Reduction Of Myocardial Ischemia Research Articles

Effects of Ivabradine on Myocardial Perfusion in Chronic Angina: A Prospective, Preliminary, Open-Label, Single-Arm Study.

Ivabradine reduces heart rate (HR), episodes of angina, and nitrate consumption, and increases exercise capacity in patients with chronic angina (CA). In this exploratory study, myocardial perfusion scintigraphy (MPS) was used to evaluate changes in the percentage of myocardial ischemia after ivabradine therapy in patients with CA. This prospective, open-label, single-arm study included patients with CA receiving maximum tolerated doses of beta blockers, who had a resting HR ≥ 70bpm and had experienced ischemia according to MPS during an exercise test at baseline. Participants received ivabradine 5mg twice daily (titrated according to HR) concomitant with beta blockers. A second MPS was performed after 3months, without interruption of treatment with beta blockers or ivabradine. The primary outcome was change in the percentage of myocardial ischemia from baseline to 3months. Time to ischemia during the exercise test, the proportion of patients presenting angina during the exercise test, and health status, assessed using the seven-item Seattle Angina Questionnaire-7 (SAQ-7), were also evaluated. Twenty patients (3 females) with a mean (± standard deviation [SD]) age of 62.2 ± 6.5years were included in the study, of whom 55% had diabetes, 70% had previous myocardial revascularization, and 45% had previous myocardial infarction. The percentage of patients with myocardial ischemia significantly decreased from baseline to 3months after initiation of treatment with ivabradine (- 2.9%; 95% confidence interval [CI] - 0.3 to - 5.5; p = 0.031). Mean time to appearance of ischemia increased from 403 ± 176s at baseline to 466 ± 136s at 3 months after initiation of ivabradine (Δ62 s; 95% CI 18-106 s; p = 0.008), and the proportion of patients experiencing angina during the exercise test decreased from 40% at baseline to 5% also at 3 months (p = 0.016). Mean resting HR decreased from 76 ± 7bpm at baseline to 55 ± 8bpm at 3 months (p < 0.001). The mean SAQ-7 summary score improved from 69 ± 21 at baseline to 83 ± 12 at 3months (p = 0.001). No serious adverse effects were reported. Ivabradine added to beta blockers was associated with a reduction in detectable myocardial ischemia by MPS in patients with CA. Infographic available for this article. The trial has been retrospectively registered with the Brazilian Registry of Clinical Trials (REBEC) under the following number RBR-5fysqrh (date of registration: 30 November 2023).

A Case Report of Kounis Syndrome Developing Anaphylaxis Secondary to Vitamin B and C Infusion

Kounis syndrome is a condition characterized by temporary coronary spasm, reduction in coronary blood flow and myocardial ischemia by activated mast cells as a result of an abnormal immune reaction to a drug or molecule. It is also called allergic angina and allergic myocardial infarction. It was first described by Kounis and Zarvas in 1991. (1) Kounis syndrome can be observed in all age groups regardless of the history of coronary artery disease. Kounis syndrome may occur due to environmental factors such as drugs, intracoronary stent implantation, foods, insect bites, bee stings, pollen, latex exposure etc. In our case report, acute coronary syndrome occurring during anaphylaxis secondary to vitamin B and C infusion, which is frequently used in clinical practice, will be explained.

Additional improvement in regional myocardial ischemia after intracardiac injection of bone marrow cells during CABG surgery.

Post-procedure residual ischemia is associated with worse prognosis in patients with coronary artery diasease (CAD). We evaluated whether autologous bone marrow-derived cells (BMC) contribute to additional reduction in regional stress-induced myocardial ischemia (SIMI) in patients undergoing incomplete coronary artery bypass graft surgery (CABG). In a double-blind, randomized, placebo-controlled trial, we enrolled 143 patients (82% men, 58 ± 11 years) with stable CAD and not candidates for complete CABG. They received 100 million BMC (n = 77) or placebo (n = 66) injected into ischemic non-revascularized segments during CABG. The primary outcome was improvement on SIMI quantified as the area at risk in injected segments assessed by cardiovascular magnetic resonance (CMR) 1, 6, and 12 months after CABG. The reduction in global SIMI after CABG was comparable (p = 0.491) in both groups indicating sustained beneficial effects of the surgical procedure over 12 month period. In contrast, we observed additional improvement in regional SIMI in BMC treated group (p = 0.047). Baseline regional SIMI values were comparable [18.5 (16.2-21.0) vs. 18.5 (16.5-20.7)] and reached the lowest values at 1 month [9.74 (8.25; 11.49) vs. 12.69 (10.84; 14.85)] for BMC and placebo groups, respectively. The ischemia's improvement from baseline represented a 50% difference in regional SIMI in favor of the BMC transplanted group at 30 days. We found no differences in clinical and LVEF% between groups during the 12 month follow-up period. The 1 month rate of major adverse cerebral and cardiovascular events (MACCE) (p = 0.34) and all-cause mortality (p = 0.08) did not differ between groups 1 month post intervention. We provided evidence that BMC leads to additional reduction in regional SIMI in chronic ischemic patients when injected in segments not subjected to direct surgical revascularization. This adjuvant therapy deserves further assessment in patients with advanced CAD especially in those with microcirculation dysfunction. https://clinicaltrials.gov/, identifier NCT01727063.

Surgical approach for anomalous aortic origin of a coronary artery: A comparison of two techniques.

Un-roofing is the most common technique utilized for repair of anomalous aortic origin of a coronary artery (AAOCA). There are very few publications directly comparing un-roofing to another surgical technique, like reimplantation. The prospectively collected Children's Memorial Hermann Heart Institute Society of Thoracic Surgeon's Database was retrospectively reviewed from 2007 to 2021. Surgical patients were included if they underwent un-roofing or reimplantation of the AAOCA. The primary outcomes of this study were operative characteristics and postoperative outcomes. Secondary outcomes included angiographic outcomes, aortic regurgitation incidence, ventricular function, and symptom relief. From 2007 to 2021, there were 12 patients who underwent either a reimplantation (n = 9, 73%) or un-roofing (n = 3, 27%) for an AAOCA. The hospital length of stay was a median of 1.8 days longer for reimplantation compared to un-roofing. The last follow-up echocardiogram was a median of 52.2 days later in the reimplantation group. There was one patient (11%) in the reimplantation group that had more than or equal to mild aortic regurgitation and mild systolic ventricular dysfunction. Outpatient follow-up was incomplete and there was no postoperative computed tomographic angiography in the un-roofing cohort. Coronary artery reimplantation is a valuable alternative surgical technique to un-roofing for the repair of AAOCA. There are still some concerns with the creation of aortic regurgitation or incomplete symptom relief with any surgical technique. Longer-term follow-up and prospective studies will be needed to show an effective reduction of myocardial ischemia and risk of sudden cardiac death.

Autologous skeletal myoblast patch implantation prevents the deterioration of myocardial ischemia and right heart dysfunction in a pressure-overloaded right heart porcine model.

Right ventricular dysfunction is a predictor for worse outcomes in patients with congenital heart disease. Myocardial ischemia is primarily associated with right ventricular dysfunction in patients with congenital heart disease and may be a therapeutic target for right ventricular dysfunction. Previously, autologous skeletal myoblast patch therapy showed an angiogenic effect for left ventricular dysfunction through cytokine paracrine effects; however, its efficacy in right ventricular dysfunction has not been evaluated. Thus, this study aimed to evaluate the angiogenic effect of autologous skeletal myoblast patch therapy and amelioration of metabolic and functional dysfunction, in a pressure-overloaded right heart porcine model. Pulmonary artery stenosis was induced by a vascular occluder in minipigs; after two months, autologous skeletal myoblast patch implantation on the right ventricular free wall was performed (n = 6). The control minipigs underwent a sham operation (n = 6). The autologous skeletal myoblast patch therapy alleviated right ventricular dilatation and ameliorated right ventricular systolic and diastolic dysfunction. 11C-acetate kinetic analysis using positron emission tomography showed improvement in myocardial oxidative metabolism and myocardial flow reserve after cell patch implantation. On histopathology, a higher capillary density and vascular maturity with reduction of myocardial ischemia were observed after patch implantation. Furthermore, analysis of mRNA expression revealed that the angiogenic markers were upregulated, and ischemic markers were downregulated after patch implantation. Thus, autologous skeletal myoblast patch therapy ameliorated metabolic and functional dysfunction in a pressure-overloaded right heart porcine model, by alleviating myocardial ischemia through angiogenesis.

Rekanalisation chronischer Koronarverschlüsse

Recanalisation of chronic total coronary occlusions - what is the evidence and which patients will benefit? Abstract. Continuous improvement of recanalisation techniques and newer device technologies significantly improved the success of revascularisation in percutaneous coronary intervention (PCI) of chronic total occluded coronary arteries (CTO) in the past few years. The best documented clinical benefit of CTO-PCI is symptom control, based on a reduction of myocardial ischemia. In contrast, there is still an ongoing controversial debate regarding the prognostic benefit of successful CTO-PCI shown in several observational studies. Therefore, the indication for CTO-PCI is primarily based on patients' symptoms and the extent of myocardial ischemia. The risk / benefit ratio for the individual patient has to be estimated from technical complexity of the CTO lesion, the extent of the coronary artery disease and the ventricular function. Recanalisation strategy should be escalating, as most of the CTOs can be successfully recanalised with standard antegrade recanalisation techniques. With the implementation of retrograde CTO techniques, the likelihood for recanalisation success is very high (> 90 %) even in complex anatomies, combined with low complication rates in specialised centers. According to the operator's expertise a complete catheter-based revascularisation can be achieved nowadays even in patients with CTO and coronary multi-vessel disease.

Sutureless Perceval versus Bioprosthetic Aortic Valve, Single Center Experience

Background: High-risk patients are currently presenting for aortic valve replacement (AVR). Sutureless valves may decrease the operative risk in those patients. The objective of this study was to compare the short-term and one-year follow-up results of the sutureless Perceval valve versus bioprosthetic aortic valve.&#x0D; Methods: The data of patients who underwent elective AVR with bioprosthesis were collected From March 2012 to March 2017. The patients were divided into two groups; group 1 included the patients who had a sutureless aortic valve (Perceval) (n= 25; 3.57% of total AVR patients), and group 2 included patients who had conventional bioprosthesis (n= 50; 7.1% of total AVR patients).&#x0D; Results: The median age of patients in group 1 was 67 years (25th- 75th percentiles; 64-71), and in group 2 was 66 years (25th- 75th percentiles: 63 to 69). There is no significant difference in the patients’ comorbidities between the two groups. The median duration of the ischemic time was significantly lower in group 1 (33 (25th- 75th percentiles: 32- 35) vs. 60.5 (58- 66), respectively; p&lt; 0.001). Perceval valve was used more commonly in patients who had minimally invasive AVR (n= 21 (84%) in group 1 vs. 11 (22%) in group 2; p&lt;0.001). Postoperative complications were comparable between both groups. The early paravalvular leak was non-significantly higher in group 1 (12% vs. 2%; p= 0105). The mean postoperative gradient was lower in group 1 (7 (7-9) vs. 10 (8-12) mmHg; p&lt;0.001). The changes in valvular gradient were not significantly different between both groups (p= 0.5). The hospital stay was lower in patients received Perceval valve (Coefficient: -1.3; 95% Cl: -2.3- -0.29; p=0.012)&#x0D; Conclusion: Sutureless aortic valve (Perceval) is a new surgical technique for AVR, with potential advantages of reducing cross-clamp time and a subsequent reduction in myocardial ischemia, duration of cardiopulmonary bypass, and maintaining satisfactory hemodynamic outcomes through reducing patient prosthesis mismatch. All these advantages could help in decreasing postoperative hospital stay.

Nutrition, risk factors, prevention, and imaging: The 2018 Mario Verani Lecture

Heart disease has been the leading cause of death in the United States since 1918. Cardiac mortality rates have dramatically decreased in this era of advanced medical and interventional therapies. However, this has been aptly described as “mopping up the floor instead of turning off the faucet.” With this recognition, prevention in cardiology is poised to become a central focus. Within prevention, dietary intervention is recognized as the single largest opportunity for improved cardiovascular outcomes, including improvement or elimination of cardiac risk factors, prevention of myocardial infarction, stroke and cardiovascular death, and reduction of plaque burden and myocardial ischemia. Cardiac imaging, particularly nuclear perfusion and coronary computed tomographic angiography, plays a critical role in early diagnosis and serial evaluation of myocardial ischemia and coronary artery disease. These techniques have the potential to help refine research protocols and evaluate their success by providing intermediate markers of improved myocardial blood flow and coronary plaque morphology.

Is Exercise Treadmill Time or Reduction in Myocardial Ischemia the Appropriate Primary Endpoint to Assess Success of Percutaneous Coronary Intervention in Stable Angina (ORBITA)?

1 Objectives: In vivo fluorescence imaging in the second near-infrared window region (NIR-II, 1,000-1,700 nm) holds great promise for providing deeper tissue penetration, higher spatial resolution and signal-to-noise ratios than those obtained at the conventional near-infrared window I region (NIR-I, 650-900 nm), because of its reduced tissue autofluorescence and photon scattering, and low levels of photon absorption of long-wavelength photons. Developing semiconducting polymer nanoparticles (NPs) with a strong absorption peak at 808 nm, excellent photostability and biocompatibility will be highly important and find broad uses for efficient in vivo NIR II imaging. Methods: A diketopyrrolopyrrole-based semiconducting polymer NP (PDFT1032) as a novel NIR-II fluorescent probe has been developed for the first time. The versatile use of PDFT1032 for several important biomedical applications in NIR-II window have been demonstrated, including NIR-II optical imaging of tumor using subcutaneous osteosarcoma model, assessing of vascular embolization therapy of tumor, and sentinel lymph node biopsy (SLNB) with high spatial and temporal resolution. Results: Hydrophobic PDFT were encapsulated with the amphiphilic PEGylated phospholipid to provide excellent water-soluble and biocompatible PDFT1032 NP, with high monodispersity, homogeneity, particle size 68 nm in PBS, a unique absorption peak at 809 nm, and fluorescence emission peak at 1,032 nm. No apparent cytotoxicity of PDFT1032 to NIH3T3 cells was observed even with the concentration up to 150 μg/mL. In addition, the H&E staining of the major organs, including heart, liver, spleen, lung, and kidney, at 21 days after intravenous injection of PDFT1032 (1 mg/kg) demonstrated no obvious damages and necrotic lesions. Further NIR-II imaging showed that the nanoprobe clearly visualized the subcutaneous osteosarcoma up to 3 days with high tumor-to-background ratio (TBR, up to 3.4 ± 0.16 for lateral position and 2.4 ± 0.15 for prone position). Ex vivo fluorescent images also demonstrated the favorable contrast between tumor and skin because of the low fluorescence signal of skin. Lastly, with the help of NIR-II imaging and PDFT1032 nanoprobe, the axillary lymph node was clearly identified within short time and dissected from the ambient tissue and then confirmed by histological analysis. Conclusions: Excellent biocompatibility, favorable hydrophilicity, and desirable chemical and optical properties render NIR-II PDFT1032 a highly promise probe with a potential of being widely applicable in clinical imaging and surgical treatment of malignancy.

The Use of β-blockers in Patients with Ventricular Ectopic Heartbeat in the Early and Distant Postinfarction Period

Aim: to increase the effectiveness of patients after Q-, QS- myocardial infarction rehabilitation, based on the study of clinical, instrumental and biochemical changes in cases of cardiac arrhythmias, and development on this basis of new approaches to treatment. Materials and Methods. The clinical, instrumental and biochemical examinations were carried out for 70 patients who had Q-, QS-myocardial infarction (MI) with a ventricular ectopic heartbeat on the regenerative period since the acute coronary syndrome development in 1, 3, and 6 months. The features of the ventricular ectopic heartbeat course in patients with myocardial infarction against the backdrop of sotalol and carvedilol use and influence of applied treatment on the clinical and pathogenetical features of patients’ functional recovery in early and distant (prolonged) postinfarction period were analyzed. Results. Analyzing the dynamics of coronary artery disease clinical manifestations in patients with ventricular arrhythmia (VA) with myocardial infarction against the backdrop of sotalol and carvedilol treatment it has been noted a marked decrease in anginal chest pain manifestation, feeling of palpitations, disruption of the heart, shortness of breath, feeling of breath shortness, etc. in all groups of patients. The positive effect of therapy had been increasing since the 3 week during the 3-month long treatment. Results of heart rate Holter monitoring have shown a marked antiarrhythmic effect of metoprolol, carvedilol and sotalol. In particular, in all groups of patients the frequency of VA reduced by half, the percentage of high grade VA decreased namely pair and group arrhythmia, ventricular bigeminy. Assessment of hemodynamic parameters in the process of patients with ST treatment has represented the marked trend and a further significant increase in ejection fraction and other contractile dysfunction forms correction. This positive trend was the most relevant in the application of carvedilol, a slightly less in patients treated with metoprolol and sotalol. Conclusions. Sotalol in patients after ACS has an ability to reduce the ventricular ectopic heartbeat episodes number and prevents life-threatening arrhythmias, provides a permanent and controlled decrease of heart rate, corrects left ventricle (LV) contractility and processes of postinfarction remodeling of the heart. When using carvedilol it has been noticed a reduction of LV postinfarction remodeling processes, improvement of contractile function of myocardium, antianginal and antiarrhythmic effects, normalization of heart rate variability, reduction of myocardial ischemia, reduction in sudden cardiac death cases.

Reduction of Myocardial Ischemia-Reperfusion Injury by Inhibiting Interleukin-1 Alpha.

Interleukin-1α (IL-1α) released by dying cells is an alarmin that activates the innate immunity. We hypothesized that after myocardial ischemia-reperfusion (I/R) injury, IL-1α amplifies the myocardial damage by activating the inflammasome and caspase-1. Adult male CD1 mice were used. The left anterior descending coronary artery was ligated for 30 minutes, after 24 hours of reperfusion. An IL-1α blocking antibody (15 μg/kg intraperitoneally) or matching vehicle was given after reperfusion. A subgroup of mice underwent sham surgery. We assessed the effects of IL-1α blockade on caspase-1 activity, infarct size, cardiac troponin I serum levels, and left ventricular fractional shortening, 24 hours after I/R. I/R led to inflammasome formation, and IL-1α blockade significantly reduced inflammasome formation, reflected by a >50% reduction in caspase-1 activity versus vehicle (P = 0.03). IL-1α blockade also reduced the infarct size (-52% infarct expressed as percentage of area at risk, and -79% for cardiac troponin I serum levels, P < 0.001 vs. vehicle) and preserved the left ventricular fractional shortening (31 ± 3% vs. 25 ± 2%, P < 0.001 vs. vehicle). IL-1α blockade after I/R reduces the inflammasome activation, decreases the infarct size, and preserves the left ventricular function. IL-1α blockade may therefore represent a novel therapeutic strategy to reduce I/R injury.

Effects of Transendocardial Delivery of Bone Marrow-Derived CD133+ Cells on Left Ventricle Perfusion and Function in Patients With Refractory Angina: Final Results of Randomized, Double-Blinded, Placebo-Controlled REGENT-VSEL Trial.

New therapies for refractory angina are needed. Assessment of transendocardial delivery of bone marrow CD133+ cells in patients with refractory angina. Randomized, double-blinded, placebo-controlled trial enrolled 31 patients with recurrent Canadian Cardiovascular Society II-IV angina, despite optimal medical therapy, ≥1 myocardial segment with inducible ischemia in Tc-99m SPECT who underwent bone marrow biopsy and were allocated to cells (n=16) or placebo (n=15). Primary end point was absolute change in myocardial ischemia by SPECT. Secondary end points were left ventricular function and volumes by magnetic resonance imaging and angina severity. After 4 months, there were no significant differences in extent of inducible ischemia between groups (summed difference score mean [±SD]: 2.60 [2.6] versus 3.63 [3.6], P=0.52; total perfusion deficit: 3.60 [3.6] versus 5.01 [4.3], P=0.32; absolute changes of summed difference score: -1.38 [5.2] versus -0.73 [1.9], P=0.65; and total perfusion deficit: -1.33 [3.3] versus -2.19 [6.6], P=0.65). There was a significant reduction of left ventricular volumes (end-systolic volume: -4.3 [11.3] versus 7.4 [11.8], P=0.02; end-diastolic volume: -9.1 [14.9] versus 7.4 [15.8], P=0.02) and no significant change of left ventricular ejection fraction in the cell group. There was no difference in number of patients showing improvement of ≥1 Canadian Cardiovascular Society class after 1 (41.7% versus 58.3%; P=0.68), 4 (50% versus 33.3%; P=0.63), 6 (70% versus 50.0%; P=0.42), and 12 months (55.6% versus 81.8%; P=0.33) and use of nitrates after 12 months. Transendocardial CD133+ cell therapy was safe. Study was underpowered to conclusively validate the efficacy, but it did not show a significant reduction of myocardial ischemia and angina versus placebo. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01660581.

NEWBORNS POSTHYPOXIC CARDIOPATHY: NEW TREATMENT OPTIONS

Objective of the research – to assess efficacy and safety of drug Elkar® 100 mg/ml for intravenous and intramuscular injection in treatment of newborns with posthypoxic cardiopathy. Patients were randomized into 2 groups, comparable in age, gestational age, severity of cerebral ischemia. The main group (n=43) in addition to standard therapy received Elkar® intravenously at a dose of 50–100 mg/kg/day, the comparison group (n=40) received only standard therapy for posthypoxic cardiopathy. The control group consisted of 20 children without clinically significant CNS and cardiovascular system (CVS) lesions. Elkar® contributed to a significant improvement in clinical status and optimization of postnatal CVS adjustment, manifesting as effective reduction of electrical instability and myocardial ischemia, heart rate recovery, systolic and diastolic function normalization, size of right heart chambers, reduced the diameter and hemodynamic significance of fetal functioning communications, restored vegetative regulation of heart rate and its circadian organization, helped to reduce rhythm pauses duration and arrhythmias representation. Elkar® intravenous use was satisfactorily tolerated by newborns and had no clinically significant adverse effects. The most rapid and complete regression of posthypoxic cardiopathy manifestations revealed after intravenous drug use at a dose of 80–100 mg/kg/day and continuing oral administration up to 1 month.

Coronary Sinus Reducer implantation: a new treatment for chronic refractory angina

Refractory angina is a chronic condition characterized by the presence of disabling symptoms due to severe obstructive coronary artery disease not improved by either optimal medical therapy and/or percutaneous or surgical revascularization. Mortality rates associated with this condition are quite low in clinically stable patients on optimal medical therapy. However, rehospitalization rates are high. In this subgroup of patients there is thus a clinical need for new therapies targeting an improvement of symptoms but taking into account the potential impact in terms of healthcare and costs. A considerable number of innovative therapeutic modalities for the treatment of refractory angina have been investigated over the years. However, none of them has become a standard of care. Devices implanted in coronary sinus are a possible therapeutic option in these patients that may alleviate myocardial ischemia by forcing redistribution of coronary blood flow from less ischemic subepicardium to the more ischemic subendocardium, potentially relieving symptoms of ischemia. The coronary sinus Reducer (Neovasc Inc., Richmond B.C., Canada) is a percutaneous implantable device designed to achieve controlled narrowing of the coronary sinus and to increase its upstream pressure. Coronary sinus Reducer implantation was associated with improvement in symptoms and reduction of myocardial ischemia in pre-clinical and clinical studies. Recently, a randomized, double-blind, multicenter clinical trial demonstrated, in 104 patients with refractory angina, its benefit in improving symptoms, when compared to placebo.

45. Ezetimibe and statins yields on silent holter ambulatory myocardial ischemia

Further cholestrol lowering may affect silent ischemia detected on holter monitoring. Cholesterol lowering is associated with a reduction in cardiovascular morbidity and mortality. Statins are the main drugs for cholesterol lowering. Ezetimibe when added to statins gives further reduction in cholesterol but its long-term effect on cardiovascular morbidity and mortality and ischemic events is not known. This study sought to determine whether further cholesterol lowering with ezitimibe will also results in a reduction of myocardial ischemia during daily life. We enrolled 50 patients with proven stable coronary artery disease (CAD) and at least one episode of ST-segment depression on ambulatory ECG monitoring. All of them were receiving optimal therapy for CAD including statin therapy for cholesterol reduction. 25 patients were randomized to continue their statin therapy (Statin only group) and 25 to recieve statin plus ezitimibe 10 mg/day (ezitimibe group). Serum cholesterol and LDL cholesterol levels and ambulatory monitoring were repeated after 4–6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, and baseline serum cholesterol levels. The ezitimibe group had lower mean total and LDL cholesterol levels at study end and experienced a significant reduction in the number of episodes of ST-segment depression compared with the statin only group. ST-segment depression was completely resolved in 13 of 25 patients (52%) in the ezitimibe group versus 3 of 25 (12%) in the statin only group. The ezitimibe group exhibited a highly significant reduction in ambulatory ischemia (P < .001). By logistic regression, treatment with ezitimibe was an independent predictor of ischemia resolution. Further cholesterol lowering with ezitimibe can result in reduction or resolution of myocardial ischemia recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG.

Invited Commentary

Rapid deployment and sutureless valves are being implanted with increasing frequency—particularly in Europe—but specific patient populations for these devices remain to be defined. Theron and colleagues [1Theron A. Gariboldi V. Grisoli D. et al.Rapid deployment of aortic bioprosthesis in elderly patients with small aortic annulus.Ann Thorac Surg. 2016; 101: 1434-1442Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar] have focused on the use of rapid deployment valves in a clinically important subgroup of patients in this issue of The Annals, namely, elderly patients with a small aortic annulus. Severe aortic stenosis is often accompanied by fibrosis and calcification of the aortic root in elderly patients, resulting in an inability to insert an adequately sized prosthesis. Simple implantation of a hemodynamically superior valve would be preferable to annular enlargement procedures in elderly patients. Aortic annular enlargement is associated with prolonged aortic cross-clamp and cardiopulmonary bypass times [2Kulik A. Al-Saigh M. Chan V. et al.Enlargement of the small aortic root during aortic valve replacement: is there a benefit?.Ann Thorac Surg. 2008; 85: 94-100Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar] and can be particularly challenging in patients with a calcified aortic root. Previous studies have demonstrated excellent hemodynamic performance for rapid deployment and sutureless valves [3Folliguet T.A. Laborde F. Zannis K. et al.Sutureless Perceval aortic valve replacement: results of two European centers.Ann Thorac Surg. 2012; 93: 1483-1488Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar, 4Borger M.A. Moustafine V. Conradi L. et al.A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement.Ann Thorac Surg. 2015; 99: 17-25Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar]. Furthermore, a recent randomized clinical trial demonstrated significant reductions in early transvalvular gradients and prevalence of patient-prosthesis mismatch—despite a relatively small sample size—in patients receiving a rapid deployment valve compared with similarly sized conventional bioprostheses [4Borger M.A. Moustafine V. Conradi L. et al.A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement.Ann Thorac Surg. 2015; 99: 17-25Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar]. The hemodynamic benefits of these devices, combined with their rapid implantation times and subsequent reduction in myocardial ischemia [3Folliguet T.A. Laborde F. Zannis K. et al.Sutureless Perceval aortic valve replacement: results of two European centers.Ann Thorac Surg. 2012; 93: 1483-1488Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar, 4Borger M.A. Moustafine V. Conradi L. et al.A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement.Ann Thorac Surg. 2015; 99: 17-25Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 5Schlomicher M. Haldenwang P.L. Moustafine V. Bechtel M. Strauch J.T. Minimal access rapid deployment aortic valve replacement: initial single-center experience and 12-month outcomes.J Thorac Cardiovasc Surg. 2015; 149: 434-440Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar], may make them an ideal option in elderly patients with a small aortic annulus. In addition, rapid deployment valves appear to facilitate minimally invasive operations. Minimally invasive rapid deployment valve implantation may represent an effective and financially attractive alternative to transcatheter aortic valve replacement procedures in medium-risk elderly patients. One may expect lower paravalvular leak rates and possibly decreased pacemaker implantation requirements compared with transcatheter aortic valve replacement. Results of two large, nearly completed U.S. Food and Drug Administration approval trials will hopefully shed more light on the use of these devices in elderly patients with small aortic annuli and whether they represent a good alternative to transcatheter aortic valve replacement in this patient population. Rapid Deployment of Aortic Bioprosthesis in Elderly Patients With Small Aortic AnnulusThe Annals of Thoracic SurgeryVol. 101Issue 4PreviewAortic valve replacement in elderly patients with a small aortic annulus remains challenging. Patient–prosthesis mismatch (PPM) should be prevented without impacting operative mortality. Hemodynamic benefits resulting from rapid-deployment aortic valve replacement with the Edwards Intuity bioprosthesis for this indication were evaluated. Full-Text PDF

Abstract 15913: Statin And Ezetimibe in Silent Ambulatory Myocardial Ischemia (SESAMI Trial)

Introduction: Cholesterol lowering is associated with a reduction in cardiovascular morbidity and mortality. Statins are the main drugs for cholesterol lowering. Ezetimibe when added to statins gives further reduction in cholesterol but its long-term effect on cardiovascular morbidity and mortality and ischemic events is not known. This study sought to determine whether further cholesterol lowering with ezitimibe will also results in a reduction of myocardial ischemia during daily life. Hypothesis: Further cholestrol with ezetimibe lowering may reduce silent ischemia. Methods: We enrolled 50 patients with proven stable coronary artery disease (CAD) and at least one episode of ST-segment depression on ambulatory ECG monitoring. All of them were receiving optimal therapy for CAD including statin therapy for cholesterol reduction. 25 patients were randomized to continue their statin therapy (Statin only group) and 25 to recieve statin plus Ezitimibe 10mg/day (ezitimibe group). Serum cholesterol and LDL cholesterol levels and ambulatory monitoring were repeated after 4 to 6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, and baseline serum cholesterol levels. Holters were read by a blinded cardiologist. Results: The ezitimibe group had lower mean total and LDL cholesterol levels at study end and experienced a significant reduction in the number of episodes of ST-segment depression compared with the statin only group. ST-segment depression was completely resolved in 13 of 25 patients (52%) in the ezitimibe group versus 3 of 25 (12%) in the statin only group. The ezitimibe group exhibited a highly significant reduction in ambulatory ischemia (P&lt;.001). By logistic regression, treatment with ezitimibe was an independent predictor of ischemia resolution. Conclusions: Further cholesterol lowering with ezitimibe can result in reduction or resolution of myocardial ischemia recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG. A larger study is required to confirm this results. This may be translated into long term mortality reduction for CAD by adding ezetimibe.

Improvement of myocardial function and perfusion after successful percutaneous revascularization in patients with chronic total coronary occlusion

BackgroundPercutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of a coronary artery can provide benefits in terms of myocardial function and survival but the procedure is complex and the success rate is relatively low. To assess these benefits, myocardial function, ischemia and viability should be clearly determined by means of a reliable diagnostic test. This study aimed to assess ventricular function and myocardial ischemia before and after PCI for CTO using cardiac magnetic resonance (CMR). NYHA functional class was also assessed before and after PCI. Methods and resultsCMR studies were performed in 43 consecutive patients (7 females; aged 64±9.6y.o.) with CTO scheduled for PCI and repeated 6months post-PCI. PCI was successful in 33 (77%) of them. In this group CMR had shown inducible perfusion defects in 26 (79%) before PCI, while they were observed in 10 (30%) post-PCI CMR study (p<0.001). The number of segments showing inducible perfusion defect (3.4±2 prevs. 2.9±4.5 post-PCI, p=0.002) was significantly reduced in this group. Regional contractile function of segments showing viability also improved significantly in the group with successful CTO PCI compared to the group with an unsuccessful procedure. NYHA functional class for angina also improved in patients with successful revascularization while it remained unchanged in the group with unsuccessful procedures. ConclusionsA successful CTO PCI leads to a reduction in inducible myocardial ischemia and to an improvement in regional wall motion, which results in clinical improvement.

Statin and ezetimibe in silent ambulatory myocardial ischemia (sesami trial)

Background Cholesterol lowering is associated with a reduction in cardiovascular morbidity and mortality. Statins are the main drugs for cholesterol lowering. Ezetimibe when added to statins gives further reduction in cholesterol but its long-term effect on cardiovascular morbidity and mortality and ischemic events is not known. This study sought to determine whether further cholesterol lowering with ezitimibe will also results in a reduction of myocardial ischemia during daily life. Methods We enrolled 50 patients with proven stable coronary artery disease (CAD) and at least one episode of ST-segment depression on ambulatory ECG monitoring. All of them were receiving optimal therapy for CAD including statin therapy for cholesterol reduction. 25 patients were randomized to continue their statin therapy (Statin only group) and 25 to recieve statin plus ezitimibe 10 mg/day (ezitimibe group). Serum cholesterol and LDL cholesterol levels and ambulatory monitoring were repeated after 4–6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, and baseline serum cholesterol levels. Holters were read by a blinded cardiologist. Results The ezitimibe group had lower mean total and LDL cholesterol levels at study end and experienced a significant reduction in the number of episodes of ST-segment depression compared with the statin only group. ST-segment depression was completely resolved in 13 of 25 patients (52%) in the ezitimibe group versus 3 of 25 (12%) in the statin only group. The ezitimibe group exhibited a highly significant reduction in ambulatory ischemia ( P Conclusions Further cholesterol lowering with ezitimibe can result in reduction or resolution of myocardial ischemia recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG.

Cardiac Remote Ischemic Preconditioning Prior to Elective Major Vascular Surgery (CRIPES): Study Design and Rationale

Background: Vascular surgery is considered a high-risk operation with an anticipated perioperative risk of serious cardiac ischemic complications in excess of 10%. One potential strategy for reduction of myocardial ischemia during the perioperative period is Remote Ischemic Preconditioning (RIPC). Design: The Cardiac Remote Ischemic Preconditioning Prior to Elective Vascular Surgery (CRIPES, NCT: 01558596) is a prospective, randomized, sham-controlled phase 2 trial using RIPC prior to elective vascular surgery. CRIPES plans to enroll and treat 180 patients over 4 years and gather safety and efficacy data for one-month after surgery. Preliminary estimates for two potential measures of efficacy will be examined: 1) a two-part test of postsurgical increases in cardiac troponin I as a measure of myonecrosis and 2) the proportion of patients in each treatment arm meeting the universal definition of myocardial infarction. Discussion: Knowledge gained from the CRIPES study will help inform further testing of RIPC prior to non-cardiac surgery.