Efficiency of radiofrequency ablation for surgical treatment of chronic atrial fibrillation in rheumatic valvular disease

Background

It remains unclear whether concomitant radiofrequency ablation procedure in valvular surgery could offer additional benefits to patients with rheumatic valvular disease. We designed a prospective and randomized control study to evaluate the efficacy of surgical radiofrequency ablation in patients with rheumatic heart disease.

Methods

From June 2008 to July 2011, 210 patients with chronic atrial fibrillation and rheumatic heart disease were randomized: (1) control group, patients underwent only valve replacement followed by amiodarone for rhythm control, (2) left atrial group (LA group), patients underwent valve replacement and left atrial mono-polar radiofrequency ablation, (3) bi-atrial group (BA group), patients underwent valve replacement and bi-atrial mono-polar radiofrequency ablation. The primary endpoints included: cardiac death, stroke, and recurrent AF after discharge.

Results

There was no perioperative death. One patient died 4 months after MVR in BA group. In univariate Cox analysis, the two ablation groups were associated with less AF (BA group vs control group: P < 0.001; LA group vs control group: P < 0.001) as well as atrial tachycardia arrhythmia (AF/AT/AFL) recurrent (BA group vs control group: P < 0.001; LA group vs control group: P = 0.02). The comparison between BA and LA groups revealed no differences in terms of AF (P = 0.06) or AF/AT/AFL (P = 0.09). Atrial transport function restoration rate 12 months after operation was 31.4% in LA group, 32.9% in BA group, and 8.6% in control group respectively (P < 0.01).

Conclusions

Radiofrequency ablation concurring with valvular surgery can bring a higher sinus rhythm restoration rate when compared with medical anti-arrhythmic drug therapy in low-medium risk rheumatic heart disease.The trial was registered on Clinicaltrials.gov (registry number NCT01013688).     

Benefits and risks of additional ablation of complex fractionated atrial electrograms for patients with atrial fibrillation: A systematic review and meta-analysis

Background

The benefits and risks of additional complex fractionated atrial electrograms (CFAE) ablation in patients with atrial fibrillation (AF) remain unclear.

Methods

Trials were identified in PubMed, Embase, Web of Science, and Cochrane Database, reviews, and reference lists of relevant papers. The primary end point was the recurrence of atrial arrhythmias after a single ablation.

Results

We meta-analyzed 11 studies (total, n = 983) using random-effects model to compare PVI (n = 478) with PVI plus CFAE ablation (PVI + CFAE) (n = 505). Additional CFAE ablation reduced recurrence of atrial tachyarrhythmia after a single procedure (pooled RR 0.73; 95% CI 0.61, 0.88; P = 0.0007) at ≥ 3-month follow-up. There was no evidence of heterogeneity among studies (I² = 33%). Subgroup analysis demonstrated that additional CFAE ablation reduced rates of recurrence in nonparoxysmal AF (RR 0.68; 95% CI 0.47, 0.99; P = 0.05), whereas had no effect on patients with paroxysmal AF (RR 0.79; 95% CI 0.59, 1.06; P = 0.12). Eight studies reported results of post-procedure ATs. The addition of CFAE ablation increased the rate of post-procedure ATs (RR 1.77; 95% CI 1.02, 3.07; P = 0.04). Additional CFAE ablation significantly increased mean procedural times (245.4 + 75.7 vs. 189.5 + 62.3 min, P < 0.001), mean fluoroscopy (72.1 + 25.6 vs. 59.5 + 19.3 min, P < 0.001), and mean RF energy application times (75.3 + 38.6 vs. 53.2 + 27.5 min, P < 0.001).

Conclusions

The adjunctive CFAE ablation could provide additional benefit in terms of reducing recurrence of atrial tachyarrhythmia for patients with nonparoxysmal AF but not for patients with paroxysmal AF after a single procedure with or without antiarrhythmic drugs (AADs). The main risk of adjunctive CFAE ablation is the increasing rate of untraceable postablation ATs.     

A pilot trial of autologous bone marrow mononuclear cell transplantation through grafting artery: A sub-study focused on segmental left ventricular function recovery and scar reduction

Background

Our preliminary study suggested that patients with chronic myocardial infarction (MI) and heart failure could potentially benefit from CABG combined with aBM-MNC by improving global left ventricular (LV) function. The purpose of this sub-study was to quantitatively evaluate the effectiveness of aBM-MNC transplantation during CABG in patients with chronic MI by intensively analyzing the global and segmental LV function, the scar, and the relationships between the function recovery and the scar transmural extent.

Methods

A randomized, double-blinded, placebo-controlled study was performed in 50 patients with chronic MI. The patients were randomly allocated into CABG with stem cell transplantation (group A) and CABG only (group B) groups. CMR assessments of global and segmental left ventricular function and scar tissue were performed before surgery and repeated at 12 months after CABG and aBM-MNC transplantation.

Results

The left ventricular ejection fraction (LVEF) improved by 13.5% and 8.0% in group A and B respectively (P = 0.04). Segmental analysis of regional LV function recovery indicated that more improvement in contractility was found in group A within the same degree of the infarct transmurality (P = 0.017) and showed a predominant interaction in the most severely affected segments (76–100%, P = 0.016). Decrease in infarct size between the two groups did not reach statistical difference (9.4% vs. 6.0%, P = 0.100).

Conclusions

CMR assessments revealed reversed ventricular remodeling and improved systolic function and scar reduction in patients who underwent aBM-MNC transplantation during CABG. And the conjunctional use of CABG and stem cell therapy could improve the left ventricular function in patients with chronic MI.     

Cardiac contractility modulation increases action potential duration dispersion and decreases ventricular fibrillation threshold via β1-adrenoceptor activation in the crystalloid perfused normal rabbit heart

Background/objectives

Cardiac contractility modulation (CCM) is a new treatment being developed for heart failure (HF) involving application of electrical current during the absolute refractory period. We have previously shown that CCM increases ventricular force through β1-adrenoceptor activation in the whole heart, a potential pro-arrhythmic mechanism. This study aimed to investigate the effect of CCM on ventricular fibrillation susceptibility.

Methods

Experiments were conducted in isolated New Zealand white rabbit hearts (2.0–2.5 kg, n = 25). The effects of CCM (± 20 mA, 10 ms phase duration) on the left ventricular basal and apical monophasic action potential duration (MAPD) were assessed during constant pacing (200 bpm). Ventricular fibrillation threshold (VFT) was defined as the minimum current required to induce sustained VF with rapid pacing (30 × 30 ms). Protocols were repeated during perfusion of the β1-adrenoceptor antagonist metoprolol (1.8 μM). In separate hearts, the dynamic and spatial electrophysiological effects of CCM were assessed using optical mapping with di-4-ANEPPS.

Results

CCM significantly shortened MAPD close to the stimulation site (Basal: 102 ± 5 [CCM] vs. 131 ± 6 [Control] ms, P < 0.001). VFT was reduced during CCM (2.6 ± 0.6 [CCM] vs. 6.1 ± 0.8 [Control] mA, P < 0.01) and was correlated (r² = 0.40, P < 0.01) with increased MAPD dispersion (26 ± 4 [CCM] vs. 5 ± 1 [Control] ms, P < 0.01) (n = 8). Optical mapping revealed greater spread of CCM induced MAPD shortening during basal vs. apical stimulation. CCM effects were abolished by metoprolol and exogenous acetylcholine. No evidence for direct electrotonic modulation of APD was found, with APD adaptation occurring secondary to adrenergic stimulation.

Conclusions

CCM decreases VFT in a manner associated with increased MAPD dispersion in the crystalloid perfused normal rabbit heart.     

Comparisons of detailed arterial healing response at seven months following implantation of an everolimus- or sirolimus-eluting stent in patients with ST-segment elevation myocardial infarction

Background

The difference of arterial healing response following everolimus-eluting stent (EES) or sirolimus-eluting stent (SES) implantation in patients with ST-segment elevated myocardial infarction (STEMI) has not been compared in detail.

Methods

Thirty-five patients with STEMI were randomly implanted with an EES or SES (23 EES, 12 SES). At seven months, neointimal thickness (NIT) and strut malapposition were evaluated by optical coherence tomography (OCT) and the grade and heterogeneity of neointimal coverage (NIC) and development of intra-stent thrombi were evaluated by angioscopy.

Results

No significant differences were noted in clinical events experienced by the two groups, although one patient with an EES died following a papillary muscle rupture and one patient with a SES experienced sub-acute stent thrombosis. On OCT, although the EES implants showed a greater NIT than the SES implants (94.8 ± 88.8 μm vs 65.6 ± 63.3 μm, P < 0.0001), both the EES and SES showed an excellent suppression of neointimal proliferation in the culprit lesion of STEMI. The frequency of uncovered and malapposed struts of EES was significantly lower than that of SES (2.7% vs. 15.7%, P < 0.0001, 0.7% vs. 2.3%, P < 0.0001, respectively). The ratio of stents fully covered with neointima of EES group was significantly higher than that of SES group (P = 0.04). Angioscopic analysis also showed greater dominant NIC grade with homogenous NIC in EES than in SES (P = 0.03, P = 0.0002, respectively). The incidence of massive intra-stent thrombus of EES was lower than that of SES (P = 0.05).

Conclusion

For patients with STEMI, EES may promote better arterial healing response than SES.     

Personalized antiplatelet therapy according to CYP2C19 genotype after percutaneous coronary intervention: A randomized control trial

Objective

The objective of this study is to compare personalized antiplatelet therapy according to CYP2C19 phenotype with conventional antiplatelet therapy in patients after percutaneous coronary intervention (PCI).

Methods

A total of 600 patients with coronary artery disease (CAD) undergoing PCI randomly received a personalized antiplatelet therapy (group A; n = 301) or conventional antiplatelet treatment (group B; n = 299). For group A, antiplatelet therapy was performed according to CYP2C19 phenotype. For group B, the patients received conventional antiplatelet treatment without detected CYP2C19 genotype. The primary end point was compared between these two groups. This study is registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-11001807).

Results

The primary end point occurred in 27 patients assigned to conventional treatment as compared with 8 patients assigned to personalized therapy (cumulative event rate, 9.03% vs. 2.66%; P < 0.01). The composite rate of death, myocardial infarction, or stroke at 180 days occurred in 3 and 18 patients in the two groups, respectively (cumulative event rate, 1.0% and 6.2%, P < 0.01). The cumulative 180-day incidence of ST was significantly lower in group A than in group B (0.66% vs. 3.01%, P = 0.032). The 180-day incidence of MI (0.33% vs. 3.01%, P = 0.011) and death (0.33% vs. 2.34%, P = 0.011) was fewer than that in control, respectively. We did not find the significant difference in bleeding events between the 2 groups.

Conclusion

Personalized antiplatelet therapy according to CYP2C19 genotype after PCI can significantly decrease the incidence of major adverse cardiovascular events and the risk of 180-day ST in Chinese population.     

Vitamin D and prognosis in acute myocardial infarction

Background

Vitamin D status (VDS) has been linked to mortality and incident acute myocardial infarction (AMI) in healthy cohorts. Associations with recurrent adverse cardiovascular events in those with cardiovascular disease are less clear. Our objective was to assess the prevalence and prognostic impact of VDS on patients presenting with AMI.

Methods

We measured plasma 25-(OH)D₃ and 25-(OH)D₂ using isotope dilution tandem mass spectrometry, in 1259 AMI patients (908 men, mean age 65.7 ± 12.8 years). The primary endpoint was major adverse events (MACE), a composite of death (n = 141), heart failure hospitalisation (n = 111) and recurrent AMI (n = 147) over median follow-up of 550 days (range 131–1095). Secondary endpoints were fatal and non-fatal MACE.

Results

Almost 74% of the patients were vitamin D deficient (< 20 ng/ml 25-(OH)D). Plasma 25-(OH)D existed mainly as 25-(OH)D₃ which varied with month of recruitment. Multivariable survival Cox regression models stratified by recruitment month (adjusted for age, gender, past history of AMI/angina, hypertension, diabetes, hypercholesterolaemia, ECG ST change, Killip class, eGFR, smoking, plasma NTproBNP), showed 25-(OH)D₃ quartile as an independent predictor of MACE(P < 0.001) and non-fatal MACE(P < 0.01), but not death. Using the lowest 25-(OH)D₃ quartile(< 7.3 ng/ml) as reference for MACE prediction, the 2nd, 3rd and 4th quartiles showed significantly lower hazard ratios (HR 0.59(P < 0.002), 0.58(P < 0.001), and 0.59(P < 0.003) respectively). For non-fatal MACE prediction, the 2nd, 3rd and 4th 25-(OH)D₃ quartiles were all significantly different from the lowest reference quartile (HR 0.69(P < 0.05), 0.54(P < 0.003) and 0.59(P < 0.014) respectively).

Conclusions

VDS is prognostic for MACE (predominantly non-fatal MACE) post-AMI, with approximate 40% risk reduction for 25-(OH)D₃ levels above 7.3 ng/ml.     

Early eicosapentaenoic acid treatment after percutaneous coronary intervention reduces acute inflammatory responses and ventricular arrhythmias in patients with acute myocardial infarction: A randomized,controlled study

Objective

We examined whether early loading of eicosapentaenoic acid (EPA) reduces clinical adverse events by 1 month, accompanied by a decrease in C-reactive protein (CRP) values in patients with acute myocardial infarction (MI).

Background

Acute MI triggers an inflammatory reaction, which plays an important role in myocardial injury. EPA could attenuate the inflammatory response.

Methods

This prospective, open-label, blinded endpoint, randomized trial consisted of 115 patients with acute MI. They were randomly assigned to the EPA group (57 patients) and the control group (58 patients). After percutaneous coronary intervention (PCI), 1800 mg/day of EPA was initiated within 24 h. The primary endpoint was composite events, including cardiac death, stroke, re-infarction, ventricular arrhythmias, and paroxysmal atrial fibrillation within 1 month.

Results

Administration of EPA significantly reduced the primary endpoint within 1 month (10.5 vs 29.3%, p = 0.01), especially the incidence of ventricular arrhythmias (7.0 vs 20.6%, p = 0.03). Peak CRP values after PCI in the EPA group were significantly lower than those in the control group (median [interquartile range], 8.2 [5.6–10.2] mg/dl vs 9.7 [7.6–13.9] mg/dl, p < 0.01). Logistic regression analysis showed that EPA use was an independent factor related to ventricular arrhythmia until 1 month, with an odds ratio of 0.29 (95% confidence interval, 0.09 to 0.96, p = 0.04).

Conclusions

Early EPA treatment after PCI in the acute stage of MI reduces the incidence of ventricular arrhythmias, and lowers CRP values.     

Effects of a nonnutritive sweetener on body adiposity and energy metabolism in mice with diet-induced obesity

Objective

Nonnutritive sweeteners (NNSs) have been studied in terms of their potential roles in type 2 diabetes, obesity, and related metabolic disorders. Several studies have suggested that NNSs have several specific effects on metabolism such as reduced postprandial hyperglycemia and insulin resistance. However, the detailed effects of NNSs on body adiposity and energy metabolism have not been fully elucidated. We investigated the effects of an NNS on energy metabolism in mice with diet-induced obesity (DIO).

Methods

DIO mice were divided into NNS-administered (4% NNS in drinking water), sucrose-administered (33% sucrose in drinking water), and control (normal water) groups. After supplementation for 4 weeks, metabolic parameters, including uncoupling protein (UCP) levels and energy expenditure, were assessed.

Results

Sucrose supplementation increased hyperglycemia, body adiposity, and body weight compared to the NNS-administered and control groups (P < 0.05 for each). In addition, NNS supplementation decreased hyperglycemia compared to the sucrose-administered group (P < 0.05). Interestingly, NNS supplementation increased body adiposity, which was accompanied by hyperinsulinemia, compared to controls (P < 0.05 for each). NNS also increased leptin levels in white adipose tissue and triglyceride levels in tissues compared to controls (P < 0.05 for each). Notably, compared to controls, NNS supplementation decreased the UCP1 level in brown adipose tissue and decreased O₂ consumption in the dark phase.

Conclusions

NNSs may be good sugar substitutes for people with hyperglycemia, but appear to influence energy metabolism in DIO mice.     

A critical challenge: Dosage-related efficacy and acute complication intracoronary injection of autologous bone marrow mesenchymal stem cells in acute myocardial infarction

Background

Previous studies showed improvement in heart function by injecting bone marrow mesenchymal stem cells (BMSCs) after AMI. Emerging evidence suggested that both the number and function of BMSCs decline with ageing. We designed a randomized, controlled trial to further investigate the safety and efficacy of this treatment.

Methods

Patients with ST-elevation AMI undergoing successful reperfusion treatment within 12 hours were randomly assigned to receive an intracoronary infusion of BMSCs (n = 21) or standard medical treatment (n = 22) (the numbers of patients were limited because of the complication of coronary artery obstruction).

Results

There is a closely positive correlation of the number and function of BMSCs vs. the cardiac function reflected by LVEF at baseline (r = 0.679, P = 0.001) and at 12-month follow-up (r = 0.477, P = 0.039). Six months after cell administration, myocardial viability within the infarct area by 18-FDG SPECT was improved in both groups compared with baseline, but no significant difference in the BMSCs compared with control groups (4.0 ± 0.4% 95%CI 3.1–4.9 vs. 3.2 ± 0.5% 95%CI 2.1–4.3, P = 0.237). 99mTc-sestamibi SPECT demonstrated that myocardial perfusion within the infarct area in the BMSCs did not differ from the control group (4.4 ± 0.5% 95%CI 3.2–5.5 vs. 3.9 ± 0.6% 95%CI 2.6–5.2, P = 0.594). Similarly, LVEF after 12 and 24 months follow-up did not show any difference between the two groups. In the BMSCs group, one patient suffered a serious complication of coronary artery occlusion during the BMSCs injection procedure.

Conclusions

The clinical benefits of intracoronary injection of autologous BMSCs in acute STEMI patients need further investigation and reevaluation.     

Estimation of infarct size using transthoracic Doppler echocardiographic measurement of coronary flow reserve in infarct related and reference coronary artery

Background

Patients in chronic phase of myocardial infarction (MI) have decreased coronary flow reserve (CFR) in infarct related artery (IRA) that is proportional to the extent of microvascular/myocardial damage. We proposed a novel model for the assessment of microvascular damage and infarct size using Doppler echocardiography evaluation of CFRs of the IRA (LAD) and reference artery (RCA).

Methods

Our study included 34 consecutive patients (28 men, mean age 50 ± 11 years) with first anterior STEMI and single vessel disease successfully treated with primary PCI. All patients underwent SPECT MPI for the assessment of infarct size (expressed as a percentage of myocardium with fixed perfusion abnormalities) and CFR evaluation of LAD and RCA. CFR derived percentage of microvascular damage (CFR PMD) was calculated as: CFR PMD = (CFR RCA − CFR LAD) / (CFR RCA − 1) × 100 (%).

Results

CFR PMD correlated significantly with all parameters evaluating the severity of myocardial damage including: peak CK activity (r = 0.632, p < 0.001), WMSI (r = 0.857, p < 0.001), ejection fraction (r = − 0.820, p < 0.001), left ventricular end diastolic (r = 0.757, p < 0.001) and end systolic volume (r = 0.794, p < 0.001). Most importantly, CFR PMD (22 ± 17%) correlated significantly with infarct size by SPECT MPI (21 ± 17%) (r = 0.874, p < 0.001).

Conclusions

CFR PMD derived from the proposed model was significantly related to echocardiographic and enzymatic parameters of infarct size, as well as to myocardial damage assessed by SPECT MPI in patients with successfully reperfused first anterior STEMI.     

Characterization of mid-term atrial geometrical and electrical remodeling following device closure of atrial septal defects in adults

Purpose

Late-onset atrial arrhythmia after successful closure of atrial septal defect (ASD) is not uncommon. Right atrial (RA) enlargement and increased electrocardiographic P-wave dispersion (Pd) independently predict the development of atrial arrhythmia. Data on the degree of right atrial (RA) geometrical and electrical remodeling following device closure of ASD are limited.

Methods

Echocardiography and electrocardiography (ECG) were performed in 58 consecutive patients (47 ± 17 years) before and at 3 months after ASD closure. Persistent RA enlargement was defined as RA volume index (RAVI) ≥ 21 ml/m² at 3 months. Pd was calculated as the difference between maximal and minimal P-wave durations in 12-lead ECG.

Results

RA size reduced (RAVI: 50 ± 28 vs. 26 ± 16 ml/m², p < 0.001) and Pd on ECG decreased (53 ± 17 vs. 49 ± 20 ms, p < 0.05) significantly at 3 months when compared to baseline. However, persistent RA enlargement remained evident in 31 patients (53%). As a group, they were older with higher pulmonary arterial systolic pressure, larger Qp/Qs, longer maximal P-wave duration and Pd than those with normalized RA. Pd reduction only occurred in patients with normalized RA size. The 3-month Pd (hazard ratio: 1.033, p < 0.001) predicted the presence of incomplete RA geometrical remodeling. ROC curve revealed that Pd ≥ 45 ms at 3 months was 77% sensitive and 86% specific in revealing residual RA enlargement.

Conclusion

Both atrial geometrical and electrical reverse remodeling were evident at 3 months following ASD closure. However, only half of the included patients had normalization of RA size which could be revealed by a simple ECG surrogate of intra-atrial conduction disturbance.     

Drug eluting balloon versus drug eluting stent in percutaneous coronary interventions: Insights from a meta-analysis of 1462 patients

Background

Drug eluting balloons (DEB) have been developed to overcome the limitations of drug eluting stents (DES), but clinic results of various DEB studies are still not consistent. Thus, we performed a meta-analysis to compare outcomes of DEB and DES for the treatment of coronary artery disease (CAD).

Methods

Medline/Web databases were searched for studies comparing DEB and DES for obstructive CAD, reporting late lumen loss (LLL) and rates for overall mortality, myocardial infarction (MI), stent thrombosis (ST) and target lesion revascularization (TLR).

Results

8 studies (1462 patients) were included in the meta-analysis. Compared with DES, DEB treated patients showed non-significantly higher LLL (weighted mean difference [WMD] 0.32, 95% confidence interval [CI] − 0.15 to 0.78, P = 0.18) and non-significantly higher rate of binary restenosis (odds ratio [OR] 1.40 [0.68–2.48], P = 0.36). Mortality (OR 1.13[0.54–2.37], P = 0.74), MI (OR 0.95, [0.50–1.80], P = 0.87), ST (OR 1.12, [0.34–4.19], P = 0.77) and TLR rates (OR 1.19[0.60–2.38], P = 0.61) were similar between the 2 treatments. A pre-specified meta-regression analysis showed that LLL WMD and TLR OR were inversely correlated to the prevalence of diabetes (P < 0.0001) and directly correlated to reference coronary diameters (P < 0.001).

Conclusions

The present meta-analysis showed that compared to DES, DEB use resulted in similar clinical efficacy and safety. Thus DEB could be considered a reasonable alternative to DES for the treatment of CAD in selected clinical settings (Clinicaltrials.gov identifier: NCT01760200).     

Feature-tracking cardiovascular magnetic resonance as a novel technique for the assessment of mechanical dyssynchrony

Background

Myocardial tagging using cardiovascular magnetic resonance (CMR) is the gold-standard for the assessment of myocardial mechanics. Feature-tracking cardiovascular magnetic resonance (FT-CMR) has been validated against myocardial tagging. We explore the potential of FT-CMR in the assessment of mechanical dyssynchrony, with reference to patients with cardiomyopathy and healthy controls.

Methods

Healthy controls (n = 55, age: 42.9 ± 13 yrs, LVEF: 70 ± 5%, QRS: 88 ± 9 ms) and patients with cardiomyopathy (n = 108, age: 64.7 ± 12 yrs, LVEF: 29 ± 6%, QRS: 147 ± 29 ms) underwent FT-CMR for the assessment of the circumferential (CURE) and radial (RURE) uniformity ratio estimate based on myocardial strain (both CURE and RURE: 0 to 1; 1 = perfect synchrony)

Results

CURE (0.79 ± 0.14 vs. 0.97 ± 0.02) and RURE (0.71 ± 0.14 vs. 0.91 ± 0.04) were lower in patients with cardiomyopathy than in healthy controls (both p < 0.0001). CURE (area under the receiver-operator characteristic curve [AUC]: 0.96), RURE (AUC: 0.96) and an average of these (CURE:RURE_AVG, AUC: 0.98) had an excellent ability to discriminate between patients with cardiomyopathy and controls (sensitivity 90%; specificity 98% at a cut-off of 0.89). The time taken for semi-automatically tracking myocardial borders was 5.9 ± 1.4 min.

Conclusion

Dyssynchrony measures derived from FT-CMR, such as CURE and RURE, provide almost absolute discrimination between patients with cardiomyopathy and healthy controls. The rapid acquisition of these measures, which does not require specialized CMR sequences, has potential for the assessment of mechanical dyssynchrony in clinical practice.     

Significant association between angiotensin-converting enzyme gene insertion/deletion polymorphism and risk of recurrent miscarriage: A systematic review and meta-analysis

Background

Many studies have investigated the association between angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and risk of recurrent miscarriage, but the impact is unclear due to inconsistencies among those studies. This study aimed to quantify the strength of the association between ACE I/D polymorphism and recurrent miscarriage risk by performing a systematic review and meta-analysis.

Design and Methods

We searched PubMed, Embase, Web of Science, and Wanfang Medicine databases for eligible articles relating the association between ACE I/D polymorphism and risk of recurrent miscarriage in humans. We estimated the summary odds ratios (ORs) with their 95% confidence intervals (95% CIs) to assess the association.

Results

Eleven studies with a total of 3357 individuals were included in this meta-analysis. Compared to the ACE II genotype, DD and ID were both associated with increased risk of recurrent miscarriage (OR _{DD versus II} = 1.81, 95% CI 1.23–2.66, P = 0.003; OR _{ID versus II} = 1.50, 95% CI 1.25–1.80, P < 0.001). Sensitivity analyses further confirmed the association above. No evidence of publication bias was observed.

Conclusion

Meta-analyses of available data show a significant association between ACE I/D polymorphism and recurrent miscarriage risk, and the ACE polymorphic D allele contributes to increased risk of recurrent miscarriage.     

Impact of hyperglycemia in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: The HORIZONS-AMI trial

Background

Few studies have examined the association between hyperglycemia and adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We therefore evaluated the prognostic utility of admission hyperglycemia in the HORIZONS-AMI trial.

Methods and results

Admission glucose levels were available in 3405 of 3602 (94.5%) enrolled patients, of which 566 patients (16.6%) were known to have diabetes. Outcomes were assessed at 30 days and 3 years, stratified by baseline glucose level and diabetes status. Median [IQR] admission glucose level in the entire study cohort was 138.0 [115.4, 171.0] mg/dl. Multivariable adjusted 30-day mortality was significantly increased in all patients with admission glucose in the highest glucose tertile vs. the lower two-thirds (HR [95%CI] = 3.53 [1.89, 6.60], p < 0.0001); in patients with diabetes (4.40 [2.04, 9.50], p = 0.0002); and in patients without diabetes (3.33 [1.16, 9.55], p = 0.03). By ROC analysis, the best cut-off values for 30-day mortality were 169 mg/dl for all patients (AUC = 0.76), 149 mg/dl for patients without diabetes (AUC = 0.77), and 231 mg/dl for patients with diabetes (AUC = 0.69). Baseline hyperglycemia was also an independent predictor of 3-year mortality in all patients (HR [95%CI] = 1.93 [1.35, 2.76], P = 0.0003), patients with diabetes (2.65 [1.28, 5.47], P = 0.008), and patients without diabetes (1.58 [1.05, 2.36], P = 0.03).

Conclusions

In patients with STEMI undergoing primary PCI, admission hyperglycemia is an independent predictor of early and late mortality in both patients with and without known diabetes.     

Dedicated two-stent technique in complex bifurcation percutaneous coronary intervention with use of everolimus-eluting stents: The EES-bifurcation study

Objectives

To compare the outcomes of initial one-stent (1S) versus dedicated two-stent (2S) strategies in complex bifurcation percutaneous coronary intervention (PCI) using everolimus-eluting stents (EES).

Background

PCI of true bifurcation lesions is technically challenging and historically associated with reduced procedural success and increased restenosis. Prior studies comparing initial one-stent (1S) versus dedicated two-stent (2S) strategies using first-generation drug-eluting stents have shown no reduction in ischemic events and more complications with a 2S strategy.

Methods

We performed a retrospective study of 319 consecutive patients undergoing PCI at a single referral center with EES for true bifurcation lesions, defined by involvement of both the main vessel (MV) and side branch (SB). Baseline, procedural characteristics, quantitative coronary angiography and clinical outcomes in-hospital and at one year were compared for patients undergoing 1S (n = 175) and 2S (n = 144) strategies.

Results

Baseline characteristics were well-matched. 2S strategy was associated with greater SB acute gain (0.65 ± 0.41 mm vs. 1.11 ± 0.47 mm, p < 0.0001). In-hospital serious adverse events were similar (9% with 2S vs. 8% with 1S, p = 0.58). At one year, patients treated by 2S strategy had non-significantly lower rates of target vessel revascularization (5.8% vs. 7.4%, p = 0.31), myocardial infarction (7.8% vs. 12.2%, p = 0.31) and major adverse cardiovascular events (16.6% vs. 21.8%, p = 0.21).

Conclusion

In this study of patients undergoing PCI for true coronary bifurcation lesions using EES, 2S strategy was associated with superior SB angiographic outcomes without excess complications or ischemic events at one year.     

Thyroid hormone improves the mechanical performance of the post-infarcted diabetic myocardium: A response associated with up-regulation of Akt/mTOR and AMPK activation

Objective

Thyroid hormone (TH) is shown to be protective against cardiac and pancreatic injury. Thus, this study explored the potential effects of TH treatment on the functional status of the postinfarcted diabetic myocardium. Diabetic patients have worse prognosis after acute myocardial infarction (AMI).

Materials/Methods

AMI was induced by left coronary ligation in rats previously treated with 35 mg/kg streptozotocin (STZ), (DM-AMI). TH treatment was initiated at 2 weeks after AMI and continued for 6 weeks (DM-AMI + TH), while sham-operated animals served as control (DM-SHAM).

Results

TH treatment increased cardiac mass, improved wall stress and favorably changed cardiac geometry. TH significantly increased echocardiographic left ventricular ejection fraction (LVEF%): [54.2 (6.5) for DM-AMI + TH vs 37 (2.0) for DM-AMI, p < 0.05]. TH treatment resulted in significantly increased insulin and decreased glucose levels in serum. The ratios of phosphorylated (p)-Akt/total Akt and p-mTOR/total mTOR were increased 2.0 fold and 2.7 fold in DM-AMI + TH vs DM-AMI respectively, p < 0.05. Furthermore, the ratio of p-AMPK/total AMPK was found to be increased 1.6 fold in DM-AMI + TH vs DM-AMI, p < 0.05.

Conclusion

TH treatment improved the mechanical performance of the post-infarcted myocardium in rats with STZ-induced diabetes, an effect which was associated with Akt/mTOR and AMPK activation.     

Role of psoriasis as independent predictor of cardiovascular disease: A meta-regression analysis

Background

Despite the proved association between psoriasis and cardiovascular risk exposure, there are no data about the role of psoriasis as an independent predictor of such risk. The aim of this study was to investigate whether any association between psoriasis and excess cardiovascular risk exposure is independent from confounding factors.

Methods

Meta-analysis and meta-regression analysis were performed using data extracted from observational studies (identified by MEDLINE, EMBASE and CINAHL) investigating the relationship between psoriasis and cardiovascular disease with at least 6 points on the New Castle-Ottawa quality scale. Two reviewers with methodological expertise conducted data extraction independently.

Results

Thirteen studies including patients with psoriasis showed an increased risk of cardiovascular disease (RR = 1.24 [1.18–1.31]; P = 0.0001). These patients still presented a significantly larger cardiovascular risk in the presence of smoking (RR = 1.14 [CI = 1.13–1.15] P < 0.0001), obesity (RR = 1.11 [CI = 1.07–1.14] P = 0.0003) and hyperlipidemia (RR = 1.05 [CI = 1.03–1.07] P = 0.0006), but not in the presence of hypertension (RR = 1.03 [CI = 0.98–1.09] P = 0.4647) and diabetes (RR = 0.95 [CI = 0.90–1.01] P = 0.6502).

Conclusions

Patients with psoriasis carry an about 25% increased relative risk of cardiovascular disease. This risk appears to be independent of smoking, obesity and hyperlipidemia.     

Electrophysiological characteristics of left atrial diverticulum in patients with atrial fibrillation: Electrograms,impedance and clinical implications

Background

Left atrial diverticulum (LAD) is not rare in patients with atrial fibrillation (AF). Recent reports focused on its morphology however data on its electrophysiological characteristics are lacking. Our study aims to investigate the electrogram and impedance features of LAD.

Methods

This study included 24 patients (mean age, 58.5 ± 10.7 years) with LAD undergoing catheter ablation for AF and 24 gender-and-age-matched individuals without LAD as controls. A bipolar LAD electroanatomic map was acquired in sinus rhythm from all study participants. Points were acquired for diverticulum in the LAD group and for corresponding areas in the control group. Electrogram deflections were counted, bipolar voltage and impedance were measured for each point, and average ?impedance and highest ?impedance were calculated.

Results

A total of 234 points were collected in the two groups. In the LAD vs. control group, median (Q1, Q3) of electrogram deflections was 6 (5, 7) and 4 (4, 5) (P < 0.0001), respectively, voltage was not significantly different (1.58 ± 0.68 mV vs. 1.28 ± 0.65 mV, P = 0.10), and average ?impedance was significantly higher in the LAD group (19.5 ± 9.0 Ω vs 3.9 ± 1.7 Ω, P < 0.0001). A cut-off value of 9.5 Ω for ?impedance predicted LAD with sensitivity, specificity, and positive and negative predictive values of 83.5%, 92.8%, 92.1% and 84.9%, respectively.

Conclusions

Electrogram was more fractionated and impedance was higher at LAD than in corresponding areas without LAD, which might help to differentiate LAD during catheter ablation for AF.