Coronary Artery Disease: Lancellotti P

Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU, Zamorano JL, Anonymous00198. · Institute of Clinical Physiology, Via G. Moruzzi, 1, 56124 Pisa, Italy. · Eur J Echocardiogr. · Pubmed #18579481 links to  free full text

Abstract: Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding - coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.

Moonen M, Lancellotti P, Zacharakis D, Pierard L. · CHU Sart Tilman, Department of Cardiology, Liege, Belgium. · Echocardiography. · Pubmed #19291016 No free full text.

Abstract: Stress echocardiography is increasingly used but its major limitation is the subjective interpretation of wall motion changes requiring experience. Speckle tracking enables simultaneous evaluation of radial, longitudinal, and circumferential myocardial deformation. Recently, two-dimensional (2D) strain has been found to be as reliable as sonomicrometry for the assessment of left ventricular (LV) regional function. In the presence of inducible ischemia, longitudinal and circumferential abnormalities preceed the decrease in radial deformation. Optimal cutoffs have been obtained from 2D strain rate (SR) at peak dobutamine stress to predict coronary artery disease. However, 2D strain rate does not yet provide incremental accuracy to visual interpretation by experts. Speckle tracking strain could be useful to better identify contractile reverse and biphasic response of viable myocardium but there are not yet clinical studies published in this setting. Preliminary results suggest that 2D strain obtained during exercise could be useful in asymptomatic patients with severe aortic stenosis or organic mitral regurgitation (MR). In conclusion, the reliability and clinical importance of 2D strain during stress will be specified by further investigations.

Moonen ML, Hanssen M, Radermecker MA, Lancellotti P. · Department of Cardiology, University Hospital Sart Tilman, B-4000 LIEGE, Belgium. · Eur J Cardiothorac Surg. · Pubmed #18848457 No free full text.

Abstract: We report the case of spontaneous rupture of a coronary artery. It was that of a 56-year-old man admitted for dyspnoea and anterior thoracic pain. The most striking feature on physical examination was the marked cyanosis of his face, upper part of the thorax and the upper limb. The patient was haemodynamically unstable with tachycardia and hypotension. Cardiac tamponade was confirmed by echocardiography and computed tomography of the thorax. The patient was transferred for surgery. Emergency sternotomy revealed pericardial bloody effusion and a continuous bleeding around the posterior interventricular artery. No other perioperative findings could explain the haemopericardium. Haemostasis was obtained by a suture of the bleeding coronary artery.

Legrand V, Lancellotti P, Waleffe A, Piérard L. · CHU Sart-Tilman, Liège. · Rev Med Liege. · Pubmed #17725188 No free full text.

Abstract: Cardiovascular diseases are the leading cause of mortality in the so-called industrial countries. An appropriate management is mandatory and its modalities should be known and applied by physicians. European and American recommendations are regularly published and updated. They are available on the web sites of the European Society of Cardiology (www.escardio.org), the American Heart Association (www.aha.org) and the American College of Cardiology (www.acc.org This article describes the recent therapeutic options of some cardiovascular diseases, especially coronary artery disease, valvular diseases, atrial fibrillation and implantable defibrillator, but is far to be exhaustive.

Lebois F, Allepaerts S, Lancellotti P, Piérard LA. · Service de Cardiologie, CHU Liège. · Rev Med Liege. · Pubmed #12940114 No free full text.

Abstract: The aging of the cardiovascular system leads to an increased incidence of hypertension, coronary artery disease and ischemic stroke. Since cardiovascular disease is the leading cause of morbidity and mortality in patients > or = 70 years old, prevention seems crucial for improving quality of life and reducing medical costs. In this article we present some aspects of cardiovascular prevention in elderly patients.

Delanaye P, Lancellotti P, Moonen M, Radermecker MA. · Service de Cardiologie, Université de Liège. · Rev Med Liege. · Pubmed #11820034 No free full text.

Abstract: Rupture of the interventricular septum is a classical complication of acute myocardial infarction. The diagnosis should be evoked when the patient's hemodynamic condition deteriorates in the presence of a new systolic murmur. A transthoracic or, preferably, transesophageal echocardiography confirms the diagnosis. Early surgical correction constitutes the best treatment. Despite recent progresses, mortality remains high but long term results are encouraging. The risk factors conditioning prognosis, the surgical options and the question of simultaneous coronary bypass will be discussed after a thorough review of the literature.

Lancellotti P, Benoit T, Rigo P, Pierard LA. · Division of Cardiology University Hospital of Liège, B-4000 Liège, Belgium. · Heart. · Pubmed #11602542 links to  free full text

Abstract: OBJECTIVE: To compare the relative accuracy of dobutamine stress echocardiography (DSE) and quantitative technetium-99m sestamibi single photon emission computed tomography (mibi SPECT) for detecting infarct related artery stenosis and multivessel disease early after acute myocardial infarction. DESIGN: Prospective study. SETTING: University hospital. METHODS: 75 patients underwent simultaneous DSE and mibi SPECT at (mean (SD)) 5 (2) days after a first acute myocardial infarct. Quantitative coronary angiography was performed in all patients after imaging studies. RESULTS: Significant stenosis (> 50%) of the infarct related artery was detected in 69 patients. Residual ischaemia was identified by DSE in 55 patients and by quantitative mibi SPECT in 49. The sensitivity of DSE and mibi SPECT for detecting significant infarct related artery stenosis was 78% and 70%, respectively, with a specificity of 83% for both tests. The combination of DSE and mibi SPECT did not change the specificity (83%) but increased the sensitivity to 94%. Mibi SPECT was more sensitive than DSE for detecting mild stenosis (73% v 9%; p = 0.008). The sensitivity of DSE for detecting moderate or severe stenosis was greater than mibi SPECT (97% v 74%; p = 0.007). Wall motion abnormalities with DSE and transient perfusion defects with mibi SPECT outside the infarction zone were sensitive (80% v 67%; NS) and highly specific (95% v 93%; NS) for multivessel disease. CONCLUSIONS: DSE and mibi SPECT have equivalent accuracy for detecting residual infarct related artery stenosis of >/= 50% and multivessel disease early after acute myocardial infarction. DSE is more predictive of moderate or severe infarct related artery stenosis. Combined imaging only improves the detection of mild stenosis.

Cosyns B, Haberman D, Droogmans S, Warzée S, Mahieu P, Laurent E, Moonen M, Hernot S, Lancellotti P. · CHIREC, Cardiology department, Free University of Brussels, Belgium. · Cardiovasc Ultrasound. · Pubmed #19531259 links to  free full text

Abstract: BACKGROUND: In clinical practice and in clinical trials, echocardiography and scintigraphy are used the most for the evaluation of global left ejection fraction (LVEF) and left ventricular (LV) volumes. Actually, poor quality imaging and geometrical assumptions are the main limitations of LVEF measured by echocardiography. Contrast agents and 3D echocardiography are new methods that may alleviate these potential limitations. METHODS: Therefore we sought to examine the accuracy of contrast 3D echocardiography for the evaluation of LV volumes and LVEF relative to MIBI gated SPECT as an independent reference. In 43 patients addressed for chest pain, contrast 3D echocardiography (RT3DE) and MIBI gated SPECT were prospectively performed on the same day. The accuracy and the variability of LV volumes and LVEF measurements were evaluated. RESULTS: Due to good endocardial delineation, LV volumes and LVEF measurements by contrast RT3DE were feasible in 99% of the patients. The mean LV end-diastolic volume (LVEDV) of the group by scintigraphy was 143 +/- 65 mL and was underestimated by triplane contrast RT3DE (128 +/- 60 mL; p < 0.001) and less by full-volume contrast RT3DE (132 +/- 62 mL; p < 0.001). Limits of agreement with scintigraphy were similar for triplane andfull-volume, modalities with the best results for full-volume. Results were similar for calculation of LV end-systolic volume (LVESV). The mean LVEF was 44 +/- 16% with scintigraphy and was not significantly different with both triplane contrast RT3DE (45 +/- 15%) and full-volume contrast RT3DE (45 +/- 15%). There was an excellent correlation between two different observers for LVEDV, LVESV and LVEF measurements and inter observer agreement was also good for both contrast RT3DE techniques. CONCLUSION: Contrast RT3DE allows an accurate assessment of LVEF compared to the LVEF measured by SPECT, and shows low variability between observers. Although RT3DE triplane provides accurate evaluation of left ventricular function, RT3DE full-volume is superior to triplane modality in patients with suspected coronary artery disease.

Płońska-Gosciniak E, Lancellotti P, Kleinrok A, Gackowski A, Gasior Z, Kowalik I, Gozdzik A, Kasprzak JD. · Pomeranian Medical University Szczecin, Szczecin, Poland. · J Am Soc Echocardiogr. · Pubmed #18585894 No free full text.

Abstract: BACKGROUND: Rapid cardiac pacing using a permanent pacemaker may be used as a nonpharmacologic stress during echocardiographic imaging for diagnosing coronary artery disease (CAD). We presented the final results of a national multicenter study, the Polish study on Rapid Pacing Stress Echocardiography (Pol-RAPSE), aimed at the assessment of the safety and accuracy of rapid cardiac pacing for the noninvasive diagnosis of CAD in women and men. METHODS: We have analyzed 149 tests performed in 100 patients with permanent pacemakers (27% ventricular pacing [VVI], 10% atrial pacing [AAI], 63% dual chamber pacing [DDD]) referred for stress echocardiography. All patients underwent coronary angiography as a reference for assessing the accuracy of rapid cardiac pacing stress echocardiography (RAPSE). Significant CAD was defined as luminal diameter reduction more than 50% in at least 1 major epicardial coronary artery. RESULTS: Peak stress was obtained in 73 patients using physiologic stimulation of right atrium by and mode or in 76 patients by VVI mode. Significant CAD was detected by angiography in 46% of women and 57% of men (P = not significant). The feasibility of the test was 98%. Overall accuracy of the test was slightly lower in women than in men (75% vs 88%, P = .04), although there were no significant differences in sensitivity, specificity, and positive and negative predictive values between the genders. In women (n = 48), the accuracy of RAPSE performed in AAI and VVI mode was 79% and 70% with no significant difference and in men was 89% and 87%, respectively (P = not significant). CONCLUSION: RAPSE is a safe and feasible modality for diagnosing CAD. The method offers slightly higher accuracy in men compared with women. Overall efficacy is satisfactory with both AAI and VVI pacing, although easier interpretation of peak AAI/DDD images results in a trend toward better accuracy.

Davin L, Lancellotti P, Bruyere PJ, Gach O, Pierard L, Legrand V. · University Hospital of Liège, Belgium. · Acta Cardiol. · Pubmed #17824293 No free full text.

Abstract: OBJECTIVES: The recent newer advances in computed tomography have dramatically changed our approach to imaging cardiac disease. This study sought to compare the diagnostic value of 16-multi-detector spiral computed tomography (MSCT) for detecting coronary artery stenosis. METHODS: A total of 88 consecutive patients (52 men, mean age 68 +/- 8 years) with atypical chest pain, stable angina or suspicion of ischaemia at stress test were studied by MSCT and invasive coronary angiography (ICA). The MSCT images and multiplanar reconstructions were analysed regarding the presence of > or =50% coronary artery lesion. RESULTS: All 88 scans obtained at a mean heart rate of 68 +/- 8 beats/min were interpretable. Sixteen coronary segments were evaluated in each patient. Of the 1320 segments examined, 148 (11%) showed poor image quality.A total of 150 significant lesions were detected using ICA, and 80 of 150 (53%) were detected by MSCT. Sensitivity, specificity, positive and negative predictive values were as follows: 53%, 97%, 68%, and 94%. Fifty-four patients had > or =50% coronary stenosis.The diagnosis was confirmed by MSCT in 42 patients and correctly ruled out in 30. By patient-based analysis, positive and negative predictive values were 91% and 71%. CONCLUSION: Although its specificity is high, the sensitivity of 16-slice MSCT for detecting > or =50% coronary stenosis in non-selected patients submitted to ICA is rather low suggesting that for daily practice the diagnostic value of this technique should be improved.

Cosyns B, Lancellotti P, Van Camp G, Droogmans S, Schoors D. · Cardiology Department, Universitair Ziekenhuis, Brussels, Belgium. · Int J Cardiol. · Pubmed #17719663 No free full text.

Abstract: Dobutamine stress echocardiography (DSE) has been shown to be a very useful non-invasive technique for the detection of coronary artery disease. However, inadequate transthoracic images preclude the use of DSE in a significant proportion of patients. Transesophageal (TEE) or transthoracic contrast echocardiography (CE) can however overcome this limitation. The comparison between the two techniques has never been investigated during a stress test. Therefore, we designed a prospective study to compare DSE-CE and DSE-TEE for the detection of coronary artery disease in patients with poor echo image quality. We studied 42 patients scheduled for quantitative coronary angiography. Prospective DSE-CE and DSE-TEE with maximum one day interval were performed in a random order. Significant coronary artery disease was detected in 30 patients, nine with single vessel disease and 21 with multivessel disease. Sensitivity of DSE was higher with CE than with TEE (90% vs 87%, p=NS). There was no significant difference with respect to specificity in both groups (100% vs 92%, p=NS). The diagnostic accuracy was similar in both groups (93% vs 88%, NS). The kappa value for identical interpretation of a stress echocardiography study was nearly identical with both modalities 0.75 to 0.78. In poorly echogenic patients, DSE-CE is a valuable alternative for the detection of myocardial ischemia in comparison with DSE-TEE. Because DSE-CE is more comfortable than TEE, it should be used in patients with suboptimal transthoracic echocardiograms for the evaluation of coronary artery disease during DSE.

Lancellotti P, Stainier PY, Lebois F, Piérard LA. · Department of Cardiology, University Hospital of Liège, Liège, Belgium. · Am J Cardiol. · Pubmed #16253603 No free full text.

Abstract: In patients with heart failure, exercise-induced increases in mitral regurgitation (MR), which convey a poor prognosis, are related to the dynamic distortion of mitral valve geometry. It was hypothesized that dynamic MR may also be related to intermittent changes in left ventricular synchronicity during exercise.

Lancellotti P, Kulbertus HE, Piérard LA. · Division of Cardiology, University Hospital of Liège, Sart Tilman, B-4000 Liège, Belgium. · Am J Cardiol. · Pubmed #15165927 No free full text.

Abstract: To assess the predictors of rapid QRS widening in patients with chronic ischemic left ventricular dysfunction, 82 patients who underwent > or =2 electrocardiograms and exercise Doppler echocardiography were studied. In a multivariate analysis, left ventricular end-diastolic volume, a large increase in mitral regurgitant volume during exercise, and diabetes emerged as independent predictors of QRS widening.

Lancellotti P, Lebrun F, Piérard LA. · Department of Cardiology, University Hospital of Liège, Liège, Belgium. · J Am Coll Cardiol. · Pubmed #14662253 No free full text.

Abstract: OBJECTIVES: We sought to examine the determinants of exercise-induced changes in ischemic mitral regurgitation (MR) in patients with left ventricular (LV) dysfunction. BACKGROUND: In the post-myocardial infarction (MI) phase, ischemic MR contributes to worsening of symptoms and of LV dysfunction. METHODS: In this study, 70 patients in the chronic, post-MI phase, with LV ejection fraction <45% and at least mild MR, underwent semi-supine exercise Doppler echocardiography. The effective regurgitant orifice (ERO) of MR was quantified at rest and during exercise. Exercise-induced changes in ERO were compared with changes in mitral deformation and in local and global LV remodeling. RESULTS: The wide range of exercise-induced ERO changes that were observed was unrelated to the degree of MR at rest (r = 0.20). Effective regurgitant orifice changes correlated best with changes in mitral deformation (i.e., differences in systolic mitral tenting area, systolic annular area, and coaptation height) (p < 0.0001). Posterior displacement of the papillary muscles was associated with larger changes in the ERO in both infarct groups. In patients with inferior MI, a decrease in the ERO was related to improvement in wall motion (r = 0.68). The independent predictors of ERO changes during exercise were changes in systolic annular area for all infarct categories, in tenting area and wall motion score in the global population and those with inferior infarction, and in apical displacement of mitral leaflets for patients with anterior MI. CONCLUSIONS: The degree of MR at rest is unrelated to exercise-induced changes in EROs, which are related to those in local LV remodeling and in mitral deformation but not those in global LV function.

Lancellotti P, Hoffer EP, Piérard LA. · Department of Cardiology, University Hospital, Liège, Belgium. · J Am Coll Cardiol. · Pubmed #12679214 No free full text.

Abstract: OBJECTIVE: The aim of this study was to determine the accuracy of exercise echocardiography (EE) for detecting infarct-related artery (IRA) stenosis and predicting functional recovery early after acute myocardial infarction (AMI). BACKGROUND: Dobutamine stress echocardiography is widely used for identifying jeopardized myocardium. The clinical usefulness of a biphasic response detected during EE has never been investigated. METHODS: A total of 114 consecutive patients with a first AMI and > or = 2 dyssynergic segments in the infarct-related territory underwent semi-supine continuous EE 6 +/- 2 days after AMI. Quantitative coronary angiography was performed in all patients after EE. A follow-up echocardiogram was obtained one month later. RESULTS: Ninety-seven patients had significant (> or = 50%) IRA stenosis, and 26 had multivessel disease. Residual ischemia was identified in 77 patients (biphasic response in 62 and worsening response in 15). The sensitivity and specificity of ischemia during EE for predicting IRA stenosis were 75% and 76%, respectively. The sensitivity of a biphasic response was higher than the sensitivity of a worsening response (61% vs. 14%, p < 0.0001). Wall motion abnormalities induced in other vascular territories were specific (97%) and moderately sensitive (62%) for the detection of multivessel disease. Functional recovery was observed in 75 patients. Two independent variables predicted contractile recovery: contractile reserve during EE (p < 0.0001) and elective angioplasty of the IRA (p = 0.002). A biphasic response, but not sustained improvement, predicted reversible dysfunction (73% vs. 9%, p < 0.0001). CONCLUSIONS: A biphasic response can be detected during exercise. Exercise echocardiography is an accurate tool for detecting IRA stenosis and predicting functional improvement early after AMI.

Gach O, Lancellotti P, Pierard LA. · Division of Cardiology, University Hospital of Liège, Belgium. · Acta Cardiol. · Pubmed #11712830 No free full text.

Abstract: Meningitis due to Neisseria meningitidis occurred in a young man. On admission, he was in septic shock and the electrocardiogram revealed convex upwards ST-segment elevation in inferior and lateral leads. Rapid and complete normalisation of the ECG was observed and the patient had a favourable evolution with intensive therapy.The mechanisms of the ECG abnormalities in this disease are unclear. In this patient, ST-segment elevation was probably related to severe transmural ischaemia or prolonged coronary artery spasm as suggested by increase and decrease of cardiac enzymes and transient echocardiographic wall motion abnormalities without pericarditis. However, myocarditis could not be completely ruled out.