Total Scar Score Research Articles

A Comparative Study to Evaluate the Effectiveness of Thiosinaminum 3X in Dissolving LSCS Scar in Women

Background: In women, having an LSCS scar, is distressing and can damage a person's body image, self-esteem, identity, and social interactions. It was seen that homoeopathic medicines had positive effects on scar resolution but the scientific studies for showing its effectiveness are rarely found. This study is designed in order to evaluate the effectiveness of Thiosinaminum 3x in dissolving LSCS scar in women of sangareddy. Objectives: 1. To Assess the effectiveness of Thiosinaminum in dissolving LSCS Scar. 2. To compare the effectiveness of Thiosinaminum 3X potency in women having the LSCS scar for a duration of 1 [Group-A] and 2 years [Group-B]. Materials and methods: The study was conducted among women having LSCS Scar for the duration of not more than 2 years from different areas of Sangareddy, out of which 30 patients were selected by simple random method. The women were advised to take Thiosinaminum 3x. Vancouver scar scale was used to assess the scar among these individuals. Results: In assessing the Objective – 1, there was statistical difference found with the use of Thiosinaminum3x in dissolving LSCS Scar in both the groups, thus accepting the alternate hypothesis. Whereas for Objective – 2, in comparing both the groups, ‘P-value’ of the test between the groups was more than 0.005 which shows that Thiosinaminum had shown its effect under both the groups and there is not much variation in them. Irrespective of the duration of the scar, Thiosinaminum 3x had found to be effective in scar dissolution. Conclusion: It was concluded from the study that Thiosinaminum 3x acts effectively in dissolving LSCS Scar as there was difference noted in the total scar score obtained before and after medication. Among the two groups selected for the study, there was no statistical difference found in the action of Thiosinaminum 3x. While in assessing the individual parameters of the scar scale, much difference was found in vascularity and pigmentation in Group A, whereas in pigmentation and pliability for Group B. Keywords: Vancouver Scar Scale, LSCS Scar, Thiosinaminum, Scar Assessment

Predictors of procedural failure of left bundle branch pacing in scarred left ventricle.

Presence of scar at the implantation-site is considered as a major factor in determining the success of left bundle branch pacing (LBBP). We aimed at analyzing the predictors of procedural failure in patients with scarred-left ventricle (LV) as demonstrated by cardiac-magnetic resonance-imaging (CMR). This was a retrospective, observational single-center-study that included consecutive cardiomyopathy patients with LV-scar as demonstrated by late-gadolinium-enhancement (LGE) in CMR requiring LBBP. Procedural-failure was defined as the inability to penetrate the septum to reach the LV subendocardium RESULTS: A total of 25 cardiomyopathy patients demonstrated LGE in CMR and were included in the study. LBBP was successful in 16 patients (group-I; 64% acute-procedural-success). In the remaining 9 patients (group-II) lead could not be penetrated and hence biventricular-pacing was done. LBBP resulted in reduction in QRS-duration and improvement in LV ejection fraction in group-I patients during a mean follow-up of 11.2 ± 3.7 months. Computed-tomography-angiography after LBBP showed the successful lead deployment site (LBBP-Zone) as the overlapping areas of inferior aspect of antero-septum and superior aspect of infero-septum (segment 2/3; AHA-model) in short-axis view(figure-1C). CMR showed LGE in significantly more number of LV-segments and high scar-burden in group-II as compared to group-I (figure-1). A total scar score value of >1.0 predicted failure with 100%-sensitivity and 75%-specificity. CMR revealed transmural-scar in the LBBP-Zone in all patients in group-II (n = 9; 100%). Transmural scar in LBBP-Zone by CMR had 100%-sensitivity and 100%-specificity for predicting the procedural-failure. CMR helps in predicting the procedural failure of LBBP in patients with scarred LV. Presence of transmural-LGE in the LBBP-Zone predicts failure with high sensitivity and specificity.

Association Between Myocardial Scar Burden and Left Ventricular Ejection Fraction in Ischemic Cardiomyopathy.

BackgroundThis study was conducted to assess the relationship between scar burden (extent and severity) and the follow-up left ventricular ejection fraction (LVEF).MethodsPatients were referred for viability assessment with late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging. To measure the transmural extent of LGE in each segment (scar score), we used a five-point scale system. Baseline ejection fraction (EF) and at follow-up were recorded. LVEF classified as non-severe and severely depressed.ResultsThe study included 178 patients (males: 88.8%; mean age: 57.1±10.02 years; mean baseline LVEF: 28.61±10.39). In patients with severe baseline LVEF, the mean scar percentage was higher than that in patients who had non-severe LVEF (38.8±19.41 vs. 24.61±21.21; p˂0.001). On linear regression analysis, aldosterone antagonist and total scar score significantly predicted follow-up ejection fraction (EF) (B=-7.083, p˂0.001 and B=-3.038, p=0.038, respectively). Left anterior descending artery (LAD) territory viability and baseline EF significantly predicted change in EF in patients with LVEF ≤ 35% (B=5.389, p=0.009 and B=-0.581, p˂0.001, respectively). On binary regression analysis for the prediction of at least 5% improvement in EF in patients with baseline EF ≤ 35%, baseline EF and LAD viability were significant (B=-0.15, p=0.014 and B=1.042 and p=0.054, respectively).ConclusionsThe extent of myocardial scar and viability of LAD territory are identified as the important and independent parameters for the predictions of improvement in EF even after adjustment for demographics and baseline EF and following the standards of care medication.

Evaluation of relationship between myocardial injury and left ventricular mechanical dyssynchrony using 99Tcm-MIBI myocardial perfusion SPECT and 18F-FDG myocardial metabolic PET imaging

Objective To investigate the relationship between myocardial injury and damage of mechanical synchrony in the left ventricle of patients with ischemic cardiomyopathy (ICM) using 99Tcm-MIBI MPI and gated 18F-FDG myocardial metabolic PET imaging. Methods A total of 113 ICM patients (100 males, 13 females; average age (58±10) years) underwent 99Tcm-MIBI MPI and gated 18F-FDG myocardial metabolic PET imaging from July 2015 to December 2015 in Fu Wai Hospital were retrospectively analyzed. Three-point scoring system was used for quantitative assessment of myocardial ischemia and myocardial infarction in each segment. Total ischemic score (TIS) and total scar score (TSS) of 17 segments were calculated in each patient. The phase bandwidth (BW) and phase SD were derived from phase analysis. Pearson correlation analysis and logistic regression analysis were used. Results TSS were correlated with BW and SD in all 93 patients with myocardial infarction (r values: 0.517, 0.470, both P 0.05). Logistic regression analysis showed that the number of myocardial infarction segments and TSS were associated with mechanical dyssynchrony. Conclusion Myocardial infarction is the main factor of left ventricular mechanical dyssynchrony in ICM patients, but chronic myocardial ischemia has no significant influence on mechanical dyssynchrony. Key words: Myocardial ischemia; Myocardial contraction; Myocardial perfusion imaging; Tomography, emission-computed, single-photon; Positron-emission tomography; Technetium Tc 99m sestamibi; Deoxyglucose

Assessment of burn-specific health-related quality of life and patient scar status following burn

IntroductionThis study assessed patient-perceived levels of scar assessment and burn-specific quality of life (QOL) in Korean burn patients admitted to burn care centers and identified differences in scar assessment and QOL based on various patient characteristics. MethodsA cross-sectional descriptive study using anonymous paper-based survey methods was conducted with 100 burn patients from three burn centers specializing in burn care in South Korea. ResultsMean subject age was 44.5 years old, and 69% of the subjects were men. The overall mean QOL was 2.91 out of 5. QOL was lowest for the work subdomain (2.25±1.45) followed by the treatment regimen subdomain (2.32±1.16). The subjects’ mean total scar assessment score was 35.51 out of 60, and subjects were most unsatisfied with scar color. Subjects with low income, flame-source burns, severe burns, visible scars, and scars on face or hand reported significantly lower QOL. Subjects with severe burn degree and burn range perceived their burn scar condition to be worse than that of others. ConclusionThe results show that burn subjects experience the most difficulties with their work and the treatment regimen. Subjects with severe burn and visible scarring have a reduced QOL and a poor scar status. Scar management intervention may improve QOL of burn patients especially those with severe burn and visible scars. Further studies are warranted to evaluate the relationship between scar assessment and QOL.

Can We Predict the Presence and Severity of Intra-Abdominal Adhesions before Cesarean Delivery

Aims: The study aimed to investigate whether we can predict the presence and severity of intra-abdominal adhesions before cesarean delivery using patient history, symptoms, and abdominal skin scar characteristics. Methods: In this prospective study, 143 pregnant women with history of previous abdominal surgery were included and they delivered by cesarean. Preoperative abdominal scar characteristics and symptoms as well as intraoperative abdominal adhesions were evaluated using the Manchester Scar Scale, a symptomatology questionnaire and the More Comprehensive Adhesion Scoring Method, respectively. Results: Patients with adhesions (n = 98) and without adhesions (n = 45) had similar baseline characteristics. In the adhesion group, abdominal scar scoring parameters were significantly increased. However, there was no significant correlation among total scar score, adhesion score, and symptom score. Conclusion: Despite the availability of many proposed methods, accurate prediction of the severity of surgery-related adhesions is beyond our current abilities. Therefore, as healthcare providers, obstetricians should avoid unnecessary use of the cesarean approach. This approach is more effective, beneficial, realizable, and reasonable than the prediction of surgery-related adhesions.

006 Myocardial infarction and viability assessment by 12 lead ECG vs gold standard cardiac magnetic resonance

Introduction Q-waves on 12 lead ECG is considered a marker of transmural myocardial infarction (MI) and is used universally. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) accurately identifies MI and has become the gold standard for the assessment of myocardial viability. Aim: Determine the diagnostic accuracy of Q-waves to identify MI and predict regionality. Ascertain the CMR predictors of Q-wave. Methods Data collected on 498 consecutive patients (mean age 64 years, 71% males) referred for CMR with suspected IHD. Patients with non-IHD were excluded. Q waves in ≥2 precordial leads from V1-V4 reflected LAD territory. Transmural infarction was defined as >50% LGE. Results 290 patients demonstrated MI, 157 transmural and 133 sub-endocardial based on LGE. Diagnostic accuracy of Q-wave as a marker of transmural MI was 66% and as a predictor of previous MI was 55%. 126 had pathological Q-waves, 40% in LAD territory, 55% non-LAD and 5% a combination. Of those with anterior (LAD) Q waves, 68% demonstrated LAD territory LGE and in non-LAD Q waves, 67% demonstrated a non-LAD territory infarct by LGE. On multivariate analysis, total scar score and >75% thickness LGE were significant predictors of Q wave. Conclusion Presence of pathological ECG Q-waves is not only a poor marker of myocardial scarring, but also a poor predictor of viability and regionality when compared to CMR. Presence of Q wave correlates only with total scar score and >75% LGE. In clinical decision-making, clinicians need to be aware of the limitations of ECG Q-waves.

Donor-site closure using absorbable dermal staple for deep inferior epigastric artery perforator flaps: its efficacy and cosmetic outcomes.

BackgroundSurgeons tend to pay less attention to the donor site during breast reconstruction using deep inferior epigastric artery perforator flaps because attention is focused on microanastomosis and breast shaping. Therefore, donor site closure is typically performed by a secondary operator. We present consistently reduced operative times and improved scar quality using an absorbable dermal staple.MethodsRetrospective review was performed on 25 patients who were either standard suture controls (group I, n = 15) or received absorbable staples (group II, n = 10). Mean age, flap size, whole operative time, and length of hospital stay were collected. The donor site scar was evaluated by three plastic surgeons in a blinded manner using the modified Vancouver scar scale 6 months after surgery. Data were analyzed with the independent t test, and a p value ≤0.05 was considered significant.ResultsNo differences were detected between the groups for age, harvested flap size, or length of hospitalization. However, operative time was significantly longer in group I (1.07 ± 0.24 min/cm2) than that in group II (0.86 ± 0.16 min/cm2, p = 0.015). The total scar assessment score was significantly lower in group II (3.8 3 ± 1.30) than that in group I (5.27 ± 1.83, p = 0.043).ConclusionsAbsorbable dermal stapling reduced operative time, compared to that of traditional suturing. In addition, scar quality from absorbable dermal staples was superior to that resulting from traditional sutures.Level of evidenceII.

Effect of Dermal Thickness on Scars in Women with Type III-IV Fitzpatrick Skin.

Both patients and physicians desire minimal scarring after surgical procedures. The removal of foreign bodies from around the wound, prevention of infection, and wound closure without tension is recommended for reducing scarring. The reasons underlying the differing appearance of scars between different anatomical regions of the same individual are not fully understood. Moreover, to our knowledge, the relationship between incision width and dermal thickness in different anatomical regions has yet to be investigated. Hence, in the present study, we aimed to determine the effect of dermal thickness on scar formation. Fifty patients who were treated and followed up for breast hypertrophy between 2010 and 2013 were retrospectively investigated. In all patients, a 2 × 2-cm skin biopsy specimen was obtained from the medial right breast at the horizontal line of the T scar. A routine superomedial pedicle breast reduction was subsequently performed. The extracted excision materials and skin biopsy specimens were examined pathologically. Dermal thickness was measured from the starting point of the subcutaneous tissue to the end point of the epidermis, at four different sites. The average dermal thickness was then calculated for each patient. The skin color of all patients was determined according to the Fitzpatrick classification. Scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the flap confluence. After the measurements, the scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height by two plastic surgeons and a clinical nurse, who were blinded to patient data. The mean age of the 50 female patients was 40.8 years (range 18-65 years). The average follow-up period was 16 months (range 12-18 months). An average of 987.5 g (range 505-1621 g) of breast and fatty tissue was removed. The average dermal thickness was 4.99 mm (range 3.5-6.8 mm). The most common skin type was Fitzpatrick type IV (33 patients). The average total scar score was 14 (range 8-25). The total scar score was not significantly associated with dermal thickness. The scar width in patients with a dermal thickness of <0.5 cm was narrower than that in patients with a dermal thickness of ≥0.5 cm. Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, regardless of scar width. The study findings show that increased dermal thickness is a risk factor for wide scar formation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Association between Multilayer Left Ventricular Rotational Mechanics and the Development of Left Ventricular Remodeling after Acute Myocardial Infarction

The identification of patients at risk for developing left ventricular (LV) remodeling after acute myocardial infarction (AMI) has crucial prognostic implications. The aims of this study were (1) to investigate the relationship between peak subepicardial and subendocardial twist and infarct transmurality, as assessed using contrast-enhanced magnetic resonance imaging, and (2) to evaluate the association between peak subepicardial and subendocardial twist and LV remodeling 6 months after AMI. A total of 213 patients with ST-segment elevation AMIs who underwent three-dimensional echocardiography for LV volumes and functional assessment and two-dimensional speckle-tracking analysis for the evaluation of LV twist (subendocardial vs subepicardial) were retrospectively included. A subgroup of 40 patients underwent magnetic resonance imaging within 2 months for infarct size quantification. Peak subepicardial twist was strongly related to infarct size (number of segments with transmural scar: r(2) = 0.526, P < .001; total scar score: r(2) = 0.515, P < .001) compared with peak subendocardial twist (number of segments with transmural scar: r(2) = 0.379, P < .001; total scar score: r(2) = 0.331, P < .001). In the overall population, 44 patients (21%) developed significant LV remodeling at 6-month follow-up (LV end-systolic volume increase ≥ 15%). These patients showed significantly more impaired peak subepicardial and subendocardial twist at baseline compared with patients without LV remodeling (4.5 ± 1.3° vs 9.4 ± 3.5°, P < .001; 7.0 ± 3.2° vs 12.9 ± 5.8°, P < .001, respectively). Importantly, peak subepicardial twist (odds ratio, 0.241; 95% confidence interval, 0.134-0.431; P < .001) and peak troponin T (odds ratio, 1.152; 95% confidence interval, 1.006-1.320; P = .041) were independently associated with the development of LV remodeling. Peak subepicardial twist strongly reflects infarct transmurality as assessed with magnetic resonance imaging and is independently associated with LV remodeling after AMI.

Imaging-Guided Selection of Patients With Ischemic Heart Failure for High-Risk Revascularization Improves Identification of Those With the Highest Clinical Benefit

A 65-year-old man presented to his local emergency department with rapid atrial fibrillation and acute pulmonary edema. This patient had a history of hypertension, and 2 months before this presentation, he developed progressive exertional dyspnea. The patient deteriorated in the emergency department and went into cardiogenic shock. Emergent coronary angiography revealed diffuse 3-vessel disease: a 99% proximal left anterior descending coronary artery lesion, 90% mid-right coronary artery lesion, occluded large first marginal branch, and diffuse severe disease of the left circumflex coronary artery. The initial ejection fraction (EF) on echocardiography was 15%, with mild mitral regurgitation and an estimated pulmonary artery pressure of 55 mm Hg. The patient stabilized with an intraaortic balloon pump and intensive care unit management; however, because of the diffuse nature of the disease, he was not believed to be a surgical candidate. He was transferred to another tertiary-care facility for consideration of cardiac transplantation. As part of this evaluation, a PET viability study was done that demonstrated a significant area of perfusion-metabolism mismatch in the entire anteriolateral wall. Less than 1% of the myocardium was scar, and 28% was defined as hibernating (Figure 1). Figure 1. A rest rubidium 82 and 18F-fluorodeoxyglucose (FDG) PET viability imaging study in corresponding short-axis, horizontal long-axis, and vertical long-axis slices. Perfusion images demonstrate a moderate to severe reduction in perfusion defect in the entire anterior wall, anterolateral wall, and apex. The lateral wall also has a moderate to severe perfusion defect. The FDG images (second row) demonstrate FDG uptake in the anterior wall extending to the apex and lateral wall, corresponding to a total scar score of 0.54% and a mismatch score of 26% of the ventricular myocardium. Response by Velazquez on p 270 The results of the viability test were pivotal in the decision to perform coronary artery …

End systolic volume and scar burden are incremental and independent predictors of survival in patients with severe ischemic cardiomyopathy

Background Scar burden has been shown to be an independent predictor of mortality in patients with severe ischemic cardiomyopathy (ICM). However, it is unclear how both scar burden and end systolic volume (ESV) impact outcomes in patients with severe ischemic (ICM). Purpose In patients with severe ICM, we sought to assess the association of ESV and scar burden with outcomes in severe ICM. Methods 450 patients with > 70% stenosis in ≥1 epicardial coronary artery (75% men, median age 63 years, median LV ejection fraction (EF) 22%, median ESVi 106ml, median scar % of 29%) underwent delayed hyperenhancementMRI (Siemens 1.5-T scanner, Erlangen, Germany) between 2003-2007. CMR evaluation included long and short axis assessment of LV function on balanced steady state free precession images along with assessment of myocardial scar (on phase-sensitive inversion recovery DHE-CMR sequence ~ 10-20 minutes after injection of 0.2 mmol/kg of Gadolinium dimenglumine). Scar was identified as regions of interest > 2 SD above normal myocardium. LV scar was was recorded as a percentage of the total myocardium and transmural extent (0 = none, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, and 4 = > 75%). Total scar score was determined from the summed scar score of 17 segments per patient divided by 17. Cox proportional hazards survival modeling, using a primary end-point of all-cause mortality, was used to risk-adjust comparisons. Results

Comparative Preventive Efficacy of Recombinant Tissue Plasminogen Activator (rt-PA), Urokinase, Hyaluronic acid and Enoxaparin in Post Laminectomy Epidural Fibrosis in Rats

Aim: We aimed to determine the effects of rt-PA and enoxaparin on post laminectomy epidural fibrosis and to compare the effects of these two medications with hyaluronic acid and urokinase in an experimental model of spinal epidural fibrosis. Method: Forty Spraque-Dawley rats were anaesthetized by intraperitoneal anesthesia (ketamin 8 mg/100 g) and randomly allocated to five groups. All groups were underwent L1-2 total laminectomies. Topical medications were applied to group 2-5 right after the laminectomy space. Hence, in group 1 (G1=control) only laminectomy was constituted, in group 2 (G2) laminectomy + topical Urokinase, in group 3 (G3) laminectomy + topical rt-PA, in group 4 (G4) laminectomy + topical enoxaparin and in group 5 laminectomy + topical Hyaluronic acid (G5) application were performed. The potentials of local urokinase, rt-PA, hyaluronic acid and enoxaparin in preventing the production of epidural fibrosis were assessed. Result: In inter group comparison, G1-G2, G1-G3, G1-G4, G1-G5 groups differed from each other for total scar score, middle scar score and deep scar score (p<0.05). However, G2-G3, G2-G4, G2-G5, G3-G4, G3-G5 and G4-G5 were not different from each other. Conclusion: In rats, the topical thrombolysis with fibrinolitic agents is safe and efficacious in preventing of post laminectomy epidural fibrosis. Thrombolytic therapy with topical hyaluronic acid, rt-PA, urokinase and enoxaparin may come to play an important role in the prevention of post operative spinal epidural fibrosis and arachnoiditis. Based on the results we found that rt-PA and enoxaparine inhibit the formation of epidural scar adhesions and arachnoiditis compared with control group.

Avotermin for Scar Improvement following Scar Revision Surgery: A Randomized, Double-Blind, Within-Patient, Placebo-Controlled, Phase II Clinical Trial

Skin scarring is associated with psychosocial distress and has a negative effect on quality of life. The transforming growth factor (TGF)-β family of cytokines plays a key role in scarring. TGF-β3 improves scar appearance in a range of mammalian species. This study was performed to assess the efficacy of intradermal avotermin (TGF-β3) for the improvement of scar appearance following scar revision surgery. Sixty patients (35 men and 25 women; age, 19 to 78 years; 53 Caucasians; scar length, 5 to 21 cm) received intradermal avotermin (200 ng/100 μl/linear cm wound margin) and placebo to outer wound segments immediately after, and again 24 hours after, complete (group 1) or staged (group 2) scar revision surgery. A within-patient design was chosen to control for interindividual factors that affect scarring. The primary efficacy variable was a total scar score derived from a visual analogue scale, scored by a lay panel from standardized photographs from months 1 through 7 following treatment. : Primary endpoint data from the combined surgical groups showed that avotermin significantly improved scar appearance compared with placebo (total scar score difference, 21.93 mm; p = 0.04). Profilometry showed a greater reduction in scar surface area from baseline with avotermin treatment compared with placebo, significant in group 2 at months 7 and 12 (difference, 41.99 mm and 25.85 mm, respectively; p = 0.03 for both comparisons). Histologic analysis from group 2 showed that, compared with placebo treatment, collagen organization in avotermin-treated scars more closely resembled normal skin in 14 of 19 cases. Avotermin was well tolerated. Avotermin administration following scar revision surgery is well tolerated and significantly improves scar appearance compared with placebo. Therapeutic, I.(Figure is included in full-text article.).

IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IMPLANTATION AND DEGREE OF LEFT VENTRICULAR SCARRING PREDICT SURVIVAL IN PATIENTS WITH SEVERE ISCHEMIC CARDIOMYOPATHY

Methods Patients (n = 337) with ≥ 70% disease in ≥1 epicardial coronary artery (77% men, median age 66 years, median LV ejection fraction [EF] of 22 %) undergoing CMR (Siemens 1.5-T scanner, Erlangen, Germany) between 2003-2007 were studied. CMR evaluation included long and short axis assessment of LV function on steady state free precession cine images along with assessment of myocardial scar (on inversion recovery DHE-CMR sequence ~ 10-20 minutes after injection of 0.2 mmol/ kg of Gadolinium dimeglumine). Scar was identified as regions of interest > 2 SD above normal myocardium. LV scar was categorized based on mean scar % and transmural extent (0 = none, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, and 4 = > 75%). Total scar score was determined from the summed scar score of 17 segments per patient divided by 17. 94 patients underwent subsequent ICD implantation. The composite end-point was cardiac transplantation and all-cause mortality. Results: Over a follow-up of up to 8 years, there were 107 events (102 deaths, 5 cardiac transplantations). Receiver operating characteristic curve analysis was used to select the optimum threshold of mean scar % ≥ 33%, total scar score ≥ 2.3 to predict death/transplantation. On multivariate variate analysis, only age, total scar score, diabetes, gender, and ICD implantation were independent predictors of mortality/transplantation (Table 1). ICD

Randomized phase II clinical trial of avotermin versus placebo for scar improvement

Scarring is a major problem following skin injury. In early clinical trials, transforming growth factor β3 (avotermin) improved scar appearance. The aim of this study was to determine whether an injection of avotermin at the time of wound closure is effective in improving scar appearance. Study RN1001-0042, a double-blind, randomized, within-patient, placebo-controlled trial, investigated the efficacy and safety of four doses of avotermin given once. Patients undergoing bilateral surgery to remove varicose leg veins by saphenofemoral ligation and long saphenous vein stripping were enrolled at 20 European centres. A total of 156 patients were randomized to receive one of four doses of avotermin (5, 50, 200 or 500 ng per 100 µl, at 100 µl per linear cm of wound margin), administered by intradermal injection to the groin and distal wound margins of one leg; placebo was administered to the other leg. Scar appearance was evaluated by an independent panel of lay people (lay panel), investigators and patients. The primary efficacy variable was lay panel Total Scar Score (ToScar), derived from visual analogue scale scores for groin scars between 6 weeks and 7 months. Avotermin 500 ng significantly improved groin scar appearance compared with placebo (mean lay panel ToScar difference 16·49 mm; P = 0·036). Avotermin 500 ng per 100 µl per linear cm of wound margin given once is well tolerated and significantly improves scar appearance.

Magnetic Resonance Imaging is Superior to Cardiac Scintigraphy to Identify Nonresponders to Cardiac Resynchronization Therapy

Left ventricular (LV) postero-lateral scar and total scar burden are factors responsible for a poor response to cardiac resynchronization therapy (CRT). Contrast-enhanced magnetic resonance imaging (CMR) and (99m)Tc-2-methoxy isobutyl isonitrile single photon emission computed tomography (SPECT) perfusion imaging are widely used to detect myocardial scar tissue; however, their ability to detect regional scars and predict a positive response to CRT has not been fully evaluated. CMR and SPECT were performed in 17 patients with dilated cardiomyopathy (DCM) and seven patients with ischemic cardiomyopathy (ICM) before CRT. All images were scored, using a 17-segment model. To analyze the LV scar regions by CMR, we assessed the transmural delayed enhancement extent as the transmural score in each segment (0 = no scar, 4 = transmural scar). Similarly, a perfusion defect score was assigned to each segment by SPECT (0 = normal uptake, 4 = defect). By both SPECT and CMR imaging, the total scar score was significantly higher in the ICM than in the DCM group. An LV postero-lateral wall scar region was detected using both imaging modes. By SPECT imaging, the percentage of regional scar score in the LV inferior wall was significantly higher in the DCM than in the ICM group. By SPECT imaging in the DCM group, severe perfusion defects, due to attenuation artifacts, were frequently observed in the LV inferior wall, resulting in the overestimation of scar tissue. CMR identified nonresponders to CRT more reliably than SPECT in patients with DCM.

1001 Greater degree of left ventricular scar is associated with increased mortality in patients with severe ischemic cardiomyopathy

Methods 349 patients with severe ICM >/= 70% coronary artery disease in >/= 1 epicardial vessel on angiography, mean LV ejection fraction (EF) of 24%] that underwent DHE-MRI (Siemens 1.5 T scanner, Erlangen, Germany) from 2003– 6 were studied. (Siemens, Erlangen, Germany) from 2005–6. DHE-MR images were obtained in standard long and short axis orientations (covering the entire LV), after injection of Gadolinium dimenglumine using an inversion recovery spoiled gradient echo sequence: TE 4 msec, TR 8 msec, flip angle 300, bandwidth 140 Hz/pixel, 23 kspace lines acquired every other RR-interval, field of view (varied from 228–330 in the x-direction and 260–330 in the y-direction) and matrix size (varied from 140–180 in the x-direction and 256 in the y-direction). For DHE-MRI analysis, a custom analysis package (VPT software, Siemens, Erlangen, Germany) was used to manually delineate endocardial and epicardial myocardial edges. Scar was defined (as % of myocardium in a 17-segment model on custom software, Siemens Research) on DHE-MR images, as intensity > 2 standard deviation above viable myocardium. Transmurality score was recorded in all segments as follows: 0 = no scar, 1 = 1–25% scar, 2 = 26–50%, 3 = 51– 75% and 4 = > 75%. Total scar score was calculated as transmurality score for all segments/17. LV volumes, EF, demographics, risk factors, need for cardiac transplantation (CTx) and all-cause mortality were recorded. Figure 1.

Comparison of Myocardial Infarct Size Assessed With Contrast-Enhanced Magnetic Resonance Imaging and Left Ventricular Function and Volumes to Predict Mortality in Patients With Healed Myocardial Infarction

Currently, left ventricular (LV) ejection fraction (EF) and/or LV volumes are the established predictors of mortality in patients with coronary artery disease (CAD) and severe LV dysfunction. With contrast-enhanced magnetic resonance imaging (MRI), precise delineation of infarct size is now possible. The relative merits of LVEF/LV volumes and infarct size to predict long-term outcome are unknown. The purpose of this study was to determine the predictive value of infarct size assessed with contrast-enhanced MRI relative to LVEF and LV volumes for long-term survival in patients with healed myocardial infarction. Cine MRI and contrast-enhanced MRI were performed in 231 patients with healed myocardial infarction. LVEF and LV volumes were measured and infarct size was derived from contrast-enhanced MRI. Nineteen patients (8.2%) died during a median follow-up of 1.7 years (interquartile range 1.1 to 2.9). Cox proportional hazards analysis revealed that infarct size defined as spatial extent (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.1 to 1.6, chi-square 6.7, p=0.010), transmurality (HR 1.5, 95% CI 1.1 to 1.9, chi-square 8.9, p=0.003), or total scar score (HR 6.2, 95% CI 1.7 to 23, chi-square 7.4, p=0.006) were stronger predictors of all-cause mortality than LVEF and LV volumes. In conclusion, infarct size on contrast-enhanced MRI may be superior to LVEF and LV volumes for predicting long-term mortality in patients with healed myocardial infarction.

Which parameters on magnetic resonance imaging determine Q waves on the electrocardiogram?

Studies have demonstrated that patients with Q-wave infarctions on the electrocardiogram (ECG) frequently have nontransmural scar formation, whereas non-Q-wave infarctions may have transmural scars. The precise pathophysiologic substrate that underlies Q waves remains unclear. Magnetic resonance imaging (MRI) is the preferred technique to evaluate patients who have infarction because information can be obtained on function, contractile reserve (viability), and scar tissue. Consecutive patients (n = 69) who had coronary artery disease and a history of myocardial infarction underwent MRI; the protocol included MRI at rest, small-dose dobutamine MRI, and contrast-enhanced MRI. Parameters included left ventricular ejection fraction, left ventricular volumes, end-diastolic wall thickness and contractile reserve in the infarct region, transmurality and spatial extent of scar tissue, total scar score, and quantified percent left ventricular scar tissue. MRI data were related to the presence/absence of Q waves on the ECG. Q waves were present in 39 patients (57%). Univariate analysis identified transmurality, spatial extent, total scar score, and quantified percent scar tissue as predictors of Q waves. Multivariate analysis demonstrated that quantified percent scar tissue was the single best predictor of Q waves on the ECG. A cut-off value of 17% infarcted tissue of the left ventricle yielded a sensitivity and specificity of 90% to predict the presence/absence of Q waves. When quantified percent scar tissue was removed from the model, spatial extent of infarction was the best predictor. Thus, Q waves on the ECG correlate best with quantified percent scar tissue on contrast-enhanced MR images.