High prevalence of peripheral atherosclerosis in a rapidly developing country.

Cardiovascular disease is rapidly increasing in developing countries experiencing epidemiological transition. We investigated the prevalence of peripheral atherosclerosis in a rapidly developing country and compared our findings with data previously reported in Western populations. A cardiovascular risk factor survey was conducted in 1067 individuals aged 25-64 randomly selected from the general population of Seychelles. High-resolution ultrasonography of the right and left carotid and femoral arteries was performed in a random subgroup of 503 subjects (245 men and 258 women). In each of the four arteries, arterial wall thickness (in plaque-free segments) and atherosclerotic plaques (i.e. focal wall thickening at least 1.0 mm thick) were measured separately. The prevalence of peripheral atherosclerosis was high in this population. For instance, at least one plaque > or =1.0 mm was found in, respectively, 34.9 and 27.5% of men and women aged 25-34 and at least one plaque > or =2.5 mm was found in, respectively, 58.2 and 36.9% of men and women aged 55-64. With reference to data found in the literature, the prevalence of carotid atherosclerosis appeared to be significantly higher in Seychelles than in Western populations. This study provides further evidence for the importance of cardiovascular disease in developing countries. Determinants should be identified and relevant prevention and control programs implemented.

Pulmonary artery rupture during Swan-Ganz catheterisation: a case report

Catheter-induced pulmonary artery rupture is an infrequent complication that may occur during invasive cardiopulmonary monitoring. Fatal cases are uncommon and result from hemoptysis and flooding of the opposite lung with resulting hypoyxia. Alpha-1-antitrypsin deficiency is a rare genetic disorder characterised by low serum levels of alpha-1-antitrypsin, critical in maintaining connective tissue integrity. Besides pulmonary emphysema, recent observations suggest that alpha-1-antitrypsin deficiency may also be involved in vascular wall weakening, thereby predisposing arteries to dissection and aneurysm formation. In this article, we describe an autopsy case of pulmonary artery iatrogenic rupture due to insertion of a Swan-Ganz catheter in an 82-year-old woman suffering from pulmonary hypertension and alpha-1-antitrypsin deficiency. The exact source of bleeding could not be precisely identified during autopsy due to the extent of tissue hemorrhage, though postmortem angiography revealed a contrast medium extravasation from a branch of the left pulmonary lower lobar artery. The case herein emphasises the importance of postmortem angiography in facilitating the detection of vascular injuries, the importance of familiarity with intensive care techniques and procedures on behalf of forensic pathologists as well as in-depth knowledge of all possible contributing conditions and predisposing disorders in the pathogenesis of death.

The use of contrast-enhanced MRI angiography for planning interventional catheterization

Background: Interventional catheterization is being increasingly used for relief of residual lesions in congenital heart disease. Exact anatomical imaging is crucial in the planning of an intervention. This can be provided non-invasively and without radiation by contrast-enhanced MR angiography (CEMRA). Aim: To evaluate the accuracy of the measurements of the vessels obtained by CEMRA in comparison to those obtained by conventional X-ray angiography (CXA). Methods: Retrospective blinded measurement of the diameters of aorta and pulmonary arteries on the CEMRA and CXA images, in the same locations. Comparison of the results by Pearson correlation and by calculating the limits of agreement. Results: Twenty-one children with congenital heart disease, mean age 5.6 +- 5.2 years, weight 21.1 +- 18.4 kg, underwent CEMRA and catheterization for assessment or treatment of a residual lesion. The time interval between the CEMRA and the CXA examination was 2.6 +- 2.3 months. A total of 98 measurements, 37 of the aorta and 61 of the pulmonary arteries were performed on the images obtained by each technique. The correlation between CEMRA and CXA measurements was excellent, r = 0.97, p < 0.0001. The mean difference between the two techniques was 0.018 +- 1.1mm; the limits of agreement were -2.14 and +2.18mm. Similar agreement was found for measures of the aorta (r +- 0.97, mean difference 0.20 = 1.08 mm) and of the pulmonary arteries (r +- 0.97, mean difference 0.048 = 0.89 mm). Conclusions: CEMRA provide accurate quantitative anatomical information, which highly agrees with CXA data, and can therefore be used for planning interventional catheterization.

Postmortem imaging of sudden cardiac death

Postmortem imaging is increasingly used in forensic practice in cases of natural deaths related to cardiovascular diseases, which represent the most common causes of death in developed countries. While radiological examination is generally considered to be a good complement for conventional autopsy, it was thought to have limited application in cardiovascular pathology. At present, multidetector computed tomography (MDCT), CT angiography, and cardiac magnetic resonance imaging (MRI) are used in postmortem radiological investigation of cardiovascular pathologies. This review presents the actual state of postmortem imaging for cardiovascular pathologies in cases of sudden cardiac death (SCD), taking into consideration both the advantages and limitations. The radiological evaluation of ischemic heart disease (IHD), the most frequent cause of SCD in the general population of industrialized countries, includes the examination of the coronary arteries and myocardium. Postmortem CT angiography (PMCTA) is very useful for the detection of stenoses and occlusions of coronary arteries but less so for the identification of ischemic myocardium. MRI is the method of choice for the radiological investigation of the myocardium in clinical practice, but its accessibility and application are still limited in postmortem practice. There are very few reports implicating postmortem radiology in the investigation of other causes of SCD, such as cardiomyopathies, coronary artery abnormalities, and valvular pathologies. Cardiomyopathies representing the most frequent cause of SCD in young athletes cannot be diagnosed by echocardiography, the most widely available technique in clinical practice for the functional evaluation of the heart and the detection of cardiomyopathies. PMCTA and MRI have the potential to detect advanced stages of diseases when morphological substrate is present, but these methods have yet to be sufficiently validated for postmortem cases. Genetically determined channelopathies cannot be detected radiologically. This review underlines the need to establish the role of postmortem radiology in the diagnosis of SCD.

Endotoxin impairs cardiac hemodynamics by affecting loading conditions but not by reducing cardiac inotropism.

Acute myocardial dysfunction is a typical manifestation of septic shock. Experimentally, the administration of endotoxin [lipopolysacharride (LPS)] to laboratory animals is frequently used to study such dysfunction. However, a majority of studies used load-dependent indexes of cardiac function [including ejection fraction (EF) and maximal systolic pressure increment (dP/dt(max))], which do not directly explore cardiac inotropism. Therefore, we evaluated the direct effects of LPS on myocardial contractility, using left ventricular (LV) pressure-volume catheters in mice. Male BALB/c mice received an intraperitoneal injection of E. coli LPS (1, 5, 10, or 20 mg/kg). After 2, 6, or 20 h, cardiac function was analyzed in anesthetized, mechanically ventilated mice. All doses of LPS induced a significant drop in LV stroke volume and a trend toward reduced cardiac output after 6 h. Concomitantly, there was a significant decrease of LV preload (LV end-diastolic volume), with no apparent change in LV afterload (evaluated by effective arterial elastance and systemic vascular resistance). Load-dependent indexes of LV function were markedly reduced at 6 h, including EF, stroke work, and dP/dt(max). In contrast, there was no reduction of load-independent indexes of LV contractility, including end-systolic elastance (ejection phase measure of contractility) and the ratio dP/dt(max)/end-diastolic volume (isovolumic phase measure of contractility), the latter showing instead a significant increase after 6 h. All changes were transient, returning to baseline values after 20 h. Therefore, the alterations of cardiac function induced by LPS are entirely due to altered loading conditions, but not to reduced contractility, which may instead be slightly increased.

Are there vascular density gradients along myocardial laser channels?

BACKGROUND: Clinical studies suggest that transmyocardial laser revascularization may improve regional blood flow of the subendocardial layer. The vascular growth pattern of laser channels was analyzed. METHODS: Twenty pigs were randomized to undergo ligation of left marginal arteries (n = 5), to undergo transmyocardial laser revascularization of the left lateral wall (n = 5), to undergo both procedures (n = 5) or to a control group (n = 5). All the animals were sacrificed after 1 month. Computed morphometric analysis of vascular density of the involved area was expressed as number of vascular structures per square millimeter (+/-1 standard deviation). RESULTS: The vascular density of the scar tissue of the laser channel was significantly increased in comparison with myocardial infarction alone: 49.6+/-12.8/mm2 versus 25.5+/-8.6/mm2 (p < 0.0001). The vascular densities of subendocardial and subepicardial channel areas were similar: 52.9+/-16.8/mm2 versus 46.3+/-13.6/mm2 (p = 0.41). The area immediately adjacent to the channels showed a vascular density similar to that of normal tissue: 6.02+/-1.7/mm2 versus 5.2+/-1.9/mm2 (p = 0.08). In the infarction + transmyocardial laser revascularization group, the channels were indistinguishable from infarction scar. CONCLUSIONS: Scars of transmyocardial laser revascularization channels exhibit an increased vascular density in comparison with scar tissue of myocardial infarction, which does not extend into their immediate vicinity. There was no vascular density gradient along the longitudinal axis of the channels.

Mechanisms of Symptomatic Spinal Cord Ischemia After TEVAR: Insights From the European Registry of Endovascular Aortic Repair Complications (EuREC).

Abstract Purpose: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p = 0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p = 0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p = 0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Effect of an I.V. bolus of phenylephrine or ephedrine on skin blood flow during spinal anesthesia

Effet d'un bolus intraveineux de phénylephrine ou d'éphedríne sur le flux sanguin cutané lors d'une anesthésie rachidienne Introduction : La phénylephrine et l'éphedrine sont des substances vaso-actives utilisées de routine pour corriger des épisodes d'hypotension artérielle induits par l'anesthésie intrarachidienne. L'influence de ces deux vasopresseurs sur le flux sanguin cutané (FSC) dans ce contexte n'a jusqu'à maintenant pas été décrite. Cette étude évalue l'effet d'une injection intraveineuse de 75 µg de phénylephrine ou de 7.5 mg d'éphedrine sur le FSC mesuré par Laser Doppler, dans les zones concernées parle bloc sympathiqué induit par l'anesthésie intrarachidienne (membres inférieurs) et dans les zones non concernées (membres supérieurs). Méthode :Après acceptation par le Comité d'Éthique, et obtention de leur accord écrit, 20 patients devant subir une intervention chirurgicale élective en décubitus dorsal sous anesthésie. intrarachidienne ont été inclus dans cette étude randomisée en double insu. Le FSC a été mesuré en continu par deux sondes fixées l'une à la cuisse (zone avec bloc sympathique) et l'autre sur l'avantbras (zone sans bloc sympathique). Les valeurs de FSC ont été enregistrées après l'anesthésie rachidienne (valeur contrôle), puis après l'injection i.v. dè phénylephrine (10 patients) ou d'éphedrine (10 patients) pour corriger une hypotension définie comme une chute de 20 mmHg de la pression artérielle systolique. Les variations de FSC exprimées en pourcentage de la valeur contrôle moyenne (+/- écart type) ont été analysées par le test t de Student. Résultats :Les données démographiques des patients et le niveau sensitif induit par l'anesthésie rachidienne sont similaires dans les deux groupes. Aux doses utilisées, seule l'éphedrine restaure la pression artérielle aux valeurs précédant l'anesthésie rachidienne. La phénylephrine augmente le FSC de l'avant-bras de 44% (+/- 79%) et de la cuisse de 34% (+/-24%), alors que l'éphedrine diminue le débit sanguin cutané de l'avant-bras de 16% (+/- 15%) et de la cuisse de 22% (+/-11%). Conclusion : L'injection intraveineuse de phénylephrine et d'éphedrine ont des effets opposés sur le flux sanguin cutané, et cette réponse n'est pas modifiée par le bloc sympathique.. Cette différence peut s'expliquer par la distribution des sous-types de récepteurs adrénergiques alpha et leur prédominance relative dans les veines et les artères de différents diamètres perfusant le tissu sous-cutané et la peau. L'éphedrine, èn raison de sa meilleure efficacité pour traiter les épisodes d'hypotension artérielle après anesthésie intrarachidienne devrait être préféré à la phénylephrine, leurs effets opposés sur le flux sanguin cutané n'étant pas pertinents en pratique clinique. SUMMARY Background: Phenylephrine or ephedrine is routinely used to correct hypotensive episodes fallowing spinal anaesthesia (SA). The influence of these two vasopressors on skin blood flow (SBF) has not yet been described. We have therefore evaluated the effects of an i.v. bolus of 75 µg phenylephrine or 7.5 mg of ephedrine on SBF measured by laser Doppler flowmetry during sympathetic blockade induced by SA. Methods: With Ethical Committee approval and written consent, 20 patients scheduled for elective procedures in supine position under SA were enrolled in this double-blind randomized study. SBF was measured continuously by two probes fixed at the thigh (area with sympathic blockade) and forearm level (area without sympathic blockade) respectively. SBF values were recorded after SA (control values) and then after a bolus administration of phenylephriné (n=10) or ephedrine (n=10) when systolic blood pressure decreased by 20 mmHg. Changes were expressed as percentage of control SBF values and analysed by Student's paired t-test. Results: Patient characteristics and dermatomal sensory levels were similar in both groups. Phenylephrine increases mean SBF at the forearm level by 44% (79%) [mean (SD)j and at the thigh by 34% (24%). Ephedrine decreases SBF at the forearm level by 16% (15%) and at the thigh by 22% (il%). Ephedrine bolus restores arterial blood pressure to pre-anaesthesia values, whereas phenylephrine does not. Conclusion: Administratión of phenylephrine and ephedrine has opposite effects on skin blood flow and sympathetic blockade does not modify this response. These findings could be explained by the distribution of the alpha-adrenoréceptor subtypes and their relative predominance among veins and arteries of different size perfusing the subcutaneous tissue and the skin. Ephedrine, due to its better efficacy to correct hypotensive episodes following SA, should be preferred, to phenylephrine, their opposite effects on SBF being not relevant for clinical practice.

Ambulatory blood pressure monitoring: a mean to stratify cardiovascular risk.

OBJECTIVE: Current hypertension guidelines stress the importance to assess total cardiovascular risk but do not describe precisely how to use ambulatory blood pressures in the cardiovascular risk stratification. METHOD: We calculated here global cardiovascular risk according to 2003 European Society of Hypertension/European Society of Cardiology guidelines in 127 patients in whom daytime ambulatory blood pressures were recorded and carotid/femoral ultrasonography performed. RESULTS: The presence of ambulatory blood pressures >or =135/85 mmHg shifted cardiovascular risk to higher categories, as did the presence of hypercholesterolemia and, even more so, the presence of atherosclerotic plaques. CONCLUSION: Further studies are, however, needed to define the position of ambulatory blood pressures in the assessment of cardiovascular risk.

B1-insensitive T2 preparation for improved coronary magnetic resonance angiography at 3 T.

At 3 T, the effective wavelength of the RF field is comparable to the dimension of the human body, resulting in B1 standing wave effects and extra variations in phase. This effect is accompanied by an increase in B0 field inhomogeneity compared to 1.5 T. This combination results in nonuniform magnetization preparation by the composite MLEV weighted T2 preparation (T2 Prep) sequence used for coronary magnetic resonance angiography (MRA). A new adiabatic refocusing T2 Prep sequence is presented in which the magnetization is tipped into the transverse plane with a hard RF pulse and refocused using a pair of adiabatic fast-passage RF pulses. The isochromats are subsequently returned to the longitudinal axis using a hard RF pulse. Numerical simulations predict an excellent suppression of artifacts originating from B1 inhomogeneity while achieving good contrast enhancement between coronary arteries and surrounding tissue. This was confirmed by an in vivo study, in which coronary MR angiograms were obtained without a T2 Prep, with an MLEV weighted T2 Prep and the proposed adiabatic T2 Prep. Improved quantitative and qualitative coronary MRA image measurement was achieved using the adiabatic T2 Prep at 3 T.

Continuous arterial spin labeling of mouse cerebral blood flow using an actively-detuned two-coil system at 9.4T.

Among numerous magnetic resonance imaging (MRI) techniques, perfusion MRI provides insight into the passage of blood through the brain's vascular network non-invasively. Studying disease models and transgenic mice would intrinsically help understanding the underlying brain functions, cerebrovascular disease and brain disorders. This study evaluates the feasibility of performing continuous arterial spin labeling (CASL) on all cranial arteries for mapping murine cerebral blood flow at 9.4 T. We showed that with an active-detuned two-coil system, a labeling efficiency of 0.82 ± 0.03 was achieved with minimal magnetization transfer residuals in brain. The resulting cerebral blood flow of healthy mouse was 99 ± 26 mL/100g/min, in excellent agreement with other techniques. In conclusion, high magnetic fields deliver high sensitivity and allowing not only CASL but also other MR techniques, i.e. (1)H MRS and diffusion MRI etc, in studying murine brains.

Artifact-free coronary magnetic resonance angiography and coronary vessel wall imaging in the presence of a new, metallic, coronary magnetic resonance imaging stent.

BACKGROUND: Coronary in-stent restenosis cannot be directly assessed by magnetic resonance angiography (MRA) because of the local signal void of currently used stainless steel stents. The aim of this study was to investigate the potential of a new, dedicated, coronary MR imaging (MRI) stent for artifact-free, coronary MRA and in-stent lumen and vessel wall visualization. METHODS AND RESULTS: Fifteen prototype stents were deployed in coronary arteries of 15 healthy swine and investigated with a double-oblique, navigator-gated, free-breathing, T2-prepared, 3D cartesian gradient-echo sequence; a T2-prepared, 3D spiral gradient-echo sequence; and a T2-prepared, 3D steady-state, free-precession coronary MRA sequence. Furthermore, black-blood vessel wall imaging by a dual-inversion-recovery, turbo spin-echo sequence was performed. Artifacts of the stented vessel segment and signal intensities of the coronary vessel lumen inside and outside the stent were assessed. With all investigated sequences, the vessel lumen and wall could be visualized without artifacts, including the stented vessel segment. No signal intensity alterations inside the stent when compared with the vessel lumen outside the stent were found. CONCLUSIONS: The new, coronary MRI stent allows for completely artifact-free coronary MRA and vessel wall imaging.

Regional coronary endothelial function is closely related to local early coronary atherosclerosis in patients with mild coronary artery disease: pilot study.

BACKGROUND: Coronary endothelial function is abnormal in patients with established coronary artery disease and was recently shown by MRI to relate to the severity of luminal stenosis. Recent advances in MRI now allow the noninvasive assessment of both anatomic and functional (endothelial function) changes that previously required invasive studies. We tested the hypothesis that abnormal coronary endothelial function is related to measures of early atherosclerosis such as increased coronary wall thickness. METHODS AND RESULTS: Seventeen arteries in 14 healthy adults and 17 arteries in 14 patients with nonobstructive coronary artery disease were studied. To measure endothelial function, coronary MRI was performed before and during isometric handgrip exercise, an endothelial-dependent stressor, and changes in coronary cross-sectional area and flow were measured. Black blood imaging was performed to quantify coronary wall thickness and indices of arterial remodeling. The mean stress-induced change in cross-sectional area was significantly higher in healthy adults (13.5%±12.8%, mean±SD, n=17) than in those with mildly diseased arteries (-2.2%±6.8%, P<0.0001, n=17). Mean coronary wall thickness was lower in healthy subjects (0.9±0.2 mm) than in patients with coronary artery disease (1.4±0.3 mm, P<0.0001). In contrast to healthy subjects, stress-induced changes in cross-sectional area, a measure of coronary endothelial function, correlated inversely with coronary wall thickness in patients with coronary artery disease (r=-0.73, P=0.0008). CONCLUSIONS: There is an inverse relationship between coronary endothelial function and local coronary wall thickness in patients with coronary artery disease but not in healthy adults. These findings demonstrate that local endothelial-dependent functional changes are related to the extent of early anatomic atherosclerosis in mildly diseased arteries. This combined MRI approach enables the anatomic and functional investigation of early coronary disease.

Characterization of Human Late Outgrowth Endothelial Progenitor-Derived Cells under Various Flow Conditions.

Background: Endothelial progenitor-derived cells (EPC) are a cell therapy tool in peripheral arterial disease and for re-endothelialization of bypasses and stents. Objective: To assess EPC behavior under flow conditions normally found in vivo. Results: EPC were isolated from human cord blood, cultured on compliant tubes and exposed in an in vitro flow system mimicking hemodynamic environments normally found in medium and large arteries. EPC exposed for 24 h to unidirectional (0.3 ± 0.1 or 6 ± 3 dynes/cm(2)) shear stress oriented along flow direction, while those exposed to bidirectional shear stress (0.3 ± 3 dynes/cm(2)) or static conditions had random orientation. Under bidirectional flow, tissue factor (TF) activity and mRNA expression were significantly increased (2.5- and 7.0-fold) compared to static conditions. Under low shear unidirectional flow TF mRNA increased 4.9 ± 0.5-fold. Similar flow-induced increases were observed for TF in mature umbilical vein-derived endothelial cells. Expression of tissue-type plasminogen activator (t-PA), urokinase (u-PA) and monocyte chemotactic protein 1 (MCP1) were reduced by 40-60% in late outgrowth endothelial progenitor-derived cells (LO-EPC) exposed to any flow environment, while MCP1, but not t-PA or u-PA, was decreased in HUVEC. Conclusions: Flow, in particular bidirectional, modifies the hemostatic balance in LO-EPC with increased TF and decreased plasminogen activator expression.

In vivo transformation of mouse conventional CD8alpha+ dendritic cells leads to progressive multisystem histiocytosis

Division and proliferation of dendritic cells (DCs) have been proposed to contribute to homeostasis and to prolonged antigen presentation. Whether abnormal proliferation of dendritic cells causes Langerhans cell histiocytosis (LCH) is a highly debated topic. Transgenic expression of simian virus 40 (SV40) T antigens in mature DCs allowed their transformation in vivo while maintaining their phenotype, function, and maturation capacity. The transformed cells were differentiated splenic CD8 alpha-positive conventional dendritic cells with increased Langerin expression. Their selective transformation was correlated with higher steady-state cycling compared with CD8 alpha-negative DCs in wild-type and transgenic mice. Mice developed a DC disease involving the spleen, liver, bone marrow, thymus, and mesenteric lymph node. Surprisingly, lesions displayed key immunohistologic features of Langerhans cell histiocytosis, including expression of Langerin and absence of the abnormal mitoses observed in Langerhans cell sarcomas. Our results demonstrate that a transgenic mouse model with striking similarities to aggressive forms of multisystem histiocytosis, such as the Letterer-Siwe syndrome, can be obtained by transformation of conventional DCs. These findings suggest that conventional DCs may cause some human multisystem LCH. They can reveal shared molecular pathways for human histiocytosis between humans and mice