatives were identified (129 of whom were newly diagnosed). Sixty-four patients were newly diagnosed with HC, 40 with IDC, 2 with ARVC, 5 with left ventricular noncompaction, 14 with BS, and 2 with LQTS, in whom appropriate risk stratification and medication, if needed, were initiated (specific medication in 40, 31.0%). Cardioverter-defibrillator implantation was indicated in 4 relatives for primary prevention. Ninety-two (18.7%) had a family history of sudden death (FHSCD). Consanguinity was rare but significantly associated to a higher percentage of family disease (75.0% vs 38.3%, p = 0.003) and family history of sudden death (42.1% vs 17.8, p <0.001). In conclusion, the prevalence of familial disease in inherited cardiac conditions is high. Systematic familial study identified many asymptomatic affected patients who could benefit from early treatment to prevent complications. Dedicated clinics and multidisciplinary teams are needed for proper screening programs.

Introduction and Objectives: Using gadolinium-enhanced cardiovascular magnetic resonance, it is possible to evaluate the presence of myocardial fibrosis in hypertrophic cardiomyopathy. Classical disease markers are weak predictors of functional disability in affected patients. Our objective was to study the relationship between the degree of myocardial fibrosis observed by cardiac magnetic resonance and exercise capacity., Methods: We performed cardiac magnetic resonance, echocardiography, exercise testing and Holter monitoring, along with the usual clinical assessments, in 98 patients (age, 46.3+/-15.4 years, 71.4% male) referred from two specialist hypertrophic cardiomyopathy clinics. Cardiac magnetic resonance assessment included quantifying the degree of fibrosis (i.e., the percentage of the myocardium showing enhancement) 10 min after gadolinium infusion. Symptom-limited exercise testing was used to determine exercise capacity (in metabolic equivalent [MET] units). In 71 patients, the basal N-terminal probrain natriuretic peptide (NT-proBNP) level was also measured., Results: Late enhancement was observed on cardiac magnetic resonance in 67 (68.4%) patients. These patients had a lower exercise capacity (8.04+/-3.56 MET vs. 10.41+/-3.57 MET; P=.003). There was an inverse correlation between the percentage of fibrosis and exercise capacity (r=-0.21; P=.044). The best predictor of exercise capacity was the logarithm of the NT-proBNP level (r=-0.5; P< .0001). Multivariate analysis confirmed that age, a history of atrial fibrillation, the basal NT-proBNP level and the presence of fibrosis were independent predictors of exercise capacity (r2 for the model=0.47)., Conclusions: The observation of areas of late gadolinium enhancement on cardiac magnetic resonance was independently associated with poor exercise capacity in patients with hypertrophic cardiomyopathy.

Introduction: The Thrombolysis in Myocardial Infarction (TIMI) risk score (TRS) has proven to be a useful and simple tool for risk stratification of patients with chest pain in intermediate- and high-risk populations. There is little information on its applicability in daily clinical routine with unselected populations., Aims: The aims of the study were to prospectively analyze the predictive value of the TRS in a heterogeneous population admitted for chest pain and to construct where possible a new modified model with a greater prognostic capacity., Population and Methods: Seven hundred eleven consecutive patients were admitted over a 1-year period to the cardiology unit for chest pain without ST-segment elevation. Thrombolysis in Myocardial Infarction risk score variables, relevant medical history variables, in-hospital examination results, and therapy information were collected. Cardiac events at 1 and 6 months were recorded., Results: Seventy-one (9.8%) patients had a compound event (myocardial infarction/revascularization/cardiac death) at 6 months. On multivariate analysis, the variables associated with cardiac events were left ventricular ejection fraction (EF) of <35% (hazard ratio [HR] = 2.9, P = .002), diabetes (HR = 1.8, P = .02), and TRS (HR = 1.3, P = .007). Events at 6 months were 2.3% for a TRS of 0/1, 4.2% for 2, 10.2% for 3, 11.0% for 4, and 18.7% for a score of more than 5. A new modified scale was constructed to include EF and diabetes as independent variables, and this yielded an increase of 44% in the combined event at 6 months per score unit increase (HR = 1.44, P = .001). The modified scale showed a greater predictive capacity than the original model., Conclusions: The TRS is an important short- and long-term prognostic predictor when applied to an unselected population consulting for chest pain. The inclusion of diabetes and EF as variables in the model increases predictive capacity at no expense to simplicity.

Introduction and Objectives: Coronary blood flow measurement using a Doppler guidewire is the most sensitive way of detecting the no-reflow phenomenon following reperfusion of a myocardial infarction (MI). New high-frequency Doppler probes enable coronary blood flow velocity to be measured noninvasively. Our aims were to study the different patterns of left anterior coronary artery blood flow observed by transthoracic Doppler echocardiography, and to describe their association with functional recovery following reperfusion of an anterior MI., Methods: The study included 57 patients with a mean age of 60 years (range 30-85 years). An abnormal coronary blo:d flow pattern was defined as one in which there was a high peak diastolic velocity and a short deceleration time (i.e., < or = 500 ms). We compared the regional contractility, ventricular volumes, and left ventricular ejection fraction (LVEF) measured after 72 hours with those measured 1 month after MI., Results: Overall, 31 patients (54%) had a normal coronary blood flow pattern (Group 1) and 26 (46%), an abnormal pattern (Group 2). After one month, regional contractility improved in Group-1 patients, as did LVEF, from 46.8 (8.6) to 52.6 (8.8)% (P=.002). In these patients, left ventricular volumes were unchanged. In contrast, regional contractility and LVEF remained unchanged in Group-2 patients whereas ventricular volumes increased, from 55.8 (12.9) to 62.9 (16.8) ml/m2 (P=.05), and from 32.2 (9.5) to 37.1 (14.9) ml/m2 (P< .05). Coronary blood flow pattern was the most important independent predictor of left ventricular remodeling, odds ratio =6.14 (95% CI, 1.56-24.17)., Conclusions: Transthoracic Doppler echocardiographic assessment of coronary blood flow following reperfusion of an anterior myocardial infarction can be used to identify patients with microvascular damage who are progressing towards ventricular dilatation without recovery of myocardial function.

In dilated cardiomyopathy, severe functional mitral regurgitation (MR) is associated with a poor prognosis. In 112 consecutive clinically stable patients with non-ischemic dilated cardiomyopathy, echocardiography identified 15 (14%) patients who had severe MR (age, 53+/-12 years; 80% male; left ventricular ejection fraction, 26 +/- 8%). Existing medical treatment with ACE inhibitors and beta-blockers was increased up to the maximum tolerated doses. At 6 months, MR decreased by at least one grade in 13 (87%) patients (P =.001), as did the effective regurgitant orifice area (from 0.41 [0.05] mm2 to 0.20 [0.15] mm2; P.

Introduction and Objectives: Implantable cardiac defibrillators (ICD) have been shown to improve survival in patients with myocardial infarctionand LVEF < 0.30 or LVEF < 0.40 + nonsustained ventricular tachycardia + inducible sustained arrhythmias. However, these risk stratification criteria have not been evaluated in patients who are candidates for primary percutaneous transluminal coronary angioplasty (PTCA). The objective of this study was to assess the impact of both strategies on the indication for ICD in a consecutive series of post-infarction patients treated with primary PTCA., Patients and Method: One hundred and two consecutive patients with myocardial infarction (80 men, mean age 63.6 11.5 years) included in a single-center-based regional program of primary PTCA were included in the study. A 24-h continuous ECG recording was obtained 2 to 6 weeks after the acute event, and LVEF was determined by 2D-echocardiography one month after the infarct. Patients with nonsustained ventricular tachycardia and LVEF < 0.40 underwent programmed ventricular stimulation using a standard protocol., Results: Twenty-two patients (21.6%; 95% CI, 13.6-29.6) showed at least one episode of nonsustained ventricular tachycardia in the 24 h recording. Six of them had LVEF < or = 0.40, and sustained ventricular arrhythmia was induced in 2 out of 5. LVEF < or = 0.30 was found in 3 patients, none of whom had nonsustained ventricular tachycardia. Thus, 5 patients had an indication for ICD according to either of the two risk stratification criteria., Conclusions: The prevalence of nonsustained ventricular tachycardia in post-infarction patients treated with primary PTCA is high. However, because most of them have preserved ventricular function, primary prevention with an ICD is indicated in approximately 5% of the population.

Introduction: The Influence of diabetes mellitus in the late outcome of coronary stenting remains controversial., Aim: The aim of this study was to determine the late clinical outcome of diabetics in comparison with non diabetics and to establish whether there are subgroups of diabetic patients with a greater need for target lesion revascularization., Methods: Two hundred sixteen consecutive patients (74 diabetics; 95 stents in 90 lesions and 142 non diabetics) who had successfully undergone coronary stenting were included in the study and followed over 17.6 +/- 10 months. The clinical events evaluated were target lesion revascularization, death and acute myocardial infarction. Independent predictive variables of target lesion revascularization were studied in both groups of patients., Results: The diabetic patients presented greater cardiovascular mortality (6.7% vs 1.4%; p=0.02) but the incidence of infarction was similar in the two groups (2.7% vs. 3.5%; p=0.6). The accumulated rate of target lesion revascularization at two years was 18.2% in diabetics vs 13.3% in non diabetics (p=0.09), respectively. The presence of three vessel disease (p=0.014), history of arterial hypertension ([=0.011) and residual stenosis > 0% (p=0.005) were specific predictive factors of target lesion revascularization for diabetic patients and together with vessel diameter < 3mm (p<0.001) subgroups of diabetics were independently selected with a significantly greater incidence of target lesion revascularization than the non diabetic patients., Conclusions: Following coronary stenting, diabetic patients show a greater cardiovascular mortality than non diabetics, but only some subgroups of diabetics (small vessels extensive coronary disease, associated arterial hypertension, residual stenosis) show a significantly greater risk of target lesion revascularization.