Background-The time course of neointimal formation after stent implantation has not been studied extensively by angioscopy in the drug-eluting stent era. Methods and Results-Serial angioscopic findings at first follow-up (3.6Ϯ1.1 months), second follow-up (10.5Ϯ1.6 months), and third follow-up (21.2Ϯ2.2 months) after stent implantation were compared between sirolimus-eluting stents (SES, nϭ17) and bare-metal stents (BMS, nϭ11). Neointimal coverage, thrombus, and presence of yellow plaques underneath the stents were assessed. Neointimal coverage was graded as follows: grade 0, stent struts were fully visible; grade 1, struts bulged into the lumen, although they were covered; grade 2, struts were embedded by the neointima but were seen translucently; or grade 3, struts were fully embedded and invisible. Neointimal coverage was remarkably different between SES and BMS at each follow-up point. Neointimal coverage grade was 1.1Ϯ0.5 in SES versus 2.9Ϯ0.3 in BMS at the first follow-up (PϽ0.0001), 1.1Ϯ0.5 in SES versus 3.0Ϯ0.0 in BMS (PϽ0.0001) at the second follow-up, and 1.3Ϯ0.5 in SES versus 3.0Ϯ0.0 in BMS at the third follow-up (Pϭ0.0009). No significant serial changes in coverage grade were noted in the BMS group, whereas coverage grade slightly but significantly increased at the third follow-up in the SES group (PϽ0.05). Thrombi were detected in 4 SES: a red thrombus was seen from the first to the third follow-up in 2; another was detected only at the third follow-up; and the fourth was seen at the first follow-up but disappeared at the second follow-up, associated with a new white thrombus despite dual antiplatelet therapy. Yellow plaques had disappeared by the time of the second follow-up in BMS. In contrast, yellow plaques were exposed in 71% of SES at the first follow-up and remained exposed until the third follow-up. Neointimal coverage grades correlated with thrombi (Pϭ0.002) and with yellow plaques (PϽ0.0001). Conclusions-Serial angioscopic findings up to 2 years after SES implantation were markedly different from those after BMS. Neointimal coverage was completed by 3 to 6 months in BMS. In contrast, SES demonstrated the presence of thrombi and yellow plaques even as much as 2 years after implantation. (Circulation. 2007;116:910-916.)

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These data suggest that LS is a useful index for assessing systemic volume status and predicting the severity of HF, and that the presence of liver congestion at discharge is associated with worse outcomes in patients with HF.

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Background-Mechanisms of mitral regurgitation (MR) reduction with cardiac resynchronization therapy (CRT) are complex, and their association with long-term outcome is unclear. We sought to elucidate mechanistic features of reduction in MR with CRT, which impact long-term patient survival. Methods and Results-A prospective longitudinal study of 277 patients with heart failure with QRS width ≥120 ms and ejection fraction ≤35% for CRT was performed. Quantitative echocardiography, including dyssynchrony analysis, was performed at baseline. MR was quantified by color Doppler before and 6 months after CRT. Predefined end points of death, transplant, or left ventricular assist device were tracked during 4 years. There were 114 (48%) patients with CRT with significant MR (≥moderate) at baseline; of whom 48 (42%) patients had MR improvement, and 24 (19%) patients had MR worsening after CRT. The 66 events (47 deaths, 10 transplantations, and 9 left ventricular assist devices) were strongly associated with significant MR after CRT (hazard ratio, 3.58; 95% confidence interval, 2.18-5.87; P<0.0001). Three echocardiographic features were independently associated with amelioration of significant MR after CRT by multivariable analysis: anteroseptal to posterior wall radial strain dyssynchrony >200 ms, lack of severe left ventricular dilatation (end-systolic dimension index <29 mm/m 2 ), and lack of echocardiographic scar at papillary muscle insertion sites (all P<0.05) and, when combined, were additively associated with long-term survival (P=0.0001). Conclusions-Significant MR after CRT was strongly associated with less favorable long-term survival. Echocardiographic mechanistic features were identified that were associated with improvement in MR after CRT and favorable long-term survival. to body surface area. 8 Assessment for myocardial scar focused on the papillary muscle insertion sites using a wall motion score index where akinesis or dyskinesis and a reduction in end-diastolic wall thickness ≤0.6 cm were consistent with scar as suggested by the American Society of Echocardiography and European Association of Echocardiography. 8,9 Specifically, the wall motion score index at the level of the papillary muscle attachment site was determined from the corresponding 8 LV segments as previously reported. 10,11 Figure 1. Study patient flowchart. A flowchart of consecutive patients referred for cardiac resynchronization therapy (CRT) who were included in this study. The prevalence of significant mitral regurgitation (MR) before and after CRT is shown. Quantification of MR SeverityColor Doppler quantification of MR was based on the guidelines of the American Society of Echocardiography and European Society of Cardiology 11,12 using a multiparametric approach. A Nyquist limit of 40 to 60 cm/s and a color gain were used to optimize color Doppler jet visualization. Vena contracta width was measured as the narrowest portion of the MR color Doppler jet from zoomed optimized views. The ratio of the jet area to the left atrium area was m...

Non-LBBB patients with dyssynchrony had a more favourable long-term survival than non-LBBB patients who lacked dyssynchrony. Mechanical dyssynchrony and QRS morphology are associated with outcome following CRT.

BackgroundAnalysis of left ventricular (LV) mechanical dyssynchrony may provide incremental prognostic information regarding cardiac resynchronization therapy (CRT) response in addition to QRS width alone. Our objective was to quantify LV dyssynchrony using feature tracking post processing of routine cardiovascular magnetic resonance (CMR) cine acquisitions (FT-CMR) in comparison to speckle tracking echocardiography.MethodsWe studied 72 consecutive patients who had both steady-state free precession CMR and echocardiography. Mid-LV short axis CMR cines were analyzed using FT-CMR software and compared with echocardiographic speckle tracking radial dyssynchrony (time difference between the anteroseptal and posterior wall peak strain).ResultsRadial dyssynchrony analysis was possible by FT-CMR in all patients, and in 67 (93%) by echocardiography. Dyssynchrony by FT-CMR and speckle tracking showed limits of agreement of strain delays of ± 84 ms. These were large (up to 100% or more) relative to the small mean delays measured in more synchronous patients, but acceptable (mainly <25%) in those with mean delays of >200 ms. Radial dyssynchrony was significantly greater in wide QRS patients than narrow QRS patients by both FT-CMR (radial strain delay 230 ± 94 vs. 77 ± 92* ms) and speckle tracking (radial strain delay 242 ± 101 vs. 75 ± 88* ms, all *p < 0.001).ConclusionsFT-CMR delivered measurements of radial dyssynchrony from CMR cine acquisitions which, at least for the patients with more marked dyssynchrony, showed reasonable agreement with those from speckle tracking echocardiography. The clinical usefulness of the method, for example in predicting prognosis in CRT patients, remains to be investigated.

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