Surgical procedures on various artery aneurysms are difficult to perform and require careful preparation. We have developed and now present in this paper a software platform, CardioCTNav, that can help in planning such procedures. The planning consists of a 3D rendering of the area of interest, virtual angiography, automated measurements, and virtual stent simulation.

Background Heart rate-corrected (QTc) interval may increase in the setting of ST-elevation myocardial infarction (STEMI) even after complete reperfusion of the infarct-related artery. The remaining ischemia affects ventricular repolarization and may be associated with an increased susceptibility for malignant ventricular arrhythmias. Two-dimensional (2D) speckle tracking echocardiography (STE) is an angle-independent technique for evaluating myocardial function. The study aimed to analyze the layers specific strain using STE in patients after percutaneous coronary intervention (PCI) and find a possible correlation with QTc interval. Methods 74 patients with STEMI and TIMI 3 flow after PCI were enrolled. The study did not include patients with bundle branch block, pacing, or treated with drugs that could increase the QTc interval. The evaluation consisted of clinical examination and laboratory tests. 12 leads electrocardiography evaluated QTc interval. Echocardiographic acquisitions were performed in the first 24–48 hours after PCI, and data were analyzed on the workstation. The global longitudinal strain was measured from apical views, at the level of the endocardium GLSAvgEndo, transmural GLSAvg, epicardium GLSAvgEpi; the difference bewtwen endocardium and epicardium longitudinal strain: GLSAvgEndo-GLSAvgEpi. Layer-specific GLS values were measured as the average of the longitudinal strain of 17 LV segments at each individual layer (Figure 1). Results Patients were diveded in two groups: the first included 32 patients with a single vessel disease (43.24%) and the second, 42 patients (56.75%) with multiple vessel damage, but without other indication for revascularization except the culprit lesion. Values for layers strain and QTc interval in the first group were: GLSAvgEndo: −16.2 (SD 2.98, CV 0.18), GLSAvg: −11.46 (SD 6.98, CV 0.6), GLSAvgEndo-GLSAvgEpi: 3.54 (DS 1.06, CV 0.29), QTc: 452.5 (SD 22.65, CV 0.05) and in the second group: GLSAvgEndo: −13.22 (SD 4.01, CV 0.3), GLSAvg: −11.3 (SD 3.39, CV 0.29), GLSAvgEndo-GLSAvgEpi: 3.47 (CV 1.28, CV 0.37), QTc: 490ms (SD 43.07, CV 0.08). QTc interval correlated with and layers strain in the first group: GLSAvgEndo: r=0.56, GLSAvg: r=0.67, GLSendo-GLSepi: r=0.54, and in the second group: GLSAvgEndo: r=0.73, GLSAvg: r=0.75, GLSAvgEndo-GLSAvgEpi: r=0.62. Conclusions 1. The present study identified decreased longitudinal strain in all myocardial layers in the first days after STEMI, even after a successful PCI. 2. Alterations of QTc dynamicity were more frequent in patients with multivessel lesions 3. The electrical instability related by QTc interval correlated with the myocardial tissue damage related by STE. The correlation was more evident in patients with multivessel disease, even with remaining nonsignificant lesions, suggesting an ongoing process of microcirculatory perfusion damage. Funding Acknowledgement Type of funding sources: None.

Anterior STEMI (ST-segment elevation myocardial infarction) is associated with the worst prognosis of all infarction locations. We report the case of a 37-year-old male patient who presented for two hours of severe chest pain and was diagnosed with Killip I anterior STEMI in the emergency room. The emergency coronary angiogram revealed acute thrombotic ostial LAD (left anterior descending artery) occlusion and acute thrombotic ostial ramus intermedius (RI) near-occlusion. Thrombus aspiration for the LAD occlusion was performed and a large thrombus was extracted, followed by the artery’s reperfusion. However, we noticed that there was a large diagonal branch providing septal perforating arteries and that there was a distal LAD occlusion. We implanted a drug-eluting stent on the site of the proximal LAD lesion, but we could not obtain any flow in the distal occluded LAD. The patient underwent dual antiplatelet and unfractionated heparin treatment, and, 8 days later, we performed another coronary angiogram. To our surprise, there was very few residual thrombi in the previously occluded LAD segment, and there was no more thrombus in the RI. We noticed TIMI 3 flow in all coronary arteries and an increase in the patient’s left ventricular ejection fraction was also recorded.

Defining the best percutaneous coronary intervention (PCI) in acute myocardial infarction is sometimes difficult, bearing in mind that time is of the essence in preventing myocardial tissue damage. There are invasive modalities to determine the best strategy. These include intravascular ultrasound (IVUS) and optical coherence tomography (OCT), methods that could underline plaque rupture, thrombus, positive remodeling, greater plaque burden, and tissue prolapse. Virtual histology IVUS is capable of detecting lesions containing large necrotic cores and thin cap fibroatheroma (independent predictors of no-reflow in acute myocardial patients). Using these imagistic modalities can lead the PCI strategy in order to obtain the best possible outcome of the procedure for the patient.

Alcohol septal ablation is a percutaneous intervention for hypertrophic obstructive cardiomyopathy, aiming to relieve symptoms, as an alternative to surgical myomectomy, in optimally treated but still symptomatic patients, with high surgical risk. We present the case of 65-year-old female, with persistently elevated blood pressure, presenting with severe dyspnea and angina on exertion and frequent episodes of paroxysmal nocturnal dyspnea. Clinical examination revealed an intense left parasternal systolic murmur. Electrocardiographic findings were sinus rhythm and negative T waves in V2-V6. Transthoracic echocardiography showed a small LV cavity with severe asymmetric left ventricular hypertrophy (maximum basal interventricular septum thickness of 26 mm), with important obstruction in the left ventricular outflow tract - resting gradient 77mmHg, provoked gradient 100mmHg. TOE evaluation of the mitral valve revealed significant mitral regurgitation, with intermitent telesystolic anterior motion of the anterior mitral leaflet and also P2 scallop prolapse. Further evaluation revealed a 60% stenosis of left anterior descending (LAD) artery of second segment, 60% stenosis of the left internal carotid artery, chronic renal disease (creatinine clearance 80ml/min), and moderate pulmonary hypertension. Although surgery was initially proposed to the patient, given the high operative risk (EUROSCORE II 8.45%) for a complete surgical procedure (myomectomy, mitral valve repair and coronary bypass), we attempted a stepwise approach to alleviate her symptoms. Intensive medical treatment improved blood pressure control while angioplasty of the LAD alleviated her angina. Echo-guided alcohol ablation of the interventricular septal wall was performed. Catheter-based contrast injection of a secondary septal branch of the LAD produced a subendocardial contrast in the contact area of anterior mitral valve leaflet; subsequently, embolizing the artery, producing an isolated necrosis at this level, with equalizing the pressure curves between LV and aorta. Postintervention, initial gradients were 50mmHg at rest, 100mmHg on postextrasystolic measurement. Systolic movement of the anterior leaflet maintained a mezotelesystolic pattern. At 3-months follow-up, LVOT gradients were 27/100mmHg, without any increase in pulmonary artery pressure, but with significant improvement of dyspnea. Further risk assessment by Holter ECG monitoring identified non-sustained ventricular tachycardia, so an ICD was implanted. The modest reduction in gradient was associated with significant clinical improvement in the patient’s symptomatology. This procedure has been refined in the last years, especially with the introduction of myocardial contrast echocardiography for better localizing the area at risk of infarction and to reduce the amount of alcohol used. Alcohol septal ablation may be part of a stepwise plan to improve symptoms, with lower procedural risks as compared to classic surgery.