Previous Anterior Myocardial Infarction Research Articles

Do False Tendons Prevent Adverse Left Ventricular Remodeling After Anterior Wall Myocardial Infarction? An Echocardiographic Strain Imaging Study

The role of muscular left ventricular (LV) false tendons (FTs) is poorly understood. To gain insight into their pathophysiologic significance, we adapted echocardiographic LV strain imaging software to measure LVFT longitudinal strain in subjects with normal left ventricles and in patients who sustained previous anterior wall myocardial infarction (AWMI). GE EchoPAC software was used to measure longitudinal strain in LVFTs ≥0.3 cm in diameter. Tendinous strain was measured in 11 patients with LVFTs confined to the left anterior descending artery territory (connecting the anteroseptum or anterior wall to the apex) ≥6 months after AWMI (myocardial infarction [MI]+FT+ group) and in 25 patients with normal hearts containing LVFTs (MI-FT+ group). We also compared the indexed LV end-diastolic volumes in the MI+FT+ group to that of 25 patients with previous AWMI without LVFTs (MI+FT- group). The mean LVFT strain in MI+FT+ group was 5.5 ± 6.2% and -28.9 ± 4.7% in the MI-FT+ group (p <0.0001). The indexed LV end-diastolic volume in the MI+FT+ group did not differ from the MI+FT- group (88.4 ± 17.8 vs 87.9 ± 17 ml/m2, p = 0.90). In conclusion, the negative strain (contraction) developed by LVFTs in the MI-FT+ group may help maintain normal LV size and shape by generating inward restraining forces. The development of positive strain (stretch) in LVFTs in patients in the MI+FT+ group suggests they become infarcted after AWMI. This implies that they are incapable of generating inward restraining forces that might otherwise mitigate adverse remodeling. Of note, LV volumes after AWMI do not differ whether or not LVFTs are present.

Predictive factors for alteration of diastolic function in patients with ST-elevation myocardial infarction

Introduction: Diastolic dysfunction is common in patients with myocardial infarction and is associated with a poor prognosis. Our aim in this study is to describe diastolic function and identify factors predictive of worsening diastolic function in patients admitted in the acute phase of ST-segment elevation myocardial infarction Materials and methods: This was a retrospective descriptive and analytical cohort study performed at the Cardiology Department of the University Hospital of Oujda between November 1, 2018 and October 31, 2019 including patients who presented with STEMI. Echocardiographic results were recorded to assess diastolic function within 48 hours of STEMI. The study population was divided into two groups: Group I (normal diastolic function n=49) and Group II (diastolic dysfunction n=141). Results: Our study included 204 patients, 155 (76%) of whom were men. The mean age was 63 years (SD=11), 69% of patients had diastolic dysfunction, 24.5% of whom had elevated left ventricular filling pressure. Data analysis showed that diabetes (P=0.011), previous anterior myocardial infarction location (P=0.05), impaired left ventricular ejection fraction (P&lt;0.001), left ventricular hypertrophy (P=0.002), high blood glucose on admission (P=0.02) and anemia (P=0.017) were independent predictors of diastolic dysfunction. Conclusion: Knowledge of these predictive factors is important for early detection of those at risk of developing heart failure and requiring strict clinical and echocardiographic monitoring.

Incidence of ventricular tachyarrhythmias and clinical outcomes in primary prophylactic ICD patients in relation to localization of myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction According to current guidelines, primary prophylactic ICD implantation is indicated with a class IA recommendation in patients with severely reduced EF &amp;lt; 35% and ischaemic heart disease. However, it is unclear whether there are differences in patient outcomes related to the localization of myocardial infarction. Aim of the study was to compare the incidence of ventricular tachyarrhythmias and clinical outcomes in primary prophylactic ICD-patients with ischaemic heart disease in relation to the localization of myocardial infarction. Methods A total of 448 consecutive ICD patients from a prospective single-centre ICD-registry who underwent primary prophylactic ICD implantation due to ischaemic cardiomyopathy between 1996 and 2021 were analyzed. Patients with previous anterior wall myocardial infarction (AWMI, n = 293) were compared to those with posterior wall myocardial infarction (PWMI, n = 155). Patients with both AWMI and PWMI were excluded. The median follow-up time was 6 years in both groups. Results Patients with AMWI were younger, more often female, and less often received cardiac synchronization therapy (Table 1). Patients with previous PWMI more often had ICD therapy during follow-up (Figure 1) due to the higher incidence of ventricular tachycardias (Table 1). The all-cause mortality rate was similar between both groups. Conclusion Primary prophylactic ICD patients with previous PWMI have a 10% higher incidence of ventricular tachycardias after 6-year follow-up than ICD patients with previous AMWI. This might be explained by the proximity of the inferior infarction to the mitral isthmus and should be considered when ablating VTs in patients with PWMI.

P164 PERCUTANEOUS LEFT STELLATE GANGLION BLOCK IN REFRACTORY LEFT ATRIAL TACHYCARDIA

Abstract Percutaneous left stellate ganglion block (PLSGB) has been recently implemented for the acute treatment of refractory ventricular arrhythmias (VAs). The beneficial effect on supraventricular arrhythmias susceptibility and their ventricular response is well characterized in animal models, less so in humans. Available data suggest a significant prolongation of atrial refractory period, a reduction in inducibility and duration of atrial fibrillation and of all spontaneous intra– and postoperative atrial arrhythmias after thoracic and cardiac surgery. Here we describe a case of PLSGB for focal atrial tachycardia (AT). Case: we present a 68–year–old men with hypertension, obesity, OSAS and previous anterior myocardial infarction in the setting of a trivessel coronary disease, treated with PCI and complicated by apical aneurysm, with a LVEF of 38% and a moderate mitral and aortic regurgitation. He was on chronic antiarrhythmic therapy with bisoprolol 1.25 mg and ranolazine. He presented in the ED due to palpitations, pre–syncopal episodes, and worsening dyspnea. The ECG showed very frequent, self–limiting episodes of AT with a 1:1 atrioventricular (AV) conduction and a variable heart rate (HR) between 100 and 160 bpm, alternating with sinus rhythm at 45–50 bpm, sometimes conducted with aberrancy. Isolated and repetitive premature ventricular beats (PVB, maximum 8 beats) were also documented. Amiodarone, lidocaine, and intravenous unloading therapy were tried, without benefit. Coronary angiography was negative. PLSGB with an ultrasound–guided lateral approach (local bolus of lidocaine 100 mg+ropivacaine 20 mg) was performed, without complications, inducing palpebral ptosis. Over the next 15 hours we observed the disappearance of non–sustained VAs, the reduction of PVBs, and a progressive reduction of AT burden, of mean hourly HR (from 84 to 50 bpm, –40%) and of mean HR during AT (from 158 to 84 bpm, –47%, with AV 1:1 conduction). The patient subsequently underwent ablation of an extra systolic focus found near the ostium of the right inferior pulmonary vein, with no recurrences after 18 months. Conclusions This case highlights the potential efficacy of PLSGB in the acute treatment of supraventricular arrhythmias refractory to medical therapy. Prospective studies will help us to identify the extent, time of onset, and duration of its benefit depending on the type and mechanism of the underlying arrhythmia and the clinical characteristics of the patient.

Hemodynamical consequences and tolerance of sustained ventricular tachycardia.

Factors underlying clinical tolerance and hemodynamic consequences of monomorphic sustained ventricular tachycardia (VT) need to be clarified. Intra-arterial pressures (IAP) during VT were collected in patients admitted for VT ablation and correlated to clinical, ECG and baseline echocardiographical parameters. 114 VTs from 58 patients were included (median 67 years old, 81% ischemic heart disease, median left ventricular ejection fraction 30%). 61 VTs were untolerated needing immediate termination (54%). VT tolerance was tightly linked to the evolution of IAPs. Faster VT rates (p<0.0001), presence of resynchronization therapy (p = 0.008), previous anterior myocardial infarction (p = 0.009) and more marginally larger baseline QRS duration (p = 0.1) were independently associated with VT tolerance. Only an inferior myocardial infarction was more often present in patients with only tolerated VTs vs patients with only untolerated VTs in multivariate analysis (OR 3.7, 95% CI 1.4-1000, p = 0.03). In patients with both well-tolerated and untolerated VTs, a higher VT rate was the only variable independently associated with untolerated VT (p = 0.02). Two different patterns of hemodynamic profiles during VT could be observed: a regular 1:1 relationship between electrical (QRS) and mechanical (IAP) events or some dissociation between both. VT with the second pattern were more often untolerated compared to the first pattern (78% vs 29%, p<0.0001). This study helps to explain the large variability in clinical tolerance during VT, which is clearly related to IAP. VT tolerance may be linked to resynchronization therapy, VT rate, baseline QRS duration and location of myocardial infarction.

484 PAPILLARY FIBROELASTOMA OF THE AORTIC VALVE ASSOCIATED WITH MYOCARDIAL INFARCTION, COMPLICATED BY ELECTRICAL STORM AND ENDOVENTRICULAR THROMBOSIS

Abstract Introduction Papillary fibroelastomas (PFE) are reported to be the most common tumors of the heart valves and are a possible source of systemic embolism, including myocardial infarction. Case Report We report the case of a 67-year-old female with no background of cardiovascular disease, admitted to our hospital with worsening dyspnea and chest tightness over the prior 10 days. The ECG showed a sustained hemodynamically tolerated monomorphic ventricular tachycardia, successfully treated with antiarrhythmic therapy, and ECG in sinus rhythm revealed signs of previous anterior myocardial infarction. Transthoracic echocardiogram showed a severely depressed systolic function (LVEF 19%), akinesia and thinning of the anterior wall and of all middle-apical segments, complicated by left ventricular aneurysm and endoventricular thrombosis. In the ventricular side of right aortic coronary cusp a mobile, pedunculated mass of 12×8 mm was visualized. A subsequent TEE corroborated the suspicion of PFE. She underwent cardiac MRI which showed areas of transmural late enhancement in all akinetic segments. A coronary angiography revealed sub-occlusion of the mid-anterior descending artery with no angiographic evidence of coronary atherosclerosis elsewhere. In view of her reduced LVEF and history of VT, an ICD was implanted. She started oral anticoagulant therapy and complete resolution of the endoventricular thrombosis was evidenced. After several days of electrical instability, characterized by multiple episodes of ventricular tachycardia, the clinical course was characterized by progressive clinical and electrical improvement and she was discharged in good clinical conditions after four weeks. Due to the severe impairment of the systolic function, not susceptible to surgical remodeling and the high operative risk, no indication for surgical removal of the mass was made. Conclusion Aortic PFE carry a not negligible risk of acute coronary syndrome, electrical storm and sudden death. It should be considered as the cause of myocardial infarction, and not an incidental finding, especially in patients with no angiographic evidence of coronary atherosclerosis.

C3 A RARE AND ATYPICAL CASE OF ICD POCKET HEMATOMA CONTAINING PSEUDOCHYLOUS

Abstract Subcutaneous hematoma is a complication in 2–9% of cardiac device implants.In most cases, it is drained or spontaneously reabsorbed; if untreated, there is a risk of infection.While cases of chylothorax and pseudochylothorax are rare, no previous cases of accumulation of chyliform material in the subcutaneous pockets of cardiac devices have ever been documented.We present the case of a 60–year–old man with antibody syndrome antiphospholipids, rheumatoid arthritis, previous acute anterior myocardial infarction and aorto–coronary by–pass surgery, paroxysmal atrial fibrillation, in oral anticoagulant therapy. In 2020, the patient underwent primary prophylactic dual–chamber ICD implantation (EF 33%) at another center, complicated by the formation of a large pocket hematoma, which required drainage and evacuation. In the following weeks, the patient noticed the reappearance of a large swelling in the ICD pocket; however, as it was painless and not troublesome, he did not seek medical attention. After 7 months he came to our observation with signs of heart failure. Clinical examination revealed a large swelling in the left pectoral area (Fig. 1), extending to the nipple, soft, not painful, not hot or red.The patient had no signs of infection (normal ESR, CRP, procalcitonin and WBC). We decided to drain the hematoma, given the size. At the level of the defibrillator pocket, we made a small incision, from wich 100ml of gold–colored, odorless liquid leaked out (Fig. 2), with no evidence of blood material in the pocket. The ICD–case was then wrapped in a rifampicin–releasing antibacterial bag and reinserted into the subcutaneous pocket, without further complications. The chemical–physical examination revealed a cloudy, gold–colored liquid, density of 1020, pH 8.5, high protein content (&amp;gt;400g/l), absence of glucose.Microscopic examination shows isolated leukocytes, rare erythrocytes immersed in mucoid material; this was not pus, as culture testing was negative for bacterial growth. The cholesterol concentration was 704mg/dl, triglycerides 80mg/dl (plasma cholesterol values were 91mg/dl, triglycerides 48mg/dl). The cytological analysis showed a carpet of foamy macrophages filled with cholesterol crystals (Fig. 3). Such evidence supports the diagnosis of pseudochilous, formed from the evolution of an untouched hematoma in a fibrous subcutaneous pocket for more than 6 months.This is the first case in which the presence of chyliform material is documented in an ICD pocket.

The predictive value of serum SCUBE-1 level for left ventricular thrombus in patients with post myocardial infarction heart failure

Abstract Objectives Left ventricular thrombus is regarded as one of the main myocardial infarction complications. Knowing the left ventricular thrombus symptoms prevents serious complications that may occur. This study aims to reveal any association between SCUBE-1 and left ventricular thrombus, thought to be involved in platelet aggregation and adhesion. Methods The study included 80 patients diagnosed with heart failure following acute myocardial infarction, applying for the cardiology outpatient clinic for third-month follow-up. The patients were included in two groups to see if the left ventricular thrombus was present. Thus, 22 patients were found to have left ventricular thrombus. The two groups were compared based on clinical laboratory and echocardiographic parameters. Results It was found that the patients with left ventricular thrombus had significantly higher Serum SCUBE-1 levels (p&lt;0.001). The optimal cutoff point of SCUBE-1 levels for predicting the LVT was &gt;35.1 ms, with the specificity of 86% and sensitivity of 68.4% (AUC=0.815; 95% CI, 0.699–0.931; p&lt;0.0001). SCUBE -1 level (OR=1.090, 95% CI: 1.034–1.150, p&lt;0.001) in the multiple logistic regression model continue to significantly predict LVT after adjusting for the confounding variables, as statistically significant in the univariate analysis of the variables which correlated with the SCUBE-1 levels. Conclusions SCUBE-1 level was determined to independently predict the left ventricular thrombus after a previous anterior myocardial infarction.

C55. Intramyocardial dissecting hematoma, a rare complication after myocardial infarction : a case report

Abstract Background Intramyocardial dissecting hematoma (IDH) is a rare complication of myocardial infarction (MI) that contribute to high morbidity and mortality rate. There is scarce information in literature and hence management uncertainties. Additionally, coronary reperfusion results on the occurrence of IDH is still poorly understood. Case Summary A 49-year-old man with a previous anterior wall MI 3 months before without revascularization, presented with a recent onset of New York Heart Association (NYHA) functional class IV heart failure. Echocardiographic diagnosis of IDH was based on the presence of a neocavity with an endomyocardial border extending from the LV mid inferoseptal wall to the apical segments, corroborated with cardiac magnetic resonance (CMR). Coronary angiography showed severe three-vessel disease. The patient underwent staged complete revascularization and kept on optimal medical management. With non-surgical treatment, the patient remained clinically stable and showed a gradual improvement. Repeated echocardiography up to one year after the initial diagnosis demonstrated regression of the haematoma. Discussion An unusual form of myocardial rupture that can complicate acute myocardial infarction is IDH. The diagnosis can be missed in some cases. Transthoracic echocardiography may allow diagnosing and evaluating IDH at the bedside. Controversy exists regarding whether surgical repair or conservative treatment is the best option for this condition. The appropriate management should be individualized. Conservative treatment in clinically stable patients suffering from IDH following MI and coronary intervention can be a feasible option.

C55. Intramyocardial dissecting hematoma, a rare complication after myocardial infarction : a case report

Abstract Background Intramyocardial dissecting hematoma (IDH) is a rare complication of myocardial infarction (MI) that contribute to high morbidity and mortality rate. There is scarce information in literature and hence management uncertainties. Additionally, coronary reperfusion results on the occurrence of IDH is still poorly understood. Case Summary A 49-year-old man with a previous anterior wall MI 3 months before without revascularization, presented with a recent onset of New York Heart Association (NYHA) functional class IV heart failure. Echocardiographic diagnosis of IDH was based on the presence of a neocavity with an endomyocardial border extending from the LV mid inferoseptal wall to the apical segments, corroborated with cardiac magnetic resonance (CMR). Coronary angiography showed severe three-vessel disease. The patient underwent staged complete revascularization and kept on optimal medical management. With non-surgical treatment, the patient remained clinically stable and showed a gradual improvement. Repeated echocardiography up to one year after the initial diagnosis demonstrated regression of the haematoma. Discussion An unusual form of myocardial rupture that can complicate acute myocardial infarction is IDH. The diagnosis can be missed in some cases. Transthoracic echocardiography may allow diagnosing and evaluating IDH at the bedside. Controversy exists regarding whether surgical repair or conservative treatment is the best option for this condition. The appropriate management should be individualized. Conservative treatment in clinically stable patients suffering from IDH following MI and coronary intervention can be a feasible option.

Clinical, procedural and long-term outcome of ischemic VT ablation in patients with previous anterior versus inferior myocardial infarction

BackgroundOutcome of ischemic VT ablation may differ between patients with previous myocardial infarction (MI) in relation to infarct localization.MethodsWe analyzed procedural data, acute and long-term outcomes of 152 consecutive patients (139 men, mean age 67 ± 9 years) with previous anterior or inferior MI who underwent ischemic VT ablation at our institution between January 2010 and October 2015.ResultsMore patients had a history of inferior MI (58%). Mean ejection fraction was significantly lower in anterior MI patients (28 ± 10% vs. 34 ± 10%, p < 0.001). NYHA class and presence of comorbidities were not different between the groups. Indication for the procedure was electrical storm in 43% of patients, and frequent implantable cardioverter defibrillator (ICD) therapies in 57%, and did not differ significantly between anterior and inferior MI patients. A mean of 3 ± 2 VT morphologies were inducible, with a trend towards more VT in the anterior MI group (3.1 ± 2.2 vs. 2.6 ± 1.9, p = 0.18). Procedural parameters and acute success did not differ between the groups. During a mean follow-up of 3 ± 2 years, more anterior MI patients had undergone a re-ablation (49% vs. 33%, p = 0.09, Chi-square test). There was a trend towards more ICD shocks in patients with previous anterior MI (46% vs. 34%). After adjusting for risk factors and ejection fraction, multivariable Cox regression analyses showed no significant difference in mortality (p = 0.78) and cardiovascular mortality between infarct localizations (p = 0.6).ConclusionClinical characteristics of patients with anterior and inferior MI are similar except for ejection fraction. Patients with inferior MI appear to have better outcome regarding survival, ICD shocks and re-ablation, but this appears to be related to better ejection fraction when compared with anterior MI.

Clinical significance of reversed R wave progression in right precordial leads.

Objective: Poor R wave progression in right precordial leads is a relatively common electrocardiogram (ECG) finding that indicates possible prior anterior myocardial infarction (MI); however, it is observed frequently in apparently normal individuals. In contrast, reversed R wave progression (RRWP) may be more specific to cardiac disorders; however, the significance of RRWP in daily clinical practice is unknown. The purpose of this study was to clarify the significance of RRWP in clinical practice.Materials and Methods: We analyzed consecutive ECGs obtained from 12,139 patients aged ≥20 years at Mito Kyodo General Hospital in Ibaraki between November 2009 and August 2012. Our setting is a secondary emergency hospital in the community, and the study participants were inpatients or patients who visited the general or emergency outpatient departments. RRWP was defined as RV2 < RV1, RV3 < RV2, or RV4 < RV3. Regarding ECGs considered to show RRWP, we confirmed the presence or absence of an abnormal Q wave and whether ultrasound cardiography, contrast-enhanced computed tomography, coronary angiography, and/or left ventriculography were performed to obtain detailed information.Results: RRWP was identified in 34 patients (0.3%). Among these patients, 29 (85%) had undergone cardiac evaluation. The final diagnosis was previous anterior MI in 12 patients (41%) and ischemic heart disease (IHD) without MI in 5 patients (17%). All 17 patients with IHD had left anterior descending (LAD) artery stenosis. The other patients were diagnosed with dilated (two patients, 7%) and hypertrophic (one patient, 3%) cardiomyopathy, left ventricular hypertrophy (one patient, 3%), or pulmonary embolism (one patient, 3%). Only seven patients (24%) were normal.Conclusions: RRWP is rare in daily clinical practice; however, it is a highly indicative marker for cardiac disease, particularly IHD with LAD artery stenosis.

Time series analysis of physiologic left ventricular reconstruction in ischemic cardiomyopathy

ObjectiveThe history of left ventricular reconstruction has demonstrated that the full spectrum of recoverable physiologic parameters is essential for a good functional result. We report the long-term outcome of a new surgical technique that arranges myocardial fibers in a near-normal disposition, also recovering left ventricular twisting. MethodsBetween May 2006 and October 2013, 29 consecutive patients with previous anterior myocardial infarction and heart failure symptoms underwent physiologic left ventricular reconstruction surgery and coronary revascularization. Patients were examined by means of standard echocardiography and 2-dimensional speckle tracking at 8 time steps until 7 years after surgery. Ten geometric and functional parameters were evaluated at each step and analyzed by the linear mixed model test. ResultsHospital mortality was 0%. The mean percentage of indexed end-diastolic and end-systolic volume reduction was 45.7% and 50.9%, respectively. Ejection fraction and all of the volumes were significantly different in the postoperative period with a steady correction during time. Diastolic parameters were not worsened by surgical reconstruction. Ejection fraction and deceleration time showed a significant improvement during time. Left ventricular torsion increased immediately after the surgical correction from 2.8 ± 4.4 degrees to 8.7 ± 3.9 degrees (P = .02) and was still present 4 years after surgery. ConclusionsSurgical conduction of ventricular reconstruction should be standardized to achieve the full spectrum of recoverable physiologic parameters. The renewal of ventricular torsion should be pursued as an adjunctive element of ventricular efficiency, mainly in ventricles that work at a critical level in the Frank–Starling relationship and pressure-volume loop.

0090: Comparison between non-invasive coronary flow reserve, instantaneous wave-free ratio, and fractional flow reserve, to assess the functional significance of LAD stenosis of intermediate severity

Assessment of the functional significance of left anterior descending coronary artery (LAD) stenosis of intermediate severity (IS) is challenging. A direct comparison of fractional flow reserve (FFR), instantaneous wave-free ratio (IFR), and non-invasive coronary flow reserve (CFR) has never been performed. Our objective was to test the usefulness of noninvasive CFR by comparison to invasive FFR and IFR in patients with LAD stenosis of angiographic IS and stable coronary artery disease. 58 stable consecutive patients (mean age, 68±10 years; with angiographic proximal or mid LAD stenosis of IS (40-70% diameter stenosis on quantitative coronary angiography), no previous anterior myocardial infarction, were prospectively studied. They underwent iFR which was calculated as a trans-lesion pressure ratio during a specific period of baseline diastole, FFR with intracoronary bolus adenosine (150μg), and CFR using intravenous adenosine (140μg/kg/min over 2min) in the distal part of the LAD, the same day. CFR was defined as hyperemic peak diastolic LAD flow velocity divided by baseline flow velocity, and FFR was defined as distal pressure divided by mean aortic pressure during maximal hyperemia. The mean values of iFR, FFR, and CFR were 0.88±0.07, 0.81±0.08, and 2.4±0.6 respectively. A significant correlation was found between CFR and FFR (r=0.72, curvilinear relationship), FFR and IFR (r=0.63, linear relationship), and between CFR and IFR (r=0.44) (all, p<0.01). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR <0.8, n=16) was iFR ≤0.86 with a sensitivity (Se) of 75%, specificity (Sp) of 81%, AUC 0.8±0.05; and CFR ≤2 with a Se of 82%, Sp of 85%, AUC 0.9±0.03, (all, p<0.001). Based on these cut-offs, discordant results between CFR and FFR were observed in 9 cases (accuracy 84%), between CFR and iFR in 14 cases (accuracy 76%), and between iFR and FFR in 11 cases (accuracy 81%). In stable patients with LAD stenosis of IS, non-invasive CFR is a useful tool to detect a significant lesion based on FFR. Furthermore, CFR is better correlated to FFR than to iFR, and its accuracy seems as good as iFR in this setting.

Ventricular fibrillation waveform characteristics differ according to the presence of a previous myocardial infarction: A surface ECG study in ICD-patients

BackgroundCharacteristics of the ventricular fibrillation (VF) waveform reflect arrest duration and have been incorporated in studies on algorithms to guide resuscitative interventions. Findings in animals indicate that VF characteristics are also affected by the presence of a previous myocardial infarction (MI). As studies in humans are scarce, we assessed the impact of a previous MI on VF characteristics in ICD-patients. MethodsProspective cohort of ICD-patients (n=190) with defibrillation testing at the Radboudumc (2010–2013). VF characteristics of the 12-lead surface ECG were compared between three groups: patients without a history of MI (n=88), with a previous anterior (n=47) and a previous inferior MI (n=55). ResultsAs compared to each of the other groups, the mean amplitude and amplitude spectrum area were lower, for an anterior MI in lead V3 and for an inferior MI in leads II and aVF. Across the three groups, the bandwidth was broader in the leads corresponding with the infarct localisation. In contrast, the dominant and median frequencies only differed between previous anterior MI and no history of MI, being lower in the former. ConclusionsThe VF waveform is affected by the presence of a previous MI. Amplitude-related measures were lower and VF was less organised in the ECG-lead(s) adjacent to the area of infarction. Although VF characteristics of the surface ECG have so far primarily been considered a proxy for arrest duration and metabolic state, our findings question this paradigm and may provide additional insights into the future potential of VF-guided resuscitative interventions.

Computed tomographic analysis of left ventricular volumes and function after implantation of the Parachute® endoventricular partitioning device.

Preliminary clinical experience with a percutaneous endoventricular partitioning device (Parachute®, CardioKinetix Inc., Menlo Park, CA, USA) suggests that it ameliorates global LV dysfunction and heart failure symptoms in selected patients who have suffered previous anterior myocardial infarction. Less is known of its effect on regional LV function. To gain insight into device effect on regional LV function by analysis of cardiac computed tomographic (CT) images obtained before and after device implantation. Comparative analysis of pre and 6 months post-implantation contrast-enhanced CT images from 6 subjects enrolled in the phase 1 Parachute clinical trials, including regional LV volume and systolic excursion, as well as device motion. After implantation, a significant reduction in volume of the "dynamic" LV compartment (that which was not excluded by the device) was accompanied by a significant reduction in dykinetic motion and a trend toward an improved ejection fraction. Penetration of contrast into the excluded compartment was still present at 6 months, however the apical motion was significantly less dyskinetic in 3 subjects and unchanged in the other 3. Overall device surface motion was inward in systole, a significant improvement relative to the overall dyskinetic LV apex pre-implantation. Device motion was spatially heterogeneous, which appeared to be dependent on the motility of the myocardium that anchored its individual splines. Our data suggest that the Parachute device acts as a functional impediment to flow and stretch, effectively depressurizing the apical segment.

Pacing Inter-lead Fluoroscopic RAO and LAO Distance and Cardiac Resynchronization Therapy Response

Objective: The Inter-lead Distance (ILD) between the Right and Left Ventricular (RV and LV) pacing leads may play a role in Cardiac Resynchronization Therapy (CRT) response. We sought to measure the ILD during the CRT procedure in the Left and Right Anterior Oblique (LAO and RAO) fluoroscopy projections and correlated these measurements with Trans-Thoracic Echocardiographic (TTE) reverse remodeling. The ILD was measured in the LAO and RAO projections to obtain 2 direct (LAO ILD and RAO ILD) and 1 merged bi-dimensional (LAO ILD×RAO ILD Index) body surface-normalized indexes. Methods and results: Between January and December 2010, 48 consecutive CRT patients were enrolled (15/48, 31.2% with upgrading indications). Fourty-five patients (mean age 72.6 ± 9 years, 28 males) completed the TTE follow up at mean of 12.3 ± 7.8 months. They were divided into CRT “responders” and “non-responders” according to the combined endpoint of LV Ejection Fraction (LVEF) improvement and LV End-Systolic Volume (ESV) reduction. Twenty-five (55%) patients were classified as responders. No difference in the 3 ILD indexes was found between responders and non-responders. In the univariate analysis, non-responders patients were more frequently affected by an ischemic cardiomyopathy and by a previous anterior myocardial infarction (Table 2). In the further multivariate analysis, no variable characterized the study groups. Conclusions: In our study, the mono and bi-dimensional ILD failed to predict a reverse remodeling in CRT patients.

PACE-ECG IN PREVIOUS MYOCARDIAL INFARCTION: AN UNFINISHED STORY

Aim. The diagnosis of previous myocardial infarction (MI) is difficult in patients with pacemaker and usually further tests must be done to confirm the diagnosis. To overcome this difficulty five major ECG criteria have been proposed by authors: 1. Notching 0.04 second in the ascending limb of the S wave of leads V3,4 or 5 (Cabrera’s sign), 2. Notching of the upstroke of the R wave in leads I, aVL or V6 (Chapman’s sign), 3. Q wave &gt;0.03 second in leads I, aVL or V6, 4. Notching of the first 0.04 second of the QRS complex in leads II, III, aVF, 5. Q wave &gt;0.03 second in leads II, III, aVF. The aim of this study is to find the predictive value of the five major proposed criteria for MI in pacing ECG of patients with previous MI. Material and methods. Twenty- three pacemaker patients with known MI (anterior 15, inferior 8) and 24 healthy pacemaker control patients; 17 female, 30 males, aged between 17-92 years with mean age of 59,5 ± 20 years, total 47 patients were studied. Documentation and localization of MI was based on history and confirmed by angiography and or scintigraphy. Results. Sensitivity was lower in all parameters for prediction of any MI whereas specificity was higher and ODA was moderate. Cabrera’s and Chapman’s sign had moderate sensitivity (60%-60%) whereas high specificity (90%-90%) and ODA (81%-81%) for anterior MI. Sensitivity of Q wave in I, aVL or V6 was lower (47%) for anterior MI but specificity and ODA was higher 84% and 92% respectively. Conclusion. In conclusion Cabrera’s and Chapman’s sign have a moderate sensitivity and higher specificity for recognising previous anterior MI in pacing patients.

Left atrial mechanical functions in patients with anterior myocardial infarction: a velocity vector imaging-based study

The contribution of the left atrium (LA) to left ventricular (LV) function increases in myocardial infarction (MI). To evaluate LA function by using volume measurements and a novel strain imaging method, namely velocity vector imaging (VVI), in patients with acute anterior MI. Twenty-four patients with previous anterior MI (aged 63.8 ± 4.2 years, 56% men) and 30 healthy controls (aged 60.7 ± 5.3 years, 60% men) were enrolled. LA volume measurements and VVI-derived LA peak systolic strain (S), strain rate (SRs), early diastolic (ESRd) and late diastolic strain rate (LSRd) were measured. LV diastolic function was analysed by pulsed wave-Doppler and tissue velocity ımaging. LA maximum volume index was increased in patients compared to controls (28.83 ± 7.2 vs. 19.72 ± 6.27 mL/m²,p = 0.0001). As LA active emptying volume index and fraction were increased (6.16 ± 0.7 vs. 5.46 ± 0.99 mL/m², p = 0.009 and 22.16 ± 3.07 vs. 16.78 ± 2.93%, p = 0.0001, respectively), passive emptying volume index and fraction were decreased in the patient group (6.09 ± 0.57 vs. 7.57 ± 0.61 mL/m², p = 0.0001 and 45.76 ± 6.86 vs. 56.45 ± 5.36%, p = 0.0001, respectively). However, total emptying volume index of the LA was similar between the two groups. VVI-derived LA peak systolic S, SRs and ESRd were impaired in the patient group. LA LSRd was similar between the groups. LA active emptying fraction was positively correlated with LV diastolic dysfunction and negatively correlated with LV systolic dysfunction. We demonstrated increased LA booster function and decreased LA conduit and reservoir functions in patients with prior anterior MI. Improvement in LA booster function correlated with the degree of LV systolic and diastolic dysfunction, suggesting a compensatory response of the LA.

Post myocardial infarction left ventricular dysfunction – Assessment and follow up of patients undergoing surgical ventricular restoration by the endoventricular patchplasty

Authors of this important article by D'Mello et al, have nicely presented a prospective study of clinical and echocardiographic follow up of Left Ventricular (LV) geometry of 59 consecutive patients with previous transmural anterior myocardial infarction, who underwent LV restoration, analyzed between June 2007 and May 2008.1 The authors are to be complemented for this important series which showed excellent immediate and short-term results following LV restoration surgery. The results show a progressive remodeling after ventricular reconstruction mainly by excluding the scar area. Volume reduction is more important than the post surgical shape of the ventricle. The study was done before the MRI era; and hence the images of the scar are not demonstrated in the study.2,3 Analysis of the precise mechanism of remodeling is perhaps not possible without MRI. Distinction between dyskinetic and akinetic forms of the scar are not clearly brought out; it is usually transmural with dyskinesia and subendocardial with akinesia. The size of a synergy and its extension determine the extent of remodeling.4,5 It is surprising that these 59 patients were not severe cases of ischemic failing ventricle, as the mean ejection fraction was 33.5 ± 5%, preoperative end diastolic volume index 89.7 ± 6 and end systolic volume index 48.8 ± 11.3 which are below the threshold of very severe cardiac failure. White et al have given a figure of >60 ml of end systolic volume index as the major determinant of survival after recovery from myocardial infarction.6 This work is indeed of great interest and I hope the authors with their experience will present more severe cases showing a positive interest in LV reconstruction and thereby demonstrating that the S.T.I.C.H trial was a miss organized trial.7 The global approach of heart failure by Buckberg cannot be accepted; it is apparent that Buckberg is a prisoner of his “flying fancies” trying to establish something without any serious base.7 The myocardial systolic contraction is a “twist up” like a “snake” ascension. The crux of the problem of systolic heart failure is the ventricular spherical dilatation whatever be the anatomic substrate. The surgical ventricular restoration (S.V.R) or surgical anterior ventricular restoration (S.A.V.R) are acronyms in place of left ventricular reconstruction (L.V.R.) because this technique is applied most of time only for anterior LV wall, with the objective of “volume reduction” and to get an elliptical shape of LV. Finally, I would like to emphasize the following points: Ventricular wall has a systolic concentric (centripetal contraction) confirmed by MRI video examination of left ventricular wall in 4 projections.8 Heart failure is not an entity but a syndrome with various causes; in post myocardial infarction failure, the cause is an extension of the necrotic, then fibrous and finally calcified transmural or subendocardial scar, when it reaches = or <30% of LV perimeter. The dilatation is not the cause, but the consequence; dilatation is more ovoid than spherical. LVR as proposed by as in 1984, have these main goals: to suppress or exclude the scarred asynergic wall, to abolish the mechanism of progressive dilatation i.e. the eccentric systolic motion, restoring the curvature of non-infarcted myocardium and maintain the physiological diastolic volume of the rebuilt cavity by balloon sizing before “clothing” of the cavity by a patch anchored on contractile edge of normal myocardium.9 In conclusion, this article by D'Mello et al demonstrates and emphasizes the modern approach toward post myocardial infarction heart failure which is a very prevalent disease encountered in day to day clinical practice.