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Background: The prognostic impact of functionally significant coronary artery disease, as assessed with quantitative flow ratio (QFR), in patients with severe aortic stenosis treated with transcatheter aortic valve replacement is unknown., Methods: This is a retrospective study with blind analysis of angiographic data, enrolling consecutive patients with severe aortic stenosis treated with transcatheter aortic valve replacement at 4 Italian centers. None of the patients enrolled received pre-transcatheter aortic valve replacement or concomitant coronary revascularization, either for the absence of significant coronary stenoses or by clinical decision. Visual estimation of diameter stenosis and QFR analysis were performed in all coronary arteries. The end point was all-cause mortality at a 3-year follow-up., Results: A total of 318 patients were enrolled. At visual estimation, 140 patients (44%) presented a diameter stenosis ≥50% in at least 1 coronary artery, whereas 78 patients (24.5%) had at least 1 vessel with QFR <0.80 and, therefore, included in the positive QFR group. Overall, 69 (21.7%) patients died during the follow-up. In the Kaplan-Meier analysis, patients with positive QFR experienced significantly higher rates of death during follow-up compared with those without (51.1% versus 12.1%; P <0.001), whereas no significant difference was evident in terms of death between patients with or without significant coronary artery disease according to angiographic evaluation (24.3% versus 19.7%; P =0.244). In a multivariate regression model, positive QFR was an independent predictor of all-cause death during follow-up (hazard ratio, 5.31 [95% CI, 3.21-8.76])., Conclusions: Coronary QFR can predict mortality in patients with severe aortic stenosis treated with transcatheter aortic valve replacement without revascularization., Competing Interests: None.

Background: Patients with atrial fibrillation (AF) undergoing transcatheter aortic valve implantation (TAVI) have been associated with worse short-term outcomes compared with patients in sinus rhythm but data on long-term outcomes are limited. The aim of our study was to evaluate the association between AF and short- and long-term outcomes in patients undergoing TAVI., Methods: We retrospectively evaluated patients undergoing TAVI between 2012 and 2022 in four tertiary centres. Two different analyses were conducted: (i) in-hospital and (ii) postdischarge analysis. First, we evaluated the association between preexisting AF and short-term outcomes according to VARC-3 criteria. Second, we analyzed the association between AF at discharge (defined as both preexisting and new-onset AF occurring after TAVI) and long-term outcomes at median follow-up of 3.2 years (i.e. all-cause death, hospitalization and major adverse cardiovascular events)., Results: A total of 759 patients were initially categorized according to the presence of preexisting AF (241 vs. 518 patients). The preexisting AF group had a higher occurrence of acute kidney injury [odds ratio (OR) 1.65; 95%confidence interval ( CI) 1.15-2.38] and major bleeding (OR 1.86, 95% CI 1.06-3.27). Subsequently, the population was categorized according to the presence of AF at discharge. At the adjusted Cox regression analysis, AF was independently associated with an increased risk of all-cause death and cardiovascular hospitalization [adjusted hazard ratio (aHR) 1.42, 95% CI 1.09-1.86], all-cause death and all-cause hospitalization (aHR 1.38, 95% CI 1.06-1.78) and all-cause hospitalization (aHR 1.59, 95% CI 1.14.2.22)., Conclusions: In a real-world cohort of patients undergoing TAVI, the presence of AF (preexisting and new-onset) was independently associated with both short- and long-term adverse outcomes., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Italian Federation of Cardiology.)

Cor pulmonale is a clinical syndrome associated with pulmonary hypertension, frequently complicated by congestive heart failure, commonly caused by chronic obstructive pulmonary disease (COPD). Most patients with cor pulmonale have tachycardia. However, heart rate (HR) reduction represents a primary treatment goal to improve the survival and quality of life in these patients. Ivabradine can selectively slow HR at rest and during exercise. In this prospective study, we tested the hemodynamic effects, invasively determined using right-sided cardiac catheterization, of reducing HR with ivabradine. We selected 18 patients (13 men [72.2%], mean age 67 ± 10 years) with COPD and cor pulmonale, presenting with sinus tachycardia. All patients performed clinical evaluation, electrocardiogram, spirometry, echocardiogram, 6-minute walking distance, and right-sided cardiac catheterization within 1 month of enrollment. All tests were repeated after 6 months of ivabradine treatment (median assumed dose 11.9 mg/die). We noticed a significant decrease of HR (from 98 ± 7 to 77 ± 8 beats/min, p = 0.0001), with a concomitant reduction of the congestion index (from 25.9 ± 5.1 to 19.4 ± 5.7 mm Hg, p = 0.001), and the consequent improvement of the right ventricular systolic performance (right ventricular stroke volume augmented from 56.7 ± 7.9 to 75.2 ± 8.6 ml/beat, p = 0.0001). This allows an improvement in clinical status and exercise tolerance (Borg scale score decreased from 5.2 ± 1.4 to 4.1 ± 1.3, p = 0.01 and the 6-minute walking distance increased to 252 ± 65 to 377 ± 59 m, p = 0.001). In conclusion, HR reduction significantly improves hemodynamic and clinical status of patients with tachycardia affected by COPD and cor pulmonale., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Coronary artery disease (CAD) is common in patients with aortic valve stenosis (AS) ranging from 60% to 80%. The clinical and prognostic role of coronary artery lesions in patients undergoing Transcatheter Aortic Valve Implantation (TAVI) remains unclear. The aim of the present observational study was to estimate long-term clinical outcomes by Quantitative Flow Ratio (QFR) characterization of CAD in a well-represented cohort of patients affected by severe AS treated by TAVI., Methods: A total of 439 invasive coronary angiographies of patients deemed eligible for TAVI by local Heart Teams with symptomatic severe AS were retrospectively screened for QFR analysis. The primary endpoint of the study was all-cause mortality. The secondary endpoint was a composite of cardiovascular mortality, stroke/transient ischemic attack (TIA), acute myocardial infarction (AMI), and any hospitalization after TAVI., Results: After exclusion of patients with no follow-up data, coronary angiography not feasible for QFR analysis and previous surgical myocardial revascularization (CABG) 48/239 (20.1%) patients had a QFR value lower or equal to 0.80 (QFR + value), while the remaining 191/239 (79.9%) did not present any vessel with a QFR positive value. In the adjusted Cox regression analysis, patients with positive QFR were independently associated with an increased risk of all-casual mortality (Model 1, HR 3.47, 95% CI, 2.35-5.12; Model 2, HR 5.01, 95% CI, 3.17-7.90). In the adjusted covariate analysis, QFR+ involving LAD (37/48, 77,1%) was associated with the higher risk of the composite outcome compared to patients without any positive value of QFR or non-LAD QFR positive value (11/48, 22.9%)., Conclusions: Pre-TAVI QFR analysis can be used for a safe, simple, wireless functional assessment of CAD. QFR permits to identify patients at high risk of cardiovascular mortality or MACE, and it could be considered by local Heart Teams., Competing Interests: GB: small speaker fee from Bayer, Boehringer Ingelheim, Boston, Daiichi- Sankyo and Janssen outside the present article. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Demola, Colaiori, Bosi, Musto D'Amore, Vitolo, Benatti, Vignali, Tadonio, Gabbieri, Losi, Magnavacchi, Sgura, Boriani and Guiducci.)

Background: Transcatheter aortic valve implantation (TAVI) has developed as an alternative to surgery for symptomatic high-risk patients with aortic stenosis (AS). An important complication of TAVI is acute kidney injury. The purpose of the study was to investigate if the Mehran Score (MS) could be used to predict acute kidney injury (AKI) in TAVI patients., Methods: This is a multicenter, retrospective, observational study including 1180 patients with severe AS. The MS comprised eight clinical and procedural variables: hypotension, congestive heart failure class, glomerular filtration rate, diabetes, age >75 years, anemia, need for intra-aortic balloon pump, and contrast agent volume use. We assessed the sensitivity and specificity of the MS in predicting AKI following TAVI, as well as the predictive value of MS with each AKI-related characteristic., Results: Patients were categorized into four risk groups based on MS: low (≤5), moderate (6-10), high (11-15), and very high (≥16). Post-procedural AKI was observed in 139 patients (11.8%). MS classes had a higher risk of AKI in the multivariate analysis (HR 1.38, 95% CI, 1.43-1.63, p < 0.01). The best cutoff for MS to predict the onset of AKI was 13.0 (AUC, 0.62; 95% CI, 0.57-0.67), whereas the best cutoff for eGFR was 42.0 mL/min/1.73 m 2 (AUC, 0.61; 95% CI, 0.56-0.67)., Conclusions: MS was shown to be a predictor of AKI development in TAVI patients.

Background: The aim of this study was to determine the impact of transcatheter edge-to-edge repair (TEER) on left and right ventricular (LV, RV) and left and right atrial (LA, RA) remodeling according to the mechanism of mitral regurgitation (MR) and history of atrial fibrillation (AF)., Methods: Twenty-four patients (mean age 78.54 years ± 7.64 SD; 62.5% males) underwent TEER at our center. All the patients underwent echocardiography 1.6 ± 0.9 months before the procedure and after 5.7 ± 3.5 months; functional MR accounted for 54% of cases., Results: Compared to baseline, a statistically significant improvement in LV end-diastolic diameter (LVEDD), LV indexed mass (ILVM), LV end-diastolic and end-systolic volumes (LVEDV, LVESV), indexed LA volume (iLAV), and morpho-functional RV parameters was recorded. LVEDD and LVEDV improved in primary MR cohort, whereas in secondary MR, a significant reduction in LVEDV and LVESV was found without a significant functional improvement. LA reverse remodeling was found in organic MR with a trend toward ameliorated function. Furthermore, a significant reduction of LA volumetry was detected only in patients without history of AF (AF baseline 51.4 mL/m 2 IQR 45.6-62.5 mL/m 2 f-u 48.9 mL/m 2 IQR 42.9-59.2 mL/m 2 ; p = 0.101; no AF baseline 43.5 mL/m 2 IQR 34.2-60.5 mL/m 2 f-u 42.0 mL/m 2 IQR 32.0-46.2 mL/m 2 ; p = 0.012). As regards right sections, the most relevant reverse remodeling was obtained in patients with functional MR with a baseline poorer RV function and more severe RA and RV dilation., Conclusion: TEER induces reverse remodeling involving both left and right chambers at mid-term follow-up. To deliver a tailored intervention, MR mechanism and history of AF should be considered in view of the impact on remodeling process.

Underweight or overweight patients with cardiovascular diseases are associated with different outcomes. However, the data on the relation between body mass index (BMI) and outcomes after transcatheter aortic valve implantation (TAVI) are not homogeneous. The aim of this study was to assess the role of low BMI on short and long-term mortality in real-world patients undergoing TAVI. We retrospectively included patients undergoing TAVI for severe aortic valve stenosis. Patients were classified into three BMI categories: underweight (< 20 kg/m 2 ), normal weight (20-24.9 kg/m 2 ) and overweight/obese (≥ 25 kg/m 2 ). Our primary endpoint was long-term all-cause mortality. The secondary endpoint was 30-day all-cause mortality. A total of 794 patients were included [mean age 82.3 ± 5.3, 53% females]. After a median follow-up of 2.2 years, all-cause mortality was 18.1%. Patients in the lowest BMI group showed a higher mortality rate as compared to those with higher BMI values. At the multivariate Cox regression analysis, as compared to the normal BMI group, BMI < 20 kg/m 2 was associated with long-term mortality independently of baseline risk factors and postprocedural adverse events (hazard ratio [HR] 2.29, 95% confidence interval [CI] 1.30-4.03] and HR 2.61, 95% CI 1.48-4.60, respectively). The highest BMI values were found to be protective for both short- and long-term mortality as compared to lower BMI values even after applying the same adjustments. In our cohort, BMI values under 20 kg/m 2 were independent predictors of increased long-term mortality. Conversely, the highest BMI values were associated with lower mortality rates both at short- and long-term follow-up., (© 2021. Società Italiana di Medicina Interna (SIMI).)

Pericardial effusion can dangerously precipitate patient's hemodynamic stability and requires prompt intervention in case of tamponade. We investigated potential predictors of in-hospital mortality, a composite outcome of in-hospital mortality, pericardiocentesis-related complications, and the need for emergency cardiac surgery and all-cause mortality in patients undergoing percutaneous pericardiocentesis. This is an observational, retrospective, single-center study on patients undergoing percutaneous pericardiocentesis (2010-2019). We enrolled 81 consecutive patients. Median age was 71.4 years (interquartile range [IQR] 58.1-78.1 years) and 51 (63%) were male. Most of the pericardiocentesis were performed in an urgency setting (76.5%) for cardiac tamponade (77.8%). The most common etiology was idiopathic (33.3%) followed by neoplastic (22.2%). In-hospital mortality was 14.8% while mortality during follow-up (mean 17.1 months) was 44.4%. Only hemodynamic instability (i.e., cardiogenic shock, hypotension refractory to fluid challenge therapy and inotropes) was associated with in-hospital mortality at the univariate analysis (odds ratio [OR] 7.2; 95% confidence interval [CI] 1.76-29.4). Non-neoplastic/non-idiopathic etiology and hemodynamic instability were associated with the composite outcome of in-hospital mortality, need for emergency cardiac surgery, or pericardiocentesis-related complications (OR 5.75, 95% CI 1.65-20.01, and OR 5.81, 95% CI 2.11-15.97, respectively). Multivariate Cox regression analysis adjusted for possible confounding variables (age, coronary artery disease, and hemodynamic instability) showed that neoplastic etiology was independently associated with medium-term mortality (hazard ratio [HR] 4.05, 95% CI 1.45-11.36). In a real-world population treated with pericardiocentesis for pericardial effusion, in-hospital adverse outcomes and medium-term mortality are consistent, in particular for patients presenting with hemodynamic instability or neoplastic pericardial effusion., (© 2021. Società Italiana di Medicina Interna (SIMI).)

Portopulmonary hypertension (PoPH) is a clinical condition associated with end-stage liver disease, described by the coexistence of pulmonary arterial hypertension (PAH) and portal hypertension. In PoPH patients, there is a right ventricle (RV) remodeling to compensate for the increased resistance in the lung circulation. There are no studies on the effects of the PAH-targeted pharmacological treatment on the RV dimension and function. The present study summarizes our experience in patients with PoPH treated with sildenafil in a period of 6 years (from 2013 to 2019). We enrolled 64 consecutive patients identified as PoPH, all treated with sildenafil (57.6% in monotherapy; in the other cases in association with macitentan; in 19.0% with initial combination therapy). A hemodynamic invasive cardiopulmonary study was performed at baseline and after 6 months of sildenafil treatment. In our population we showed a significative improvement in RV performance, with a significant increase in RV stroke volume (+33%), RV ejection fraction (+31%) and RV stroke work index (+17.5%). We registered the reduction of the RV cavity dimension over time in all patients treated with sildenafil (RV end diastolic diameter decreased by 15% after 6 months of follow-up). Regarding diastolic function, we highlighted a very significant reduction in RV end-diastolic pressure (-50% concerning baseline). Sildenafil was effective both when used as monotherapy and in combination with macitentan. In conclusion, Sildenafil had a positive impact on RV systolic and diastolic function in patients with PoPH and was able to conditionate the reverse remodeling of the RV., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Red cell distribution width (RDW) is recently emerging as a prognostic indicator in many cardiovascular diseases. However, less is known about its predictive role in patients undergoing transcatheter aortic valve implantation (TAVI)., Methods: We retrospectively included very high-risk patients with severe aortic valve stenosis undergoing TAVI between February 2012 and December 2019. Patients were classified according to RDW tertiles. Our primary endpoint was long-term all-cause mortality. The secondary endpoint was a composite of in-hospital major adverse events as defined by the Valve Academic Research Consortium 2 criteria and/or long-term all-cause mortality., Results: A total of 424 patients [median age 83.5 years, 52.6% females] were analysed. After a median follow-up of 1.55 years, all-cause mortality was 25.5%. At the multivariate-adjusted Cox regression analysis, patients in the highest RDW tertile were associated with a higher risk for all-cause mortality [hazard ratio [HR] 1.73, 95%confidence interval [CI] 1.02-2.95] compared with the lowest tertile. When considering RDW as a continuous variable, we found an 11% increased risk in overall mortality [HR 1.11, 95% CI 1.00-1.24] for each increased point in RDW. The highest RDW tertile was also independently associated with the occurrence of the composite endpoint [odds ratio [OR] 2.10, 95% CI 1.17-3.76] compared with lower tertiles., Conclusions: In our cohort, elevated basal RDW values were independent predictors of increased long-term mortality and higher rate of in-hospital adverse events. The inclusion of a routinely available biomarker as RDW, may help the pre-operative risk assessment in potential TAVI candidates and optimise their management., (© 2021 John Wiley & Sons Ltd.)

Background: Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) has been associated with worse outcomes. However, the impact on outcome of AKI in TAVI-patients is not well established., Methods: Inoperable patients with severe aortic stenosis (AS) undergoing TAVI in 2010-2018 were enrolled in this study. AKI and chronic kidney disease (CKD) were defined according to KDIGO guidelines. Patients were divided in two groups according to post-procedural AKI development. The primary endpoint was 30-day all-cause mortality across the two groups., Results: A total of 373 patients (mean age 82.3 ± 6) were analyzed. Compared to non-AKI patients, those who developed AKI, were treated more frequently with trans-apical TAVI (66% vs 35%, p<0.01), with greater amount of contrast medium (200.6 vs 170.4 ml, p=0.02) and in presence of clinically significant peripheral artery disease (PAD, 33% vs 21%, p=0.04). Trans-apical access (OR 3.24, 95% CI 1.76-5.60, p<0.01) was associated with a 3-fold risk of AKI. After adjustment for age, Society of Thoracic Surgery risk score (STS), PAD, access type, EF and contrast medium amount, patients with AKI presented an increased risk of 30-day all-cause mortality (HR=1.25, 95%CI 1.09-1.69, p=0.008). Patients with CKD IV and V, who developed AKI, presented a 9-fold 30-day mortality risk (HR=9.71, 95% CI 2.40-39.2, p=0.001)., Conclusion: In our analysis, AKI was a strong predictor of 30-day all-cause mortality. Particularly, patients with severe CKD with AKI showed the highest 30-day mortality risk. Thus, this group of patients might benefit from closer monitoring and specific kidney protection therapies., (Copyright © 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

The presence of clinical peripheral arterial disease (PAD) is associated with an increased risk for adverse cardiovascular outcomes in patients with coronary artery disease. However, there are few data regarding the impact of the presence and degree of the subclinical PAD on outcomes in patients with coronary artery disease. The aim of this study was to assess prospectively the grade of subclinical PAD in the setting of patients who underwent primary percutaneous coronary intervention for the prediction of intermediate- and long-term clinical outcomes. A total of 971 consecutive patients without histories of clinical PAD who under went primary percutaneous coronary intervention for ST-segment elevation myocardial infarction were included in a prospective follow-up. Subclinical PAD severity was blindly assessed on the basis of an ultrasound arterial morphologic classification defined with the assessment of wall carotid and femoral artery bifurcations. This classification included 4 increasing classes of subclinical carotid and femoral arterial wall lesions, and the total group was divided accordingly. Death and major cardiovascular and cerebrovascular events were evaluated. During a median follow-up period of 40 months, a total of 109 patients (11.2%) died, 9 (2.8%) in class I, 12 (3.1%) in class II, 37 (23.7%) in class III, and 51 (49.0%) in class IV (p <0.001). On multivariate analysis, mortality in class IV was sevenfold higher (hazard ratio [HR] 7.34, 95% confidence interval [CI] 3.3 to 16.33, p <0.001) compared to class I and was also increased in class III (HR 5.38, 95% CI 2.42 to 11.92, p <0.001). Similar results were obtained for major adverse cardiovascular and cerebrovascular events in class IV (HR 7.50, 95% confidence interval 5.36 to 10.50, p <0.0001), class III (HR 6.44, 95% CI 4.45 to 9.32, p <0.001), and class II (HR 1.73, 95% CI 1.23 to 2.43, p = 0.002). In conclusion, ultrasound arterial morphologic classification may be applied in patients with ST-segment elevation myocardial infarctions who undergo primary percutaneous coronary intervention and can stratify patients for poor clinical outcomes during long-term follow-up., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The Mehran Risk Score (MRS) has been demonstrated to be clinically useful for prediction of contrast-induced nephropathy (CIN) after nonurgent percutaneous coronary intervention. We aim to validate the MRS in the setting of Primary percutaneous coronary intervention for prediction of both CIN and short- and long-term clinical outcomes., Methods and Results: We assigned 891 consecutive patients with ST-elevation-myocardial infarction undergoing primary percutaneous coronary intervention to 4 groups of risk of CIN (RC) according to MRS (low, medium, high, and very high risk). We evaluated CIN, death, and major cardiovascular and cerebrovascular events after 25 months' mean follow-up. At multivariable analysis, mortality in very high-risk group was more than 10-fold higher (hazard ratio [HR], 10.11; 95% confidence interval [CI], 4.83 to 21.1; P<0.001) when compared with the low-risk group and was also increased in the high-risk group (HR, 6.31; 95% CI, 3.28 to 12.14; P<0.001) and medium-risk group (HR, 3.18; 95% CI, 1.83 to 5.51; P<0.001). Similarly, an increasing effect was seen across MRS strata for major cardiovascular and cerebrovascular events both in the very high-risk group (HR, 3.79; 95% CI, 2.27 to 6.6.32; P<0.001), high-risk group (HR, 1.90; 95% CI, 1.31 to 2.75; P=0.001), and medium-risk group (HR, 1.42; 95% CI, 1.10 to 1.85; P=0.007). In addition, the HR for rehospitalization increased with the increasing RC groups (HR, 3.32; 95%CI, 1.96 to 5.63; P<0.001; HR, 3.11; 95% CI, 1.35 to 7.20; P=0.008; HR, 7.73; 95% CI, 2.97 to 20.10; P<0.001, respectively). The odds ratio for CIN was 2.84 (95% CI, 1.16 to 6.92; P=0.021) in the very high RC group, 1.33 (95% CI, 0.68 to 2.61; P=0.398) in the high RC group, and 1.10 (95% CI, 0.67 to 1.79; P=0.699) in the medium RC group, as compared with the lower one., Conclusions: The MRS may be applied in the primary angioplasty setting population and is able to predict CIN and to stratify patients for poor clinical outcomes both in the short- and long-term follow-up.

One of the frequent long-term complications after stent implantation is restenosis due to the building up of a neointima within the artery, as well as endovascular hyperplasia (tissue growth). The interesting feature of the Lunar stent from Inflow Dynamics is that it is coated with a layer of iridium oxide. The iridium oxide coating is believed to reduce restenosis by decreasing the inflammatory response to the stent via its antioxidant action. The MOONLIGHT (Multicenter Objective ObservatioNal Lunar Iridiumoxide intimal GrowtH Trial) study was carried out to evaluate the immediate outcome and long-term angiographic success after implantation of Lunar stents. Between March 2001 and November 2001, 87 patients with 99 lesions were enrolled in this study and were treated with 12 and 16 mm long iridium-oxide coated Lunar stents. Delivery of the Lunar stent was successful in most lesions and the optimal radiopacity facilitated optimal stent positioning with optimal immediate clinical and angiographic results is an unselected patient and lesion population. Preliminary clinical and angiographic follow-up show a low rate of cardiac events at 6 months (16.1% MACE) and a moderate hyperplastic response.

Objective: We evaluated the association between length of hospital stay (LOS) and clinical factors, treatment intensity, and use of percutaneous coronary revascularization from 1988 to 1997., Background: Multiple factors contribute to the observed reduction in LOS for patients with myocardial infarction., Methods: We studied a series of 849 consecutive patients admitted with acute myocardial infarction to the Mayo Clinic Coronary Care Unit within three time periods: period I (1988-1990), period II (1991-1993), and period III (1994-1997)., Results: Median LOS decreased significantly between 1988 and 1997 (9 days to 5 days, 36% reduction, p < 0.0001), with significant reductions (p < 0.001) associated with certain therapies: primary reperfusion (6 days vs 7 days), b-blockers (6 days vs 8 days), and aspirin (6 days vs 8 days). Hospitalizations were lengthened by coronary artery bypass grafting (12 vs 6 days) and by serious complications (10 vs 6 days). The era of the admission (period I vs II vs III) is a significant, powerful predictor of LOS, even after adjustment for other key variables., Conclusion: The 36% reduction in LOS for acute myocardial infarction between 1988 and 1997 is related both to therapeutic modalities and temporal trends. Further study is needed to clarify whether the trend for decreasing LOS persists and influences outcome and health care quality variables.

Coronary angiography remains the standard technique for the assessment and therapy of coronary artery disease. Recently, intravascular ultrasound (IVUS) has emerged as a new adjunctive invasive tool which allows the acquisition of direct images of the atherosclerotic plaque in the cardiac catheterization laboratory; however it cannot be considered as an alternative to angiography. The aim of this article was to describe the indications, technique, and interpretation of IVUS imaging and its diagnostic and therapeutic applications, to review the pertaining literature and report the experience from our catheterization lab group. Ultrasound provides a unique method to study the regression or progression of atherosclerotic lesions in vivo. Lipid-laden lesions appear hypoechoic, fibromuscular lesions generate low-intensity or "soft echos" while the fibrous and calcified tissue impedes ultrasound penetration, obscuring the underlying vessel wall (acoustic shadowing). IVUS has been used to evaluate arterial remodeling: positive remodeling is the increase in arterial size to compensate for plaque accumulation and represents a compensatory mechanism to preserve lumen size; negative remodeling is vessel shrinkage and has been implicated in restenosis after balloon angioplasty. Positive remodeling seems to be significantly more frequent in myocardial infarction and unstable angina, negative remodeling occurs more often in stable coronary syndromes and is the main mechanism of restenosis after balloon angioplasty. In ostial and bifurcation lesion, the stenosis may be obscured by overlapping contrast-filled structures. Intermediate stenoses are particularly problematic in patients whose symptomatic status is difficult to assess. In these ambiguous situations, ultrasound provides a tomographic perspective, independent of the radiographic projection, which often allows precise lesion quantification. IVUS has emerged as the optimal method for the detection of diffuse post-transplant vasculopathy. Rapidly progressive intimal thickening (> 0.5 mm increase) in the first year after transplantation has major negative prognostic significance. The safety of IVUS is well documented, with studies reporting complication rates varying from 1 to 3%; the complications most frequently reported is transient spasm. Ultrasound allows us to evaluate plaque morphology, plaque eccentricity and lesion length, often helping in procedural decision-making. IVUS demonstrates plaque fracture and arterial wall dissection more often than angiography. Coronary angiograms frequently underestimate disease burden, whereas IVUS identifies residual plaque burden and minimal lumen diameter as the most powerful predictor of clinical outcome (restenosis). Several IVUS studies of directional atherectomy have addressed the issue of more aggressive plaque removal possibly resulting in decreased angiographic restenosis rate. IVUS imaging has played a pivotal role in the optimization of stent therapy. The concept of high-pressure stent implantation disseminated quickly, and larger trials demonstrated the safety of stent implantation using high pressures. IVUS has shown that in-stent restenosis is determined by the degree of intimal hyperplasia within the stent or in the stent border. In conclusion, the use of IVUS in the world is slowly increasing. Ultrasound commonly detects occult disease in patients with coronary artery disease. However, no short- or long-term studies have determined whether disease detected exclusively by ultrasound portends a worse prognosis as compared with "true normal" angiography.

To investigate the relevance of presenting electrocardiographic (ECG) patterns to short- and long-term mortality in nonreferral patients with acute myocardial infarction (AMI), 6 ECG patterns were analyzed. A consecutive series of 907 patients from Olmsted County, Minnesota, admitted to the Mayo Clinic Cardiac Care Unit from January 1, 1988 to March 31, 1998 for acute myocardial infarction comprised the study population. ECG patterns and distribution in the population were: (1) ST elevation alone (20.8%), (2) ST elevation with ST depression (35.2%), (3) normal or nondiagnostic electrocardiograms (18.5%), (4) ST depression alone (11.8%), (5) T-wave inversion only (10.7%), and (6) new left bundle branch block (LBBB) (3.0%). Seven- and 28-day mortalities varied significantly (p <0.01) among the 6 ECG groups. Respective mortalities were 3.0% and 6.0% for patients with normal or nondiagnostic electrocardiograms, 3.1% and 5.2% for T-wave inversion only, 7.4% and 10.6% for ST elevation alone, 9.4% and 13.1% for ST depression alone, 10.3% and 13.8% for ST elevation with ST depression, and 18.5% and 22.2% for new LBBB. Length of hospital stay (LOS) also varied among the ECG pattern groups (p <0.001) with the longest average LOS being in the new LBBB group (12.5 days). Long-term survival was similar among 5 ECG pattern groups (45% to 55% at 8 years from discharge) with the exception of LBBB (20% at 8 years). Among non-LBBB groups, ST-segment depression with or without ST elevation was associated with increased short-term mortality. Also, in this community-based population, 18.5% of patients had normal or nondiagnostic electrocardiograms.

Background: Several reports suggest that the incidence of stroke and atrial fibrillation is reduced in patients receiving physiologic pacemakers, compared with patients receiving a ventricular pacemaker., Hypothesis: The study was undertaken to address the impact of different pacing modalities on the incidence of stroke and atrial fibrillation., Methods: We prospectively analyzed 210 consecutive patients. Those with previous episodes of cerebral ischemia and/or atrial fibrillation were excluded from the study. The study population included 100 patients paced for total atrioventricular (AV) block or second-degree AV block (type II Mobitz) and 110 patients paced for sick sinus syndrome (SSS). The pacing mode was randomized. All patients underwent a brain computed tomography (CT) scan at the date of enrollment and after 1 and 2 years. Patients were followed for 2 years, and the incidence of atrial fibrillation and stroke was evaluated., Results: The incidence of atrial fibrillation was 10% at 1 year and 11% at 2 years. Comparing the different pacing modalities, we reported an increase in the incidence of atrial fibrillation in patients receiving ventricular pacing (p < 0.05). On the other hand, no difference was found between patients paced for AV block and those paced for SSS. At the end of follow-up, we reported 29 cases of cerebral ischemia: 9 patients had AV block while 20 had SSS (p < 0.05). Comparing the different pacing modalities, there was an increase in the incidence of stroke in patients receiving ventricular pacing (p < 0.05)., Conclusion: There was an increase in the incidence of stroke and atrial fibrillation in patients with ventricular pacing.

This study was performed in a population of sequential dual-chamber pacemaker-patients with isolated mitral regurgitation (MR) to identify the "ideal atrioventricular (AV) delay" and to determine the effect of sequential pacing with the ideal AV delay on MR degree. Twenty consecutive patients (age 69 +/- 7 years; 45% men) hospitalized at our institution for symptomatic III degree AV block and isolated MR were studied. All received a dual-chamber pacemaker programmed in DDD at a rate of 70 pulses/minute. The ideal AV delay was selected using echo-color Doppler parameters; it was defined as that resulting in a lower degree of MR and in the highest cardiac output. The mean "optimal short" AV delay resulted in 98 +/- 7 ms. At short AV delay we observed a significant reduction in MR severity (regurgitant fraction from 48 +/- 12% to 25 +/- 10% and jet area from 15 +/- 2 to 9 +/- 2 cm2; p <0.0001) together with an increase in stroke volume (68 +/- 16 vs 88 +/- 15 ml; p = 0.007) and mitral early-to-late peak velocity ratio (0.79 +/- 0.33 vs 1.38 +/- 0.37; p <0.0001). In conclusion, a short AV delay may be used to improve cardiac output in sequential paced patients with pure, isolated MR.

Hypothesis: This study was undertaken to determine whether echo-derived left atrial dimension and other echocardiographic, clinical, and hemodynamic parameters detected at the time of entry into the study may influence prognosis in patients with dilated cardiomyopathy during a long-term follow-up., Methods: This was a prospective cohort analysis of 123 patients with dilated cardiomyopathy. Clinical evaluation, chest x-ray, M-mode and two-dimensional echocardiogram, exercise test, 72-h ambulatory electrocardiogram monitoring, and cardiac catheterization study were performed in all patients. The study was divided into two phases: in the first phase, patients were divided into two groups according to the left atrial size (> or = 45 mm; < 45 mm), with cardiac death as the end point. In the second phase, all patients were further divided into two groups according to their clinical course. A multivariate analysis was performed to determine independent correlated parameters of cardiac mortality and overall clinical outcome., Results: Cardiac mortality rate was 47.9%: 29% in the group without left atrial dilation and 54.3% in the group with dilated left atrium. Multivariate analysis revealed that left atrium > or = 45 mm, New York Heart Association functional classes III/IV, and the presence of one or more episodes of ventricular tachycardia at Holter monitoring were independent predictors of cardiac mortality, while left atrium > or = 45 mm, left ventricular end-diastolic pressure > 17 mmHg, and exercise tolerance < or = 15 min were independent predictors of poor clinical outcome., Conclusions: Our results revealed that left atrial size is the principal independent predictor of prognosis in patients with dilated cardiomyopathy in that patients with left atrial dilation had an increase in mortality and a worse clinical outcome compared with those without left atrial dilation.

Background and Hypothesis: Dilation of the left ventricle after myocardial infarction is associated with an adverse prognosis. There are no clinical studies on the role viable myocardium in the infarcted area assumes in relation to the development of late ventricular remodeling. The hypothesis of this study was to define the relation between remodeling and the presence of viable but akinetic myocardium in the infarct area and to identify early predictors of left ventricular (LV) dilation at 1 year., Methods: In all, 92 consecutive patients with myocardial infarction were divided into two groups according to their ventricular volumes. Group I included 57 patients with normal volumes at discharge (9 +/- 3 days after acute infarction) and after 12 months or with LV dilation at discharge who had a normalization of their volumes over a 12-month period. Group II included 35 patients who, independent of their initial volumes, developed LV dilation during follow-up. Low-dose dobutamine infusion was utilized at discharge for echocardiographic evaluation of contractile recovery of viable myocardial segments., Results: At the first control, patients in Group I presented an end-diastolic volume index (EDVI) of 100 +/- 7 ml/m2 which decreased to 68.8 +/- 6.5 ml/m2 12 months later (p < 0.0001), and an end-systolic volume index (ESVI) of 47.6 +/- 6.7 ml/m2 at the first control and 30.5 +/- 8.8 ml/m2 after 12 months (p < 0.001). Patients in Group II presented a mean EDVI of 116.2 +/- 8.1 ml/m2 at the first control and 138.8 +/- 8 ml/m2 12 months later (p < 0.001), and a mean ESVI of 68.8 +/- 6.5 ml/m2 at the first control and 79.5 +/- 5.4 after 12 months (p < 0.01). Ventricular mass index (VMI) in Group I increased from 106.4 +/- 11 to 122.3 +/- 15 g/m2 (p < 0.01), while in Group II it decreased from 101.1 +/- 10 to 98.7 +/- 8 g/m2 (p = NS). In Group I, mass-to-volume ratio was 1.15 +/- 0.1 g/ml at the first control and 1.67 +/- 0.1 g/ml 12 months later (p < 0.001), while in Group II it declined from 0.88 +/- 0.1 to 0.69 +/- 0.1 g/ml (p < 0.01). The multivariate analysis revealed that ejection fraction < or = 40%, restrictive filling pattern, wall motion score index > 2.5 in response to dobutamine infusion, and mass-to-volume ratio < or = 1 g/ml, all at discharge, as well as an occluded left anterior descending artery discriminate in favor of late LV dilation and remodeling., Conclusions: Correct use of noninvasive strategies should result in early identification of postinfarct patients who are at risk of developing LV remodeling.