Myocardial SPECT Perfusion Defects in Angina Patients, Without Significant Epicardial Coronary Artery Disease. Can Pathological SPECT Affect Long-Term Prognosis?

Purpose: Patients with angina and a positive SPECT for reversible ischemia, with no or non-obstructive CAD on ICA represent a frequent clinical problem and predicting prognosis is challenging. Methods: A retrospective single center study focused on patients that underwent elective-ICA with angina and a positive SECT with no or non-obstructive CAD in the CathLab, during a seven-year period. Assessment of patients’ cardiovascular morbidity, mortality, and MACE during a follow-up period of at least three years after ICA, with the assist of a telephone questionnaire.Results: Data of all patients that underwent ICA for a period of 7 years (from January 1,2011 until December 31, 2017) in our hospital were analyzed. The patients that fulfilled the prespecified criteria were 569. At the telephone survey, 285(50.1%) were successfully contacted and agreed to participate. The mean age was 67.6 (SD8.8) years (35.4%female) and the mean follow-up time was 5.53years (SD1.85). Mortality rate was 1.7% (4 patients/non-cardiac causes) and 1,7% rate of revascularization. 31(10,9%) were hospitalized for cardiac reasons and 10,9% patients reported symptoms of HF (no patients with NYHA-Class above II). 21 had arrhythmic events and only two mild anginal symptoms. Noteworthy finding was, the mortality rate in the not-contacted group (12 out of 284, 4,2%), derived by public security records, did not differ significantly from the contacted-group. Conclusions: Patients with angina, a positive SPECT for reversible ischemia and no or non-obstructive CAD in ICA have very good long-term cardiovascular prognosis for at least 5 years.

Magnetic Resonance Imaging with Diffusion and Perfusion in Assessment of Patients with Cerebral Infarction

Background: Diffusion-weighted MR imaging is most useful for detecting irreversibly infarcted tissue, perfusion-weighted imaging may be used to identify areas of reversible ischemia as well. This work highlights the role of MR imaging in acute ischemic infarction evaluation, with particular emphasis on the importance of diffusion and perfusion MR imaging for evaluating the penumbra. Methods: This prospective study was conducted on 30 patients who were suspected to have a cerebral infarction. All patients underwent functional MRI. Results: 25 patients (83.3%) were isointense in T1 and only 5 patients (16.6%) were low intense, in T2 there was 25 patients (83.3%) were high intense and only 5 patients (16.6%) were isointense .in FLAIR there was 24 patients (80%) were high intense and only 6 patients (20%) were isointense. In DW1 all the cases show high signal also in ADC all the cases show low signal. As regards to Ischemic area: the mean rCBV (relative cerebral blood volume) in the core was 0.33±0.30 cc while in the peripheral area was 1.24±1.35 cc. There was a highly significant difference between CT and MRI in diagnosis of acute stroke with P= 0.001. Conclusion: Only depending on a single or a few parameters may not be sufficient, instead comprehensively combining the information from each MRI sequence (i.e., DWI, FLAIR and PWI) and using various mismatch parameters (DWI-FLAIR mismatch and/or PWI-DWI mismatch) may be more helpful in establishing an indication of MRI-based thrombolysis.

Beta-Blockade in Intraseptal Anomalous Coronary Artery With Reversible Myocardial Ischemia

Anomalous aortic origin of a left coronary artery (L-AAOCA) with an intraseptal course is a rare anomaly and can be associated with myocardial ischemia and sudden cardiac death. No surgical or medical intervention is known to improve patient outcomes. A 7-year-old boy with intraseptal L-AAOCA presented with nonexertional chest pain, syncope, and had reversible myocardial ischemia on provocative testing. The patient was started on β-blockade, following which his symptoms improved and resolved over a period of six years. A follow-up dobutamine stress magnetic resonance imaging no longer showed reversible ischemia, and cardiac catheterization with fractional flow reserve did not show coronary flow compromise.

Mitral anular plane excursion predicts coronary stenosis during stress echocardiography with dipyridamole

Funding Acknowledgements Type of funding sources: None. Background Dipyridamole stress echocardiography (DSE) is an important tool for detecting reversible ischemia in patients with suspected coronary artery disease (CAD); nonetheless, the results of the test are related to wall motion abnormalities, moderately operator-dependent, and left anterior descending (LAD) artery reserve, resulting in a moderate sensibility and specificity. Purpose Aim Of our study was to evaluate whether an easy-to-use parameter like mitral annular plane systolic excursion (MAPSE) could be useful to identify CAD during DSE. Methods We prospectively enrolled 512 patients that underwent DSE for suspected CAD; rest and peak MAPSE was acquired; 148 patients were referred to perform coronary angiography, with evidence of severe coronary stenosis in 91 patients. The mean age was 66.7 ±11 years, male gender was prevalent (64%). MAPSE at the peak was significantly different between patients with CAD and patient without (13,4mm vs 16,81 mm , p < 0.001); in fact, patients with CAD showed a blunted or no increase of MAPSE after dipyridamole infusion, with a significative difference in Delta Mapse (Mapse peak-Mapse rest) between groups ( -0.5mm vs 2.8mm) By using a Receiver Operating Curve, the Area under the curve was 0,764 (0.682-0.846), with the best cut-off value of +0.5mm (Sensibility 77%, Specificity 62% - Figure 1), comparabale with traditional methods like LAD reserve, FE reduction or Wall Motion Score Index. Discussion to our knowledge, this is the first study that compared the behavior of MAPSE during dipyridamole infusion in patients with and without coronary artery disease. MAPSE is a well-known surrogate of longitudinal systolic function and has increased sensitivity over traditional methods of systolic performance such as LV-EF: in this context, dipyridamole induced reversible ischemia could affect prematurely MAPSE then EF or wall motion abnormalities. In our study, in patients with evidence of reversible ischemia during DSE, a blunted or no increase of MAPSE was able to predict CAD. Incorporating this easy-to-use parameter could improve the specificity of DSE and strengthen the suspect of reversible ischemia when clear wall motion abnormalities are not found. Abstract Figure. Mean value of Mapse and ROC curve

Transplantation-Induced Ischemia-Reperfusion Injury Modulates Antigen Presentation by Donor Renal CD11c+F4/80+ Macrophages through IL-1R8 Regulation

BackgroundIn donor kidneys subjected to ischemia-reperfusion injury during kidney transplant, phagocytes coexpressing the F4/80 and CD11c molecules mediate proinflammatory responses and trigger adaptive immunity in transplantation through antigen presentation. After injury, however, resident renal macrophages coexpressing these surface markers acquire a proreparative phenotype, which is pivotal in controlling inflammation and fibrosis. No data are currently available regarding the effects of transplant-induced ischemia-reperfusion injury on the ability of donor-derived resident renal macrophages to act as professional antigen-presenting cells.MethodsWe evaluated the phenotype and function of intragraft CD11c+F4/80+ renal macrophages after cold ischemia. We also assessed the modifications of donor renal macrophages after reversible ischemia-reperfusion injury in a mouse model of congeneic renal transplantation. To investigate the role played by IL-1R8, we conducted in vitro and in vivo studies comparing cells and grafts from wild-type and IL-R8–deficient donors.ResultsCold ischemia and reversible ischemia-reperfusion injury dampened antigen presentation by renal macrophages, skewed their polarization toward the M2 phenotype, and increased surface expression of IL-1R8, diminishing activation mediated by toll-like receptor 4. Ischemic IL-1R8–deficient donor renal macrophages acquired an M1 phenotype, effectively induced IFNγ and IL-17 responses, and failed to orchestrate tissue repair, resulting in severe graft fibrosis and aberrant humoral immune responses.ConclusionsIL-1R8 is a key regulator of donor renal macrophage functions after ischemia-reperfusion injury, crucial to guiding the phenotype and antigen-presenting role of these cells. It may therefore represent an intriguing pathway to explore with respect to modulating responses against autoantigens and alloantigens after kidney transplant.

P1555 Delta mapse: an easy-to-use tool to evaluate coronary artery stenosis during dypiridamole pharmacological stress echocardiography

Background Dypiridamol stress echocardiography (DSE) is an important tool for detecting reversible ischemia in patients with suspected coronary artery disease (CAD); nonetheless the results of the test are related to visualization of wall motion abnormalities, moderately operator-dependent, and left anterior descending (LAD) artery reserve, resulting in a moderate sensibility and specificity. Aim of our study was to evaluate whether an an easy-to-use parameter like mitral annular plane systolic excursion (MAPSE) could be useful to identify CAD during DSE. Methods We prospectively enrolled 300 patients with suspected CAD and perform a DSE; at rest and peak MAPSE was acquired. 59 patients with reversibile ischemia during stress echocardiography (positive) were referred to perform coronary angiography. Patients were divided according to MAPSE behaviour during DSE: group 1 (MAPSE ≤ 0) and group 2 (delta MAPSE > 0 mm). Results The mean age of was 63 ± 11 years, male gender was prevalent (73%); no differences were found in risk factors and left vetnricular ejection fraction (LV-EF) between two groups.Coronary arteries were normal in 14 patients (23%), while significant stenosis (>70%) was found in 45 patients (77%); in 31 patients (53%) left main (LM) or proximal LAD artery were involved, while in 17 (29%) and 22 (37%) right coronary artery and circumflex artery were affected respectively. Patients with CAD showed a lower (blunted or no increase) MAPSE after dypiridamole infusion, with a significative difference in Delta Mapse (Mapse peak-Mapse rest) between groups (0,2 mm vs 2,8 mm p = 0,004) (Figure 1B). By using a Receiver Operating Curve, the Area under the curve was 0,757, with the best cut-off value for CAD prediction at Delta Mapse= +2.5 mm (sensibility 0,667 and specificity 0,809 – p = 0.012 - Figure 1b). In particular, Delta Mapse was able to predict LM/LAD stenosis (Figure 1B AUC = 0.679 ;p = 0.019), rather than right coronary artery and circumflex artery disease, with higher predictivity than delta LV-EF (AUC = 0.577; p = 0.077). Discussion To our knowledge, this is the first study that compared the behaviour of MAPSE during dypiridamole infusion in patient with and withouth coronary artery disease. MAPSE is a well-known surrogate of longitudinal systolic function and have increased sensitivity over traditional methods of systolic performance such as LV-EF; in this context, dypiridamole induced reversible ischemia could affect prematurely MAPSE then EF or wall motion abnormalities. In our study, in patients with evidence of reversible ischemia during DSE, a blunted or no increase of MAPSE was able to predict CAD, mostly driven by LM/LAD disease, on top of other well known markers of ischemia. Incorporating this easy-to-use parameter could improve specificity of DSE and strenghten the suspect of reversibile ischemia when clear wall motion abnormalities are not found. Abstract P1555 Figure 1A and 1B

Still time to perform intestinal revascularization in patients with acute mesenteric ischemia with peritonitis: An analysis of bowel viability in resections

Objective: Acute mesenteric ischemia is often fatal, and many survivors develop short bowel syndrome. To avoid massive bowel resection, revascularization is recommended for acute mesenteric ischemia patients. However, whether acute mesenteric ischemia patients with clinical peritonitis can be revascularized remains uncertain. Therefore, this study aimed to evaluate the histopathological potential reversibility of resected bowel in acute mesenteric ischemia patients with peritonitis. Methods: We retrospectively reviewed the medical records of acute mesenteric ischemia patients treated at the Kameda Medical Center between January 2001 and March 2015. Pathological evaluation regarding bowel resection was performed. Patients with and without peritonitis were compared. The primary outcome was the proportion of patients with reversible or irreversible ischemia. Patients with reversible and irreversible ischemia were characterized. Results: Of 41 patients, 17 underwent laparotomy, 6 endovascular surgery, and 18 palliative care. Among 23 patients receiving curative treatment, 7 had peritonitis and 13 did not. Seven patients of each group received bowel resection, but 85.7% of those with peritonitis had reversible ischemia. We categorized patients with ischemia into reversible and irreversible groups. The median time between symptom onset and diagnosis in the reversible group was >27 h. Systemic inflammatory response syndrome was found in 72.2% and 66.7% of the reversible and irreversible groups, respectively. Conclusion: Acute mesenteric ischemia patients with clinical peritoneal signs may have potentially reversible ischemia. As a result, revascularization should be considered, even in the case of peritonitis.