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Ciobotaru V, Combes N, Iriart X, Marijon E, Hascoet S, Nguyen A, Ternacle J, Defaye P, Jacon P, Lepillier A, Thambo JB, Teiger E, Cheneau E, Commeau P, Elbaz M. P2436Preliminary data from “LAA-Print French registry”: a large national multi-centric prospective registry evaluating a new preoperative approach based on 3Dprinted simulation in LAAC procedures. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Left atrial appendage closure (LAAC) is an alternative to OAC in patients with contra indication to OAC and AF. But LAAC may be at risk, especially in frail patients.
There are no imaging criteria to asses individual procedural risk.
Furthermore, procedural factors (double curve catheter alignment) are hard to predict
3D-printing simulation has capability to integrate all anatomical and procedural parameters and has demonstrated improvements in LAAC device sizing in a pilot study
Aim
To demonstrate efficiency of 3D-printing simulation to predict LAAC procedural risk (failure, long procedure time, pericardial effusion or others serious adverse events (SAES) or inappropriate implantations)
Methods
Open study: Prospective and Consecutive.
Recruiting 150 patients in 16 centres (of 300 patients expected).
Start: Jan 18th, 2018.
Study Completion: Nov 1st, 2019.
ClinicalTrials ID: NCT03330210.
1. Cardiac CT prior to LAAC.
2. Industrial manufacture, laser sintering, of 3D-printed models including the whole LA cavity including interatrial thin septum and vena cava (using material TPU with adequat elasticity: shore 50).
3. LAAC Simulation based on 3Dprinted models using specific sheaths and prosthesis.
Prior to LAAC procedure each operator asses a risk score for procedural failure (low/moderate/high) based on real 3D printed LAAC simulation taking into account: trans-septal puncture site/sheath alignment with LAA ostium/device deployment and stability.
4. LAAC procedure TEE guided.
5. CT or TEE control M3 or M6.
Procedural outcomes according to risk Sc Low risk (N=63) Moderate risk (N=50) High risk (N=37) p<0.05 vs High risk Failure 1 (1.6%) 1 (2%) 10 (27%) * Recaptures ≥2 4 (6%) 5 (10%) 12 (32%) * Prosthesis ≥2 2 (3%) 1 (2%) 9 (24%) * Inappropriate implantation 0 6 (12%) 7 (19%) * SAES 2 (3%) 6 (12%) 12 (32%) * Pericardial effusion (pericardiocentesis) 2 (3%) 1 (2%) 4 (11%) * Haemorrhage (≥2 points) 0 2 (4%) 5 (13%) * Coronary syndrome 0 0 4 (11%) * Time (intra left atrium) min 21±10 29±16 50±25 * *p<0.05 vs High risk group according to prospective risk score.
LAAC simulation on 3D printed model
Conclusion
3D printing simulation accurately stratifies the risk of procedure according to LA anatomy. 3D printing may guide the procedure through verification of the transseptal puncture site and/or using a specific catheter shape and device. In case of high risk, a careful assessment of risk/benefice ratio is mandatory
Acknowledgement/Funding
AG2RFondation and Boston Scientific
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Affiliation(s)
- V Ciobotaru
- Hopital Prive Les Franciscaines, Nimes, France
| | - N Combes
- Clinic Pasteur, Toulouse, France
| | - X Iriart
- Hospital Haut Leveque, Cardiology, Bordeaux-Pessac, France
| | - E Marijon
- Hôpital Européen Georges Pompidou- Université Paris Descartes, Cardiology, Paris, France
| | - S Hascoet
- Surgical Centre Marie Lannelongue, Cardiology, Le Plessis Robinson, France
| | - A Nguyen
- University Hospital Henri Mondor, Cardiology, Creteil, France
| | - J Ternacle
- University Hospital Henri Mondor, Cardiology, Creteil, France
| | - P Defaye
- University Hospital of Grenoble, Cardiology, Grenoble, France
| | - P Jacon
- University Hospital of Grenoble, Cardiology, Grenoble, France
| | - A Lepillier
- Centre Cardiologique du Nord, Cardiology, Saint Denis, France
| | - J B Thambo
- Hospital Haut Leveque, Cardiology, Bordeaux-Pessac, France
| | - E Teiger
- University Hospital Henri Mondor, Cardiology, Creteil, France
| | - E Cheneau
- Hopital Prive Clairval, Cardiology, Marseille, France
| | - P Commeau
- Polyclinique Les Fleurs, Cardiology, Ollioules, France
| | - M Elbaz
- Toulouse Rangueil University Hospital (CHU), Cardiology, Toulouse, France
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Cheneau E, Resseguier N, Vahdat B, Molon A, Bernard L, Giorgi R, Panagides D. 056 How to reduce unnecessary angiograms when patients are initially evaluated by coronary CT for coronary artery disease? Archives of Cardiovascular Diseases Supplements 2012. [DOI: 10.1016/s1878-6480(12)70452-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Cheneau E, Vahdat B, Molon A, Panagides D. 372 Single high sensitive troponin I test followed by coronary computed tomography for low risk patients admitted in chest pain unit. Archives of Cardiovascular Diseases Supplements 2012. [DOI: 10.1016/s1878-6480(12)70768-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Bonello L, Pansieri M, Mancini J, Bonello R, Maillard L, Barnay P, Rossi P, Ait-Mokhtar O, Jouve B, Collet F, Peyre JP, Wittenberg O, de Labriolle A, Camilleri E, Cheneau E, Cabassome E, Dignat-George F, Camoin-Jau L, Paganelli F. High on-treatment platelet reactivity after prasugrel loading dose and cardiovascular events after percutaneous coronary intervention in acute coronary syndromes. J Am Coll Cardiol 2011; 58:467-73. [PMID: 21777742 DOI: 10.1016/j.jacc.2011.04.017] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 04/14/2011] [Accepted: 04/19/2011] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the relationship between platelet reactivity (PR) after a loading dose (LD) of prasugrel and thrombotic events. BACKGROUND Post-treatment PR has been shown to be strongly associated with the occurrence of major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) in the clopidogrel era. Prasugrel is a new P2Y(12)-adenosine diphosphate receptor with a higher potency on PR. METHODS A prospective multicenter study included patients who underwent successful PCI for acute coronary syndromes and received prasugrel therapy. Vasodilator-stimulated phosphoprotein (VASP) index was measured after the prasugrel LD. High on-treatment PR was defined as a VASP index ≥50%. MACE included cardiovascular death, myocardial infarction, and definite stent thrombosis at 1 month. RESULTS Three hundred one patients were enrolled. The mean VASP index after 60 mg of prasugrel was 34.3 ± 23.1%. High on-treatment PR was observed in 76 patients (25.2%). Patients experiencing thrombotic events after PCI had significantly higher VASP indexes compared with those free of events (64.4 ± 14.4% vs. 33.4 ± 22.7%; range: 51% to 64% and 5% to 47.6%, respectively; p = 0.001). Kaplan-Meier analysis comparing good responders and patients with high on-treatment PR demonstrated a significantly higher rate of MACE in patients with suboptimal PR inhibition (log-rank p < 0.001). Receiver-operating characteristic curve analysis found a cutoff value of 53.5% of the VASP index to predict thrombotic events at 1 month (r = 0.86, p < 0.001). Patients with minor or major Thrombolysis In Myocardial Infarction unrelated to coronary artery bypass grafting bleeding and those without had similar VASP indexes (30 ± 17.8% vs. 34.3 ± 23%, p = 0.70). CONCLUSIONS Despite the use of prasugrel, a significant number of patients undergoing PCI in the setting of acute coronary syndromes do not achieve optimal PR inhibition. Such patients have a higher risk for MACE after PCI.
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Affiliation(s)
- Laurent Bonello
- Département de Cardiologie, Hôpital Universitaire Nord, Faculté de Médecine, Chemin des Bourrely, Marseille, France.
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Cheneau E, Vahdat B, Bernard L, Molon A, Panagides D. Routine use of coronary computed tomography as initial diagnostic test for angina pectoris. Arch Cardiovasc Dis 2011; 104:29-34. [PMID: 21276575 DOI: 10.1016/j.acvd.2010.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 11/23/2010] [Accepted: 11/23/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Coronary computed tomography (CCT) detects coronary obstruction with high sensitivity and might be useful for diagnosis of angina pectoris. AIM In this pilot study, we sought to prospectively evaluate the performance of CCT as initial work up and determine the significance of this strategy according to the pretest likelihood of having coronary artery disease (CAD). METHODS One hundred and eighty patients with chest discomfort and suspected angina were prospectively referred for CCT with a 64-slice CT scan. Invasive coronary angiography (ICA) was performed on the basis of CCT findings (stenosis>50%). Patients were classified into tertiles according to estimated pretest probability of obstructive CAD using the Duke Clinical Score (low, intermediate and high). Strategy failure was defined as unnecessary ICA or major adverse cardiac event (MACE) within 6 months in patients without significant stenosis by CCT. RESULTS Pretest probability for CAD was 53 ± 29%. Significant stenosis was detected by CCT in 51 patients; 47 (26%) underwent ICA. Sixteen strategy failures were reported: 15 patients (10%) were referred for ICA that did not confirm significant coronary stenosis and one MACE occurred in a patient without significant stenosis by CCT. Strategy failures were 8% in low-probability, 1.7% in intermediate-probability and 15% in high-probability patients (P=0.03). CONCLUSIONS CCT as an initial step for angina diagnosis is most effective in patients with an intermediate probability of CAD. In patients with low or high likelihood, it is associated with a high rate of unnecessary ICA but not with adverse events.
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Affiliation(s)
- Edouard Cheneau
- Centre de cardiologie interventionnelle, clinique Bouchard, 77, rue du docteur-Escat, 13006 Marseille, France.
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Javaid A, Chu WW, Cheneau E, Clavijo LC, Satler LF, Kent KM, Weissman NJ, Pichard AD, Waksman R. Comparison of paclitaxel-eluting stent and sirolimus-eluting stent expansion at incremental delivery pressures. Cardiovasc Revasc Med 2007; 7:208-11. [PMID: 17174865 DOI: 10.1016/j.carrev.2006.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 09/12/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We sought to compare the adequacy of paclitaxel-eluting stent (PES) and sirolimus-eluting stent (SES) expansion based on intravascular ultrasound (IVUS) imaging criteria at conventional delivery pressures. METHODS Forty-six patients underwent SES implantation and 42 patients underwent PES implantation for de novo native coronary lesions<33 mm in length with reference lumen diameters of 2.5-3.5 mm. Stents were serially expanded with gradual balloon inflations at 14 and 20 atm. IVUS imaging was performed prior to intervention and after each balloon inflation. Stent expansion (minimal stent cross-sectional area/reference lumen cross-sectional area) was measured. Inadequate stent expansion was defined using the MUSIC criteria (all struts apposed, no tissue protrusion, and final lumen cross-sectional area>80% of the reference or >90% if minimal lumen cross-sectional area was <9 mm2). RESULTS The baseline characteristics of the two groups were similar except for shorter lesion length, larger mean lumen cross-sectional area, larger lumen diameter, and lower plaque burden in the PES group. Stent expansion was inadequate in 80% of patients with SES versus 63% of patients with PES at 14 atm, although this was not statistically significant. After 20 atm, 48% of patients with SES remained underexpanded as compared with 35% of patients with PES. CONCLUSION Drug-eluting stents showed significant underexpansion by MUSIC criteria at conventionally used inflation pressures. Higher balloon inflations are required especially during deployment of a SES. IVUS guidance is recommended to ensure optimal results and outcomes with both stents.
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Affiliation(s)
- Aamir Javaid
- Washington Hospital Center, 110 Irving Street, NW, Suite 4B-1, Washington, DC 20010, USA
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Waksman R, Leitch IM, Roessler J, Yazdi H, Seabron R, Tio F, Scott RW, Grove RI, Rychnovsky S, Robinson B, Pakala R, Cheneau E. Intracoronary photodynamic therapy reduces neointimal growth without suppressing re-endothelialisation in a porcine model. Heart 2006; 92:1138-44. [PMID: 16399853 PMCID: PMC1861129 DOI: 10.1136/hrt.2005.073486] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2005] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To examine the effects of intracoronary PhotoPoint photodynamic therapy (PDT) with a new photosensitiser, MV0611, in the overstretch balloon and stent porcine models of restenosis. METHODS 28 pigs were injected with 3 mg/kg of MV0611 systemically 4 h before the procedure. Animals were divided into either the balloon overstretch injury (BI) group (n = 19) or the stented group (n = 9). After BI, a centred delivery catheter was positioned in the artery to cover the injured area, and light (532 nm, 125 J/cm(2)) was applied to activate the drug (n = 10). Control arteries (n = 9) were not activated by light. In the stented group, the drug was light activated before stent deployment. Serial sections of vessels were processed 14 days after treatment in the BI group and 30 days after treatment in the stented group for histomorphometric or immunohistochemical analysis. RESULTS Intracoronary PDT significantly reduced intimal thickness in both BI and stented arteries (about 65%: 0.22 (SEM 0.05) mm v 0.62 (0.05) mm, p < 0.01; and about 26%: 0.40 (0.04) mm v 0.54 (0.04) mm, p < 0.01, respectively). PDT increased luminal area by CONCLUSION Intracoronary PhotoPoint PDT with MV0611 reduces intimal proliferation without suppressing re-endothelialisation in a porcine model of restenosis.
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Affiliation(s)
- R Waksman
- Division of Cardiology, Washington Hospital Center, Washington, DC, USA.
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Ohlmann P, Faure A, Morel O, Petit H, Kabbaj H, Meyer N, Cheneau E, Jesel L, Epailly E, Desprez D, Grunebaum L, Schneider F, Roul G, Mazzucotteli JP, Eisenmann B, Bareiss P. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Crit Care Med 2006; 34:1358-64. [PMID: 16557157 DOI: 10.1097/01.ccm.0000216686.72457.ec] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to determine whether assessing D-Dimer might be helpful for the management of acute aortic dissection (AAD). DESIGN Single-center retrospective case-control study. SETTING University Hospital of Strasbourg France. PATIENTS Patients were 94 consecutive patients admitted to our institution with confirmed AAD and in whom D-Dimer test had been performed at presentation. These patients were matched with 94 controls presenting with clinical suspicion of dissection, which was later ruled out. INTERVENTIONS Patient characteristics and clinical course were analyzed. MEASUREMENTS AND MAIN RESULTS Ninety-three (99%) patients with AAD had elevated D-Dimer (>400 ng/mL) with a median D-Dimer value of 8610 ng/mL (interquartile range, 2982-20,000 ng/mL). Receiver operating characteristic curves analysis showed that D-Dimer, but not C-reactive protein, troponin, lactate dehydrogenase, or leukocyte count, was predictive of a diagnosis of AAD, with a sensitivity and specificity of 99% and 34%, respectively. D-Dimer concentration positively correlated with the anatomical extension of the dissection to the different segments of the aorta (R = .47, p < .0001). A positive relationship was observed between D-Dimer and in-hospital mortality rate among patients with AAD (p = .037). On multivariate analysis, the independent predictors of in-hospital mortality were the presence of pericardial effusion (odds ratio, 6.80; confidence interval, 1.87-27.60), D-Dimer >5200 ng/mL (odds ratio, 5.38; confidence interval, 1.27-30.87), and female gender (odds ratio, 4.96; confidence interval, 1.39-19.95). CONCLUSIONS D-Dimers are elevated in patients with AAD and provide valuable diagnostic and prognostic information. In patients with acute chest pain and elevated D-Dimer, a diagnosis of AAD should also be considered. D-Dimer might be a useful complementary tool to the current diagnostic work-up of patients with suspected AAD.
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Affiliation(s)
- Patrick Ohlmann
- Fédération of cardiologie, Service de chirurgie cardiaque, Hôpitaux Universitaires de Strasbourg, France
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Javaid A, Cheneau E, Pichard A, Satler L, Kent K, Suddath W, Waksman R. Underexpansion of drug-eluting stents at conventional delivery pressures: are there differences between sirolimus- and paclitaxel-eluting stents? Cardiovascular Revascularization Medicine 2006. [DOI: 10.1016/j.carrev.2006.03.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Chu WW, Rha SW, Kuchulakanti PK, Cheneau E, Torguson R, Pinnow E, Alexieva-Fournadjiev J, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Efficacy of sirolimus-eluting stents compared with bare metal stents for saphenous vein graft intervention. Am J Cardiol 2006; 97:34-7. [PMID: 16377280 DOI: 10.1016/j.amjcard.2005.08.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Revised: 08/22/2005] [Accepted: 08/22/2005] [Indexed: 11/25/2022]
Abstract
Saphenous vein graft (SVG) intervention is associated with a significantly increased rate of periprocedural complications and late clinical and angiographic restenosis. We examined the efficacy and safety of sirolimus-eluting stents (SESs; Cypher) compared with bare metal stents (BMSs) in SVG intervention. Forty-eight patients who had 50 SVG lesions and underwent standard percutaneous coronary intervention with SESs (SES group) were compared with 57 patients who had 64 SVG lesions and underwent intervention with BMSs (BMS group). All patients received distal protection devices during SVG intervention. In-hospital, 30-day, 6-month, and 1-year clinical outcomes in the 2 groups were compared. Baseline clinical and procedural characteristics were balanced between groups. There were no deaths or Q-wave myocardial infarctions during the index hospitalization, but compared with the BMS group, patients in the SES group had significantly fewer non-Q-wave myocardial infarctions (4% vs 21%, p = 0.01), which was mainly attributed to increased periprocedural creatine kinase-MB levels. At 30-day, 6-month, and 1-year follow-ups, all clinical outcomes were similar between groups. Event-free survival at 1 year was also similar between groups (p = 0.84). In conclusion, the use of SESs in patients who undergo SVG intervention with a distal protection device is clinically safe and feasible but is not associated with decreased clinical events up to 1 year compared with BMSs.
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Kuchulakanti P, Wolfram R, Torguson R, Rha SW, Cheneau E, Clavijo L, Chu WW, Pinnow EE, Canos D, Satler LF, Suddath WO, Pichard AD, Kent KM, Waksman R. Bivalirudin compared with IIb/IIIa inhibitors in patients with in-stent restenosis undergoing intracoronary brachytherapy. Cardiovascular Revascularization Medicine 2005; 6:154-9. [PMID: 16326376 DOI: 10.1016/j.carrev.2005.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 06/23/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Bivalirudin is replacing heparin in percutaneous coronary interventions (PCIs), including vascular brachytherapy (VBT). The aim of the study was to compare bivalirudin with eptifibatide in patients with in-stent restenosis (ISR) undergoing PCI and VBT. METHODS One hundred forty-four patients treated with bivalirudin as a single antithrombotic agent were compared with 150 patients treated with eptifibatide. Bivalirudin as a bolus of 0.75 mg/kg followed by 1.75 mg/kg/h infusion until the end of the procedure, and eptifibatide as a double bolus of 180 microg/kg followed by 2 microg/kg/min infusion for 18 h after the procedure were used. The main outcome measures were in-hospital events and 30-day clinical outcomes. RESULTS Baseline clinical characteristics were similar except that patients in the eptifibatide group were younger (P=.02) and had more saphenous vein graft lesions (P<.001). Patients in the bivalirudin group had a higher number of lesions in the right coronary artery (P<.001) and a higher number of vessels treated (P<.001). Postprocedure creatinine phosphokinase (CPK)-MB levels were significantly lower in the bivalirudin group (P<.03). In-hospital events showed significantly less minor bleeding (P=.01) and a trend toward lower major bleeding and major adverse cardiac events (MACE) in the bivalirudin group (P=.06). Thirty-day outcomes showed a significantly lower incidence of non-Q-wave myocardial infarction (MI) in the bivalirudin group (P=.004). CONCLUSION Bivalirudin, as a single antithrombotic agent during PCI and VBT, is associated with significantly lower postprocedural CPK-MB elevation, minor bleeding complications, 30-day non-Q-wave MI rates, and a trend toward lower major bleeding and in-hospital MACE when compared with eptifibatide.
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Affiliation(s)
- Pramod Kuchulakanti
- Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington DC 20010, USA
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Kuchulakanti P, Wolfram R, Torguson R, Rha SW, Cheneau E, Pinnow EE, Canos D, Satler LF, Pichard AD, Kent KM, Waksman R. Brachytherapy and bivalirudin evaluation study. Am Heart J 2005; 150:832-7. [PMID: 16209990 DOI: 10.1016/j.ahj.2004.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 11/17/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bivalirudin is shown to be a competent substitute for heparin in percutaneous coronary intervention (PCI). The safety and efficacy of bivalirudin in patients undergoing PCI and vascular brachytherapy (VBT) are not known. This study aimed to assess the safety and efficacy of bivalirudin as a single antithrombotic agent in patients undergoing PCI and VBT. METHODS A total of 152 patients enrolled in the Brachytherapy and Bivalirudin Evaluation Study underwent PCI and VBT with either gamma (n = 8) or beta radiation (n = 144). The main outcome measures were in-hospital events and 30-day clinical outcomes. All patients were treated with bivalirudin (0.75 mg/kg bolus and 1.75 mg/kg per hour infusion for beta radiation, 1 mg/kg bolus and 2.5 mg/kg per hour infusion for gamma radiation) as a single antithrombotic agent during the entire procedure. RESULTS Baseline clinical and angiographic characteristics were similar between the 2 groups. More than 90% of the patients received beta radiation. In-hospital events showed a higher prevalence of acute procedural intracoronary thrombosis in patients treated with gamma- vs beta radiation (25% vs. 0.7%, P < .001). Thirty-day outcomes including death, Q-wave, and non-Q-wave myocardial infarctions, subacute stent thromboses, and repeat revascularizations were similar in both groups. CONCLUSION Bivalirudin, as a single antithrombotic agent during PCI and VBT with beta emitters, may be used safely, but its use in the setting of PCI and gamma radiation may not be acceptable due to an increased incidence of acute procedural intracoronary thrombosis.
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Affiliation(s)
- Pramod Kuchulakanti
- Division of Cardiology, Department of Internal Medicine, Washington Hospital Center, Washington, DC 20010, USA
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Rha SW, Kuchulakanti PK, Pakala R, Cheneau E, Pinnow E, Torguson R, Pichard AD, Satler LF, Suddath WO, Kent KM, Lindsay J, Waksman R. Bivalirudin versus heparin as an antithrombotic agent in patients who undergo percutaneous saphenous vein graft intervention with a distal protection device. Am J Cardiol 2005; 96:67-70. [PMID: 15979436 DOI: 10.1016/j.amjcard.2005.02.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Revised: 02/22/2005] [Accepted: 02/22/2005] [Indexed: 10/25/2022]
Abstract
Bivalirudin (Angiomax) is increasingly used as a substitute for heparin in a variety of percutaneous coronary interventions, and data on its usage in saphenous vein graft interventions are limited. This retrospective, observational study evaluated the efficacy and safety of bivalirudin compared with heparin as an antithrombotic regimen in patients who underwent saphenous vein graft intervention with distal protection devices. We found that bivalirudin use is clinically safe and feasible, with fewer vascular and ischemic complications compared with heparin.
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Affiliation(s)
- Seung-Woon Rha
- Division of Cardiology, Washington Hospital Center, Washington, DC, USA
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Cheneau E, Satler LF, Escolar E, Suddath WO, Kent KM, Weissman NJ, Waksman R, Pichard AD. Underexpansion of sirolimus-eluting stents: Incidence and relationship to delivery pressure. Catheter Cardiovasc Interv 2005; 65:222-6. [PMID: 15900554 DOI: 10.1002/ccd.20350] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We aimed to assess the incidence of underexpansion and the relationship between delivery pressure and expansion with sirolimus-eluting stents. Adequate stent expansion contributes to early and late improved outcomes. In 51 patients (53 lesions) with native coronary artery narrowing, balloon-expandable sirolimus-eluting stents (Cypher) were serially expanded with gradual balloon inflations [14 atm, 20 atm, and in case of minimal stent cross-sectional area (CSA)/reference lumen CSA < 50% at 20 atm, postdilatation with 0.5 mm larger balloon]. Intravascular ultrasound (IVUS) imaging was performed before intervention and after each gradual balloon inflation. Stent expansion (minimal stent CSA/reference lumen CSA) was measured. Stent expansion was 72% +/- 16% after 14 atm balloon inflation, 90% +/- 18% after 20 atm balloon inflation (P < 0.001 vs. 14 atm), and 90% +/- 18% at the end of the procedure (including optional postdilatations with 0.5 mm larger balloon; P = NS vs. 20 atm). Stent expansion addressed by MUSIC criteria (all struts apposed, no tissue protrusion, and final lumen CSA > 80% of the reference or > 90% if minimal lumen CSA was < 9 mm2) was adequate in 15% of the cases after 14 atm balloon inflation, in 60% after 20 atm balloon inflation (P < 0.001 vs. 14 atm), and in 60% at the end of the procedure (P = NS vs. 20 atm). Sirolimus-eluting stent underexpansion is common when deployed at conventional pressures. Increasing balloon delivery pressure or assessing stent expansion with IVUS seems warranted in order to ensure adequate sirolimus-eluting stent deployment.
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Affiliation(s)
- Edouard Cheneau
- Division of Cardiology, Washington Hospital Center, Washington, District of Columbia 20010, USA
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15
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Cheneau E, Pichard AD, Satler LF, Suddath WO, Weissman NJ, Waksman R. Intravascular ultrasound stent area of sirolimus-eluting stents and its impact on late outcome. Am J Cardiol 2005; 95:1240-2. [PMID: 15878001 DOI: 10.1016/j.amjcard.2005.01.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Revised: 01/10/2005] [Accepted: 01/06/2005] [Indexed: 10/25/2022]
Abstract
Stent area assessed by intravascular ultrasound is a strong predictor of late outcome after percutaneous coronary intervention. Because sirolimus-eluting stents (SESs) prevent intimal regrowth within the stent, achieving a larger final stent area might no longer be noteworthy; therefore, the investigators sought to determine the relevance and impact of the final stent area with SESs.
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16
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Rha SW, Kuchulakanti P, Ajani AE, Cheneau E, Pinnow EE, Canos DA, Torguson R, Pichard AD, Satler LF, Kent KM, Ramee S, Teirstein P, Lindsay J, Waksman R. Three-year follow-up after intravascular γ-radiation for in-stent restenosis in saphenous vein grafts. Catheter Cardiovasc Interv 2005; 65:257-62. [PMID: 15864805 DOI: 10.1002/ccd.20372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Washington Radiation for In-Stent Restenosis Trial in Saphenous Vein Grafts (SVG WRIST) demonstrated safety and efficacy of intravascular radiation therapy (IRT) for the treatment of in-stent restenosis (ISR) in SVG at 12 months. In this study, we aimed to examine whether the safety and efficacy of IRT is durable up to 36 months. One hundred twenty patients with diffuse ISR in SVG underwent balloon angioplasty, laser or atherectomy ablation, and/or additional stenting. After successful intervention, patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium (Ir)-192 (n = 60) or nonradioactive seeds (n = 60). The prescribed dose at 2 mm from the source was either 14 or 15 Gy in vessels 2.5-4.0 mm or 18 Gy in vessels > 4.0 mm in diameter. At 36 months, target lesion revascularization (TLR; 43% vs. 66%; P = 0.02) and target lesion revascularization-major adverse cardiac event (TLR-MACE; 49% vs. 71%; P = 0.02) rates continued to be lower in the IRT group, but both target vessel revascularization (TVR; 59% vs. 71%; P = 0.17) and TVR-MACE (63% vs. 77%; P = 0.11) rates were not. In SVG WRIST, patients with ISR treated with IRT had a marked reduction in the need for repeat TLR at 36 months, with sustained clinical benefit at 3 years despite late recurrences, which were more pronounced in the radiation group.
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Affiliation(s)
- Seung-Woon Rha
- Division of Cardiology, Washington Hospital Center, Washington, District of Columbia 20010, USA
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17
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Rha SW, Kuchulakanti PK, Pakala R, Cheneau E, Pinnow E, Gebreeyesus A, Aggrey G, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Addition of heparin to contrast media is associated with increased bleeding and peripheral vascular complications during percutaneous coronary intervention with bivalirudin and drug-eluting stents. ACTA ACUST UNITED AC 2005; 5:64-70. [PMID: 15464942 DOI: 10.1016/j.carrad.2004.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2004] [Revised: 06/16/2004] [Accepted: 06/16/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Nonionic radiographic contrast media (CM) is reported to be thrombogenic while performing diagnostic or interventional procedures. To avoid thrombosis, heparin is often added to the CM. Bivalirudin, used to replace heparin during percutaneous coronary intervention (PCI), is reported to be associated with reduced bleeding complications. We aimed to evaluate the impact of adding heparin to the CM during PCI in patients (pts) who underwent sirolimus-eluting stent (SES) implantation when bivalirudin was utilized as the sole antithrombotic agent. METHODS A total of 664 pts with 756 lesions underwent standard PCI with SES for various coronary artery lesions. Pts were treated with either bivalirudin only (the bivalirudin group; 0.75 mg/kg bolus and 1.75 mg/kg/h infusion, n = 323 pts) or bivalirudin (same dose) plus low-dose heparin added to the CM (the heparin mix group; mean dose = 2101.8+/-882.5 U, n = 341 pts) during PCI. The periprocedural, in-hospital, and 30-day clinical outcomes were compared. RESULTS Baseline clinical and angiographic parameters were similar between both groups. Periprocedural, in-hospital, and 1-month clinical outcomes, including thrombotic complications, were similar between the two groups. There was no difference in the periprocedural thrombosis rate between the groups. In the heparin mix group, the overall incidence of hematoma was significantly higher (3.8% vs. 8.5%, P = .01), there was a trend toward higher rates of blood transfusion (2.6% vs. 6.6%, P = .06) and overall vascular complications (0.01% vs. 5.3%, P <.001), including pseudoaneurysm (PSA; 0.0% vs. 2.6%, P = .004), and pts who required surgical repair (0.3% vs. 1.8%, P = .07). CONCLUSIONS The routine addition of low-dose heparin to CM during contemporary PCI does not add any protection value and is associated with higher rates of bleeding and vascular complications.
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Affiliation(s)
- Seung-Woon Rha
- Division of Cardiology, Washington Hospital Center, 110 Irving Street, NW Suite 4B-1, Washington, DC 20010, USA
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18
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Castagna MT, Mintz GS, Ohlmann P, Kotani JI, Maehara A, Gevorkian N, Cheneau E, Stabile E, Ajani AE, Suddath WO, Kent KM, Satler LF, Pichard AD, Weissman NJ. Incidence, Location, Magnitude, and Clinical Correlates of Saphenous Vein Graft Calcification. Circulation 2005; 111:1148-52. [PMID: 15723972 DOI: 10.1161/01.cir.0000157160.69812.55] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pattern of saphenous vein graft (SVG) calcification before percutaneous intervention has not been studied. METHODS AND RESULTS We used diagnostic and preintervention intravascular ultrasound (IVUS) to determine the incidence and magnitude of SVG calcification in 334 SVG lesions in 274 consecutive patients. Calcium was found in 133 SVGs (40%). Calcium was uniformly distributed among 48 lesion sites (14%), 43 proximal references (13%), and 42 distal references (13%). Calcium was superficial in 20 (40%) and deep in 28 (60%). Over the entire length of the SVGs, the maximum arc and length of calcium (in calcium-containing SVGs) averaged 174+/-107 degrees and 6.8+/-4.8 mm, respectively. In calcium-containing SVGs, lesion site arc and length of calcium measured 151+/-107 degrees and 4.1+/-3.7 mm, similar to the proximal and distal references (175+/-121 degrees and 4.0+/-2.3 mm and 177+/-121 degrees and 4.1+/-2.5 mm, respectively). Graft age (7.5+/-4.7 versus 10.5+/-4.7 years, P<0.0001), insulin-treated diabetes mellitus (40% versus 60%, P=0.02), and tobacco use (44% versus 55%, P=0.06) were clinical independent predictors of SVG calcification. CONCLUSIONS Sixty-five percent of calcium-containing SVGs had reference calcium in the absence of lesion calcium. Calcium was located primarily in SVG wall and not at the plaque. These data suggest that SVG calcium is not just part of lesion formation and maturation. SVG calcium occurred more commonly in older grafts, in insulin-treated diabetic patients, and in smokers.
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Affiliation(s)
- Marco T Castagna
- Cardiovascular Research Institute/Medstar Research Institute, Washington Hospital Center, Washington, DC 20010, USA
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19
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Pakala R, Rha SW, Kuchulakanti PK, Cheneau E, Baffour R, Waksman R. Peroxisome proliferator-activated receptor gamma; Its role in atherosclerosis and restenosis. ACTA ACUST UNITED AC 2005; 5:44-8. [PMID: 15275632 DOI: 10.1016/j.carrad.2004.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cellular proliferation and migration are fundamental processes that contribute to the injury response in major blood vessels. The resultant pathologies are atherosclerosis and restenosis. As we begin to understand the cellular changes associated with vascular injury, it is critical to determine whether the inhibition of growth and movement of cells in the vasculature could serve as a novel therapeutic strategy to prevent atherosclerosis and restenosis.
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Affiliation(s)
- Rajbabu Pakala
- Cardiovascular Research Institute, Washington Hospital Center, 110 Irving Street, NW, Suite 4B-1, Washington, DC 20010, USA
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20
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Kuchulakanti P, Kapetanakis EI, Lew R, Rha SW, Cheneau E, Satler LF, Suddath WO, Pichard AD, Kent KM, Pakala R, Haile E, Corso P, Waksman R. Impact of continued hospitalization in patients pre-treated with clopidogrel prior to coronary angiography and undergoing coronary artery bypass grafting. J Invasive Cardiol 2005; 17:5-7. [PMID: 15640529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Pre-treatment of patients with clopidogrel prior to coronary angiography (CAG) and possible percutaneous coronary intervention (PCI) is a standard practice. Candidates for coronary artery bypass surgery (CABG) are discharged or remain in the hospital until CABG after clopidogrel is discontinued. We investigated whether any differences exist in the rates of surgical complications and outcomes between these two groups of patients. We conclude that continued hospitalization of clopidogrel pre-treated patients does not confer any safety benefit with regard to post-operative complications and 30-day mortality. Discharging these patients after CAG may reduce hospitalization costs.
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Affiliation(s)
- Pramod Kuchulakanti
- Department of Internal Medicine, Washington Hospital Center, Washington, DC 20010, USA
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21
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Cheneau E, Rha SW, Kuchulakanti PK, Stabile E, Kinnaird T, Torguson R, Pichard AD, Satler LF, Kent KM, Waksman R. Impact of sirolimus-eluting stents on outcomes of patients treated for acute myocardial infarction by primary angioplasty. Catheter Cardiovasc Interv 2005; 65:469-72. [PMID: 15988741 DOI: 10.1002/ccd.20395] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sirolimus-eluting stents (SESs) are currently being used in patients undergoing percutaneous coronary intervention (PCI). SESs have not been evaluated in the treatment of acute myocardial infarction by primary angioplasty. We report our initial experience with SESs implanted during primary angioplasty. One hundred and three patients were treated within 12 hr after onset of acute myocardial infarction (AMI) with primary angioplasty and SES implantation. Those patients were compared to 504 patients treated with bare metal stents (BMSs). Angiographic success (TIMI flow grade 3 and residual stenosis < 50%) was completed in 98% of patients with SESs and no subacute stent thrombosis was reported. In-hospital outcomes were similar in the SES and BMS groups. At 6 months, major cardiac events were less frequent in the SES group than in the BMS group (9% vs. 24%, respectively; P < 0.001), driven by a lesser need for repeat revascularization with SESs (1% vs. 10.3% with BMSs; P = 0.014). Mortality at 6 months was 7% with SESs and 11% with BMSs (P = 0.14). SESs are safe and effective for the treatment of AMI by primary angioplasty. As compared to BMSs, SESs improve long-term outcome after AMI, mainly by reducing the need for repeat revascularization.
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Affiliation(s)
- Edouard Cheneau
- Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA
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22
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Chu WW, Rha SW, Kuchulakanti PK, Cheneau E, Torguson R, Pakala R, Pinnow EE, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Selective versus exclusive use of sirolimus-eluting stent implantation in multivessel coronary artery disease. Catheter Cardiovasc Interv 2005; 65:473-7. [PMID: 15973656 DOI: 10.1002/ccd.20431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sirolimus-eluting stents (SESs; Cypher) have demonstrated a significant reduction in restenosis rates when compared to bare metal stents (BMSs). The purpose of this study was to evaluate the strategy of exclusive use of two SESs versus the combination of one BMS and one SES for two-vessel coronary artery disease (CAD). It was found that the selective use of one SES combined with one BMS in patients undergoing percutaneous coronary intervention that requires more than one stent is safe, feasible, and associated with favorable procedural, 30-day, and 6-month clinical outcomes when compared to the exclusive use of SESs.
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Affiliation(s)
- William W Chu
- Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA
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23
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Wolfram R, Cheneau E, Mintz GS, Pichard AD, Satler LF, Kent KM, Suddath WO, Pinnow EE, Waksman R. Angiographic and clinical outcomes of late total occlusion versus treatment failure without late total occlusion in patients after intracoronary radiation therapy for in-stent restenosis. Am J Cardiol 2004; 94:1551-4. [PMID: 15589015 DOI: 10.1016/j.amjcard.2004.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2004] [Accepted: 08/05/2004] [Indexed: 11/19/2022]
Abstract
This study aimed to compare the outcomes of patients with late total occlusion (LTO) versus patients with recurrence in the absence of LTO after intracoronary radiation therapy for in-stent restenosis. LTO, especially in the context of acute myocardial infarction, after intracoronary radiation therapy for in-stent restenosis, is associated with negative clinical outcomes after 6 and 12 months compared with in-stent restenosis without LTO.
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Affiliation(s)
- Roswitha Wolfram
- Cardiovascular Research Institute, Division of Cardiology, Washington Hospital Center, DC, USA
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24
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Kuchulakanti P, Rha SW, Satler LF, Suddath WO, Pichard AD, Kent KM, Weissman NJ, Cheneau E, Pakala R, Canos DA, Pinnow EE, Waksman R. Safety of percutaneous coronary intervention alone in symptomatic patients with moderate and severe valvular aortic stenosis and coexisting coronary artery disease: analysis of results in 56 patients. J Invasive Cardiol 2004; 16:688-91. [PMID: 15596870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Whether percutaneous coronary intervention (PCI) alone is safe in patients with moderate or severe aortic stenosis (AS) and coexisting coronary artery disease (CAD), and whether aortic valve replacement (AVR) can be deferred in patients with moderate AS by undergoing PCI alone is not known. We conducted a retrospective study of surgically inoperable patients with AS who underwent PCI (moderate AS, n = 28; and severe AS, n = 28) and compared to those with AVR (n = 55). The clinical characteristics, procedural complications, in-hospital and long-term clinical outcomes of PCI were compared. Baseline and procedural characteristics were similar except that lower age, hypertension, and renal impairment were seen in the AVR group. In-hospital complications were comparable among the 3 groups. Six-month and 1-year rates of myocardial infarction (MI), non-Q-wave MI, death and out-of-hospital death were similar between AVR and moderate AS patients (p = NS) and significantly high (p < 0.04) in patients with severe AS. On multivariate analysis, severe AS was the only significant predictor of 6-month and 1-year mortality. Our study suggests that PCI is safe in patients with moderate AS and coexisting CAD but is associated with poor outcomes in patients with severe AS.
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Affiliation(s)
- Pramod Kuchulakanti
- Division of Cardiology, Washington Hospital Center, 110 Irving Street, N.W., Suite 4B-1, Washington, DC 20010, USA
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25
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McFadden EP, Stabile E, Regar E, Cheneau E, Ong ATL, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM, Pichard AD, Satler LF, Waksman R, Serruys PW. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 2004; 364:1519-21. [PMID: 15500897 DOI: 10.1016/s0140-6736(04)17275-9] [Citation(s) in RCA: 986] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although the safety profiles of coronary stents eluting sirolimus or paclitaxel do not seem to differ from those of bare metal stents in the short-to-medium term, concern has arisen about the potential for late stent thromboses related to delayed endothelialisation of the stent struts. We report four cases of angiographically-confirmed stent thrombosis that occurred late after elective implantation of polymer-based paxlitaxel-eluting (343 and 442 days) or sirolimus-eluting (335 and 375 days) stents, and resulted in myocardial infarction. All cases arose soon after antiplatelet therapy was interrupted. If confirmed in systematic long-term follow-up studies, our findings have potentially serious clinical implications.
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26
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Rha SW, Kuchulakanti PK, Pakala R, Cheneau E, Fournadjiev JA, Pinnow E, Gebreeyesus A, Aggrey G, Wang Z, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Bivalirudin versus heparin as an antithrombotic agent in patients treated with a sirolimus-eluting stent. Am J Cardiol 2004; 94:1047-50. [PMID: 15476623 DOI: 10.1016/j.amjcard.2004.06.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Revised: 06/30/2004] [Accepted: 06/30/2004] [Indexed: 10/26/2022]
Abstract
Bivalirudin (Angiomax) is increasingly used as a substitute for heparin in a variety of percutaneous coronary interventions. This retrospective, observational study aimed to evaluate the efficacy and safety of bivalirudin compared with heparin as an antithrombotic regimen in patients treated with sirolimus-eluting stents (Cypher) and found that bivalirudin is clinically safe and feasible, with fewer vascular and ischemic complications compared with heparin.
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27
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Stabile E, Cheneau E, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM, Pichard AD, Satler LF, Waksman R. Late thrombosis in cypher stents after the discontinuation of antiplatelet therapy. ACTA ACUST UNITED AC 2004; 5:173-6. [PMID: 16237987 DOI: 10.1016/j.carrad.2004.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Drug-eluting stents, since their approval in the United States, have become the treatment of choice for de novo coronary artery narrowing due to their ability to reduce restenosis and the need for repeat revascularization. We present two patients who underwent percutaneous coronary intervention for the treatment of multivessel coronary artery disease; both patients were treated with sirolimus-eluting stents (SES) and bare metal stents (BMS).
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Affiliation(s)
- Eugenio Stabile
- Division of Cardiology, Washington Hospital Center, DC 20010, USA
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28
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Cheneau E, Mintz GS, Leborgne L, Kotani JI, Satler LF, Ajani AE, Weissman NJ, Waksman R, Pichard AD. Intravascular ultrasound predictors of subacute vessel closure after balloon angioplasty or atherectomy. J Invasive Cardiol 2004; 16:572-4. [PMID: 15505353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND Factors leading to subacute vessel closure after percutaneous coronary intervention (PCI) have not been well established in lesions treated with balloon angioplasty or atherectomy. METHODS AND RESULTS We used intravascular ultrasound (IVUS) to determine the pre- and post-PCI characteristics involved in subacute vessel closure after PCI. Of 3,403 patients undergoing IVUS imaging during coronary balloon angioplasty or atherectomy, 8 patients (0.2%) developed angiographically documented subacute vessel closure within 1 week post-PCI and were compared to a group matched by procedure date (within 6 months), age, gender, stable or unstable angina, lesion location and treatment (balloon angioplasty or atherectomy). IVUS identified at least one cause for subacute vessel closure in 87% of patients (vs 25% in matched lesions, p < 0.01). Causes were all procedure-related and included inadequate final lumen (60%), dissection (50%) and thrombus (25%). Pre-procedure lesion characteristics were not different from matched lesions. CONCLUSIONS Subacute vessel closure after balloon angioplasty or atherectomy is mostly related to insufficient post-procedure lumen dimension or dissection.
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Affiliation(s)
- Edouard Cheneau
- Cardiac Catheterization Laboratory, Washington Hospital Center, 110 Irving Street, N.W., Suite 4B-1, Washington, D.C. 20010-2975, USA.
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29
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Cheneau E, Canos D, Kuchulakanti PK, Rha SW, Satler LF, Suddath WO, Kent KM, Pichard AD, Waksman R. Value of monitoring activated clotting time when bivalirudin is used as the sole anticoagulation agent for percutaneous coronary intervention. Am J Cardiol 2004; 94:789-92. [PMID: 15374791 DOI: 10.1016/j.amjcard.2004.05.068] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2004] [Revised: 05/21/2004] [Accepted: 05/21/2004] [Indexed: 11/30/2022]
Abstract
Anticoagulation during percutaneous coronary intervention (PCI) requires the monitoring of activated clotting time (ACT) to protect from periprocedural ischemic and bleeding complications; however, the optimal ACT values have not been established when PCI is performed with bivalirudin. After 495 consecutive patients treated for coronary artery disease with PCI received bivalirudin as a single anticoagulation agent, it was found that ACT is reproducible when bivalirudin is used during PCI and does not correlate with clinical events.
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Affiliation(s)
- Edouard Cheneau
- Division of Cardiology, Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA
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30
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Waksman R, Fournadjiev J, Baffour R, Pakala R, Hellinga D, Leborgne L, Yazdi H, Cheneau E, Wolfram R, Seabron R, Horton K, Kolodgie F, Virmani R, Rivera E. Transepicardial autologous bone marrow-derived mononuclear cell therapy in a porcine model of chronically infarcted myocardium. ACTA ACUST UNITED AC 2004; 5:125-31. [PMID: 15721847 DOI: 10.1016/j.carrad.2004.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Accepted: 10/18/2004] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Cell therapy is becoming a viable strategy to improve revascularization and myocardial function after myocardial injury. We evaluated the effect of bone marrow-derived mononuclear cell (BMMNC) transplantation on collateral vessel development and myocardial function in a porcine model of chronically infarcted heart. METHODS Myocardial infarction was produced in 13 domestic swine. At 4 weeks, animals were randomized to receive transepicardial injections of autologous BMMNCs (approximately 24x10(6) cells, n=8) or phosphate buffered saline (PBS; control, n=5) into infarcted and border regions. Collateral growth, angiogenesis, and infarct size were assessed by angiography, immunohistochemistry, and histomorphometry. RESULTS Regional contractility was assessed by transepicardial echocardiography at baseline and 4 weeks following treatment. Angiography revealed a trend toward increased collateral growth in the BMMNC group. Wall motion score index (myocardial function) was similar in both groups at baseline (1.63+/-0.16 vs. 1.25+/-0.25, P=.21) and at 4 weeks (1.83+/-0.22 vs. 1.63+/-0.38, P=.62). alpha-Actin-positive smooth muscle cells (SMCs) and Factor VIII positive endothelial cells were significantly greater in the BMMNC-injected animals (314.8+/-37.4/0.1 vs. 167.1+/-11.9/0.1 mm(2) in controls, P=.02, and 363.3+/-28.2 cells/0.1 mm(2) vs. 254.4+/-28.1 cells/0.1 mm(2) in controls, P=.03, respectively). The number of blood vessels >50 mum in diameter was significantly increased in the BMMNC group (317.9+/-54.9 vs. 149.1+/-6.1, P<.05). The size of the infarct area was smaller in the BMMNC-transplanted group than in the controls (P=.015). CONCLUSION BMMNC transplantation appears to improve angiogenesis and reduce infarct size yet results in no improvement in left ventricular function in a chronically infarcted heart.
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Affiliation(s)
- Ron Waksman
- Washington Hospital Center, Suite 4B-1, 110 Irving Street, NW, Washington, DC 20010, USA.
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Pakala R, Kuchulakanti P, Rha SW, Cheneau E, Baffour R, Waksman R. Peroxisome proliferator-activated receptor γ: Its role in metabolic syndrome. ACTA ACUST UNITED AC 2004; 5:97-103. [PMID: 15464947 DOI: 10.1016/j.carrad.2004.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Revised: 03/25/2004] [Accepted: 03/25/2004] [Indexed: 10/26/2022]
Abstract
Here we review PPARgamma function in relation to human adipogenesis, insulin sensitization, lipid metabolism, blood pressure regulation and prothrombotic state to perhaps provide justification for this nuclear receptor remaining a key therapeutic target for the continuing development of agents to treat human metabolic syndrome.
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Affiliation(s)
- Rajbabu Pakala
- Cardiovascular Research Institute, Washington Hospital Center, 110 Irving Street NW, Suite 4B-1, Washington, DC 20010, USA
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Rha SW, Waksman R, Kuchulakanti PK, Ajani AE, White LR, Canos DA, Cheneau E, Mattox V, Abbott MC, Pinnow E, Pichard AD, Satler LF, Kent KM, Lindsay J. 880-6 Three-year follow-up after intracoronary gamma radiation for in-stent restenosis in saphenous vein grafts. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)90434-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Leborgne L, Cheneau E, Wolfram R, Pinnow EE, Canos DA, Pichard AD, Suddath WO, Satler LF, Lindsay J, Waksman R. Comparison of baseline characteristics and one-year outcomes between African-Americans and Caucasians undergoing percutaneous coronary intervention. Am J Cardiol 2004; 93:389-93. [PMID: 14969608 DOI: 10.1016/j.amjcard.2003.10.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2003] [Revised: 10/14/2003] [Accepted: 10/14/2003] [Indexed: 11/19/2022]
Abstract
The objectives of this study were to determine whether there are race-based differences in baseline characteristics and in short- or long-term outcomes after percutaneous coronary intervention (PCI). African-Americans have a higher incidence of coronary artery disease but are less likely to undergo coronary revascularization than Caucasians. Little is known about the profiles and outcomes of African-Americans who undergo PCI. Consecutive series of 1,268 African-Americans and 10,561 Caucasians with symptomatic coronary artery disease who underwent PCI between January 1994 and June 2001 were analyzed. Patients hospitalized for acute myocardial infarction were excluded. African-Americans were older, were more likely to be women, and had more co-morbid baseline conditions compared with Caucasians. Preprocedure lesion characteristics were similar with regard to vessel size, length, and complexity. The rate of clinical success did not differ between the groups. African-Americans experienced more in-hospital combined events of death and Q-wave myocardial infarction (p = 0.03). After propensity score adjustment, African-American race was not an independent predictor for in-hospital events. At 1 year, African-Americans had a slightly lower rate of target lesion revascularization and a 50% higher rate of death (9.8% vs. 6.4%, p <0.001), with a relative risk of 1.52 (95% confidence interval 1.22 to 1.89). In multivariate analysis, African-American race remained a significant predictor of increased 1-year mortality (hazard ratio 1.35, 95% confidence interval 1.06 to 1.71, p = 0.01). African-Americans undergoing angioplasty have more co-morbid baseline conditions than Caucasians. Despite similar clinical success, 1-year outcomes are impaired in African-Americans.
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Affiliation(s)
- Laurent Leborgne
- Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
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Ajani AE, Waksman R, Sharma AK, Lew R, Pinnow E, Canos DA, Cheneau E, Castagna M, Cha DH, Leborgne L, Satler LF, Pichard AD, Kent KM, Lindsay J. Usefulness of periprocedural creatinine phosphokinase-MB release to predict adverse outcomes after intracoronary radiation therapy for in-stent restenosis. Am J Cardiol 2004; 93:313-7. [PMID: 14759380 DOI: 10.1016/j.amjcard.2003.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2003] [Revised: 10/06/2003] [Accepted: 10/06/2003] [Indexed: 11/18/2022]
Abstract
We aimed to analyze periprocedural creatinine phosphokinase (CPK)-MB elevation in patients treated with intracoronary radiation therapy (IRT) for in-stent restenosis (ISR) to risk stratify these patients. The clinical significance of periprocedural CPK-MB elevation after IRT for ISR is unknown. An elevated CPK-MB has been associated with increased mortality after conventional angioplasty. We evaluated 1,326 patients who were enrolled in radiation trials for ISR at the Washington Hospital Center using gamma- and beta-emitters. Patients were analyzed according to degree of CPK-MB increase within 24 hours of the index IRT procedure (normal CPK-MB, CPK-MB 1 to 3 times the upper limit of normal, or CPK-MB >3 times the upper limit of normal). Patients with CPK-MB >3 times the upper limit of normal were older (64 +/- 12 years, p = 0.04), more likely to be smokers (64%, p = 0.04), hypertensive (85%, p <0.01), and diabetic (49%, p = 0.04). The cohort with the highest CPK-MB release (CPK-MB >3 times the upper limit of normal) had significantly higher rates of adverse clinical events at 12 months (major adverse cardiac events 40%, p <0.01), including death (9.3%, p <0.01) and late thrombosis (6.3%, p <0.01). Periprocedural CPK-MB elevation is of prognostic importance in patients treated with IRT for ISR, and its analysis appears to be mandatory to risk stratify these patients. The impact of glycoprotein IIb/IIIa antagonists in reducing periprocedural CPK-MB release awaits evaluation.
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Cheneau E, Canos D, Pinnow E, Ajani AE, Satler LF, Pichard AD, Kent KM, Lindsay J, Waksman R. Impact of radiation dose on late clinical outcome after intracoronary radiation therapy: Three-year follow-up of Long WRIST. Catheter Cardiovasc Interv 2004; 62:318-22. [PMID: 15224297 DOI: 10.1002/ccd.20072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To determine the safety and efficacy, including the impact, on the late recurrence rate of an incremental gamma-radiation dose from 15 to 18 Gy, we report the 3-year clinical outcome of Washington Radiation for In-Stent Restenosis Trial for Long Lesions (Long WRIST). One hundred eighty patients with recurrent in-stent restenosis (ISR) were enrolled in the Long WRIST series and treated with (192)Ir with 1 month of antiplatelet therapy. Between 6 months and 3 years, the need for repeat revascularization was low and similar among the three groups. At 3 years, target lesion revascularization (TLR) and major adverse cardiac events (MACE) were less frequent in the 18 Gy group than in the 15 Gy group (P = 0.12 for TLR, P < 0.05 for MACE) and less frequent in the 15 Gy group as compared to the placebo group (P < 0.05 for TLR and MACE). At 3 years, a higher dose of 18 Gy with (192)Ir continues to improve the outcome of patients treated for ISR when compared to patients treated with 15 Gy or placebo.
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Affiliation(s)
- Edouard Cheneau
- Division of Cardiology, Washington Hospital Center, Washington, District of Columbia, USA
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Cheneau E, Pichard AD, Stabile E, Waksman R. Asymptomatic late stent thrombosis after sirolimus stent implantation. Cardiovasc Radiat Med 2004; 5:57-8. [PMID: 15495372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Cheneau E, Leborgne L, Canos D, Pichard AD, Satler LF, Suddath WO, Kent KM, Lindsay J, Weissman N, Waksman R. Impact of intravascular ultrasound-guided direct stenting on clinical outcome of patients treated for native coronary disease. ACTA ACUST UNITED AC 2004; 5:15-9. [PMID: 15275627 DOI: 10.1016/j.carrad.2004.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Accepted: 03/22/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite the fact that in animal models direct stenting (DS) reduces the vessel injury, in clinical practice this treatment strategy did not reduce late restenosis as compared to conventional strategy with balloon predilatation (PD). However, the influence of DS was not evaluated when stent expansion is optimized by intravascular ultrasound (IVUS) assessment. METHODS We analyzed the in-hospital and 1-year outcomes of patients at Washington Hospital Center who were treated with percutaneous coronary interventions and stent implantation when percutaneous intervention was guided by IVUS. Only patients treated for single de novo lesions were included. RESULTS In 1386 patients, 251 (18.1%) were treated with DS and 1135 (71.9%) were treated with PD. Pre- and postprocedure characteristics by angiography and IVUS were similar in both groups. Postprocedure non-Q-wave myocardial infarction (MI) occurred in 4.9% of the DS group and in 12.5% of the PD group (P = .005). At 1-year follow-up, target lesion revascularization (TLR) rate was 4.9% in the DS group and 14.8% in the PD group (P = .005). DS strategy (odds ratio = .46, confidence interval = .25-.85, P = .013) was independently correlated to lower risk for revascularization in multivariate analysis. CONCLUSION When DS is implemented by IVUS assessment, it is associated with low in-hospital and long-term events.
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Affiliation(s)
- Edouard Cheneau
- Washington Hospital Center, 110 Irving Street, NW, Suite 4B-1, Washington, DC, 20010, USA
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Wolfram R, Cheneau E, Lew R, Chan R, Pichard AD, Satler LF, Kent KM, Dilcher C, Pinnow E, Bui A, Waksman R. Effects of gamma radiation on the noninjured and unprotected left main. Catheter Cardiovasc Interv 2004; 61:477-81. [PMID: 15065141 DOI: 10.1002/ccd.10745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this study was to evaluate the effect of gamma radiation on the noninjured, unprotected left main coronary artery. Noninjured vessel segments are often radiated during treatment of in-stent restenosis with PCI and gamma radiation. Angiographic analysis using QCA methods was performed on 55 left main arteries of patients (32 with radiation of the left main compared to 23 controls) who participated in the Washington Radiation for In-Stent Restenosis Trials (WRIST). Baseline demographics and follow-up were comparable between the two groups, concluding that gamma radiation with long radiation safety margins is feasible and safe. Gamma radiation of noninjured irradiated left main vessels when used to facilitate wide radiation margins for proximal irradiated injured LAD and LCx is safe and does not compromise the vessel integrity and its lumen.
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Affiliation(s)
- Roswitha Wolfram
- Washington Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
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Wolfram R, Leborgne L, Cheneau E, Pinnow EE, Canos DA, Hellinga D, Satler LF, Pichard AD, Kent KM, Waksman R. Comparison of effectiveness and safety of three different antithrombotic regimens (bivalirudin, eptifibatide, and heparin) in preventing myocardial ischemia during percutaneous coronary intervention. Am J Cardiol 2003; 92:1080-3. [PMID: 14583359 DOI: 10.1016/j.amjcard.2003.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this retrospective, observational analysis was to compare the efficacy and safety of 3 antithrombotic regimens: bivalirudin, eptifibatide plus heparin, and heparin alone, with emphasis on preventing interventional procedural creatinine kinase-MB fraction (CK-MB) release, and consequently, myocardial necrosis.
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Affiliation(s)
- Roswitha Wolfram
- Cardiovascular Research Institute, Division of Cardiology, Washington Cancer Center, Washington, DC, USA
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Wolfram R, Leborgne L, Cheneau E, Pichard A, Satler L, Kent K, Waksman R. Comparison of creatine kinase elevation and outcome of comparison of percutaneous coronary intervention for saphenous vein graft in-stent restenosis versus de novo stenosis. Am J Cardiol 2003; 92:980-3. [PMID: 14556879 DOI: 10.1016/s0002-9149(03)00984-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Percutaneous coronary intervention of saphenous vein grafts is associated with distal embolization. We aimed to compare potential differences in patients undergoing percutaneous coronary intervention for in-stent restenosis with de novo saphenous vein graft lesions. Myocardial necrosis was associated with higher mortality regardless of lesion type.
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Kuchulakanti P, Rha SW, Cheneau E, Satler L, Pichard A, Kent K, Waksman R. Identification of “vulnerable plaque” using virtual histology in angiographically benign looking lesion of proximal left anterior descending artery. ACTA ACUST UNITED AC 2003; 4:225-7. [PMID: 15329976 DOI: 10.1016/j.carrad.2004.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Leborgne L, Cheneau E, Pichard A, Ajani A, Pakala R, Yazdi H, Satler L, Kent K, Suddath WO, Pinnow E, Canos D, Waksman R. Effect of direct stenting on clinical outcome in patients treated with percutaneous coronary intervention on saphenous vein graft. Am Heart J 2003; 146:501-6. [PMID: 12947370 DOI: 10.1016/s0002-8703(03)00309-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with frequent postprocedural enzyme elevation and late cardiac events. New strategies are proposed to minimize distal embolization and to improve the outcome of patients treated with stenting for SVG lesions. The objectives of the current study were to examine direct stenting (DS) strategy of PCI in SVG lesions and its effects on creatine-kinase (CK) release, major adverse cardiac events (MACE), and late outcome when compared to conventional stenting (CS). METHODS A consecutive series of 527 patients treated with stent implantation for SVG stenosis was analyzed. In this cohort, 170 patients with 229 lesions were treated with DS and 357 patients with 443 lesions were treated with CS. The inhospital and 12-month follow-up events were recorded and reported. RESULTS Baseline clinical and postprocedural angiographic characteristics were similar between the 2 groups except for higher preprocedural prevalence of thrombus-containing lesions in the DS group. Patients in the DS group had less CK-MB release (P <.001), and less non-Q-wave myocardial infarction (P =.024). Multivariate analysis detected unstable angina (odds ratio [OR] = 1.8, P =.03) as a correlate for non-Q-wave MI; DS was inversely associated with non-Q-wave myocardial infarction (OR = 0.65, P =.04). At 1 year, the target lesion revascularization-MACE was significantly lower in the DS group (P =.021). Multivariate analysis showed that DS (OR = 0.47, P =.007) was associated with reduction of the target lesion revascularization-MACE. CONCLUSIONS When feasible, DS may be the best approach for treating SVG stenosis.
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Affiliation(s)
- Laurent Leborgne
- Cardiovascular Research Institute, Division of Cardiology, Washington Hospital Center, Washington, DC 20100, USA
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Cheneau E, Leborgne L, Mintz GS, Kotani JI, Pichard AD, Satler LF, Canos D, Castagna M, Weissman NJ, Waksman R. Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. Circulation 2003; 108:43-7. [PMID: 12821553 DOI: 10.1161/01.cir.0000078636.71728.40] [Citation(s) in RCA: 343] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Factors leading to subacute stent thrombosis after percutaneous coronary intervention (PCI) have not been well established. We assessed the pre- and post-PCI intravascular ultrasound (IVUS) characteristics of subacute stent thrombosis. METHODS AND RESULTS We analyzed 7484 consecutive patients without acute myocardial infarction who were treated with PCI and stenting and underwent IVUS imaging during the intervention. Twenty-seven (0.4%) had angiographically documented subacute closure <1 week after PCI (median time to subacute closure, 24 hours). Subacute closure lesions were compared with a control group (selected to be 3 times the abrupt closer group) matched by procedure date (within 6 months), age, gender, stable or unstable angina, lesion location, and additional treatment (balloon angioplasty or atherectomy). Postintervention IVUS did not identify a cause in 22% and did identify at least 1 cause for abrupt closure in 78% of patients (versus 33% in matched lesions, P=0.0002). In 48% of the patients, there were multiple causes in 48% (versus 3% in matched lesions, P<0.0001). Causes included dissection (17%), thrombus (4%), and tissue protrusion within the stent struts leading to lumen compromise lumen (4%). A total of 83% of patients with >1 of these abnormal morphologies also had reduced lumen dimensions post-PCI (final lumen <80% reference lumen). Preprocedural lesion characteristics were not different from matched lesions. CONCLUSIONS Subacute stent thrombosis is infrequently related to the preintervention lesion characteristics. Inadequate postprocedure lumen dimensions, alone or in combination with other procedurally related abnormal lesion morphologies (dissection, thrombus, or tissue prolapse), contribute to this phenomenon.
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Affiliation(s)
- Edouard Cheneau
- Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
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Cheneau E, Wu Z, Leborgne L, Ajani AE, Weissman N, Pichard AD, Satler LF, Kent KM, Mintz G, Waksman R. Additional stenting promotes intimal proliferation and compromises the results of intravascular radiation therapy: an intravascular ultrasound study. Am Heart J 2003; 146:142-5. [PMID: 12851623 DOI: 10.1016/s0002-8703(03)00147-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Vascular brachytherapy (VBT) reduces in-stent restenosis (ISR). However, additional stenting at the time of radiation may be associated with a worse outcome. METHODS AND RESULTS Intravascular ultrasound (IVUS) was performed after VBT and at 6 months follow-up in 79 native artery ISR patients treated with gamma-radiation who participated in the Washington Radiation for In-Stent restenosis Trial (WRIST), Gamma-1, and Angiorad Radiation Technology for In-Stent restenosis Trial in Coronaries (ARTISTIC) trials. Patients were treated with (192)Ir at 14 or 15 Gy at 2 mm from the source. Additional stents were used to treat the ISR lesions in 45 patients; these patients were then compared with the 34 patients treated without restenting. Paired measurements included stent, lumen, and intimal hyperplasia volumes. After the VBT procedure, intimal hyperplasia volume was smaller in the group treated with additional stents (54 +/- 33 mm(3) vs 34 +/- 33 mm(3), P =.012), but minimal lumen area was similar between the 2 groups (4.3 +/- 1.5 mm(2) vs 4.7 +/- 1.4 mm(2) respectively, P = NS). Between the time of the VBT procedure and follow-up, intimal hyperplasia volume increased by 27 +/- 19 mm(3) in the restented group and by 9 +/- 21 mm(3) in the group treated without additional stents (P =.014). At 6 months, intimal volume was similar in the 2 groups, but minimal lumen area was slightly smaller in the group treated with additional stents (3.4 +/- 1.8 mm(2) vs 4.2 +/- 1.7 mm(2), P =.053). Patients treated with additional stents had more target lesion revascularizations than the group treated without additional stents (38% vs 15%, P =.02). CONCLUSIONS Additional stenting reduces intimal hyperplasia within the stents acutely. However, it compromises the benefit of VBT by promoting higher intimal regrowth within months after radiation.
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Pakala R, Leborgne L, Cheneau E, Chan RC, Yazdi H, Fournadjiev J, Weber D, Hellinga D, Kolodgie F, Virmani R, Waksman R. Radiation-Induced Atherosclerotic Plaque Progression in a Hypercholesterolemic Rabbit. ACTA ACUST UNITED AC 2003; 4:146-51. [PMID: 14984715 DOI: 10.1016/s1522-1865(03)00182-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Human observations provide rich soil for making hypotheses, but good animal models are essential for understanding the disease and to test treatment modalities. Currently, there is no standard animal model of vulnerable plaque; therefore, the purpose of this study is to develop a pathophysiologically relevant vulnerable plaque model. METHODS New Zealand White rabbits were fed with 1% hypercholesterolemic (HC) diet for 7 days, followed by balloon denudation of both the iliac arteries, and continued on 1% HC diet. Four weeks later, in 12 rabbits one of the iliac arteries was radiated (192-Ir, 15 Gy), and in five rabbits both the iliac arteries were sham treated. Following that, rabbits were fed with 0.15% HC diet. Four weeks later, arteries were processed for histomorphometry or immunohistochemistry. RESULTS Serum cholesterol levels were similar in all the groups. In radiated arteries, plaque area was significantly larger (32% larger then in sham). Macrophage-positive area in radiated arteries was 2.4 times greater than the macrophage-positive area in the nonradiated arteries. The area positive for macrophages is also positive for metalloproteinases (MMP)-1. The extent of alpha-actin positive area was significantly less (2.3-fold) in radiated arteries. CONCLUSION The atherosclerotic plaque developed in the current model is predominantly composed of macrophages expressing metalloproteinases with few smooth muscle cells (SMC)--a characteristic of vulnerable plaque. The animal model presented in this study can elucidate at least part of the mechanism of plaque vulnerability and could be used to test treatment modalities to test plaque stability.
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Affiliation(s)
- Rajbabu Pakala
- Cardiovascular Research Institute, Washington Hospital Center, 110 Irving Street, NW, Suite 4B-1, Washington, DC 20010, USA
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Cha DH, Malik IA, Cheneau E, Ajani AE, Leborgne L, Wolfram R, Porrazzo M, Satler LF, Kent KM, Pichard AD, Pinnow E, Lindsay J, Waksman R. Use of restenting should be minimized with intracoronary radiation therapy for in-stent restenosis. Catheter Cardiovasc Interv 2003; 59:1-5. [PMID: 12720231 DOI: 10.1002/ccd.10490] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Restenting at the time of intracoronary radiation therapy (IRT) for in-stent restenosis (ISR) potentially increases the risk of late total occlusion (LTO) of the treated vessel. Prolonged antiplatelet therapy with clopidogrel (6 months) has been shown to be effective in reducing LTO risk. The purpose of this study was to assess the impact of restenting on clinical outcomes following IRT for ISR with 6 months of clopidogrel. We retrospectively evaluated 1,275 patients with 6-months clinical follow-up who were enrolled in radiation trials for ISR using gamma- and beta-emitters conducted at Washington Hospital Center. Patients were analyzed according to whether additional stents were deployed at the time of IRT. The predominant indication for restenting was to optimize the final angiographic result in the event of tissue prolapse or to cover edge dissections. All patients received a minimum of 6 months of clopidogrel. Baseline clinical and angiographic characteristics were similar between the restented and nonrestented groups. Radiation was delivered successfully in all cases. At 6 months, patients treated with additional stents and IRT had a significantly higher rate of target vessel revascularization than patients without additional stents (24.6% vs. 18.7%; P = 0.011). Restenting caused more frequent late thrombosis, late total occlusion, and Q-wave myocardial infarction than no restenting (4.0% vs. 2.2%, P = 0.09; 6.1% vs. 4.3%, P = 0.14; and 1.9% vs. 0.4%, P = 0.009, respectively). Restenting for the treatment of ISR is associated with increased adverse events and should be avoided after intracoronary radiation therapy for in-stent restenosis, as restenting results in a higher recurrence rate and the potential for increased late total occlusion.
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Affiliation(s)
- Dong-Hun Cha
- Department of Cardiology, Washington Hospital Center, Washington, D.C., USA
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Cheneau E, John MC, Fournadjiev J, Chan RC, Kim HS, Leborgne L, Pakala R, Yazdi H, Ajani AE, Virmani R, Waksman R. Time course of stent endothelialization after intravascular radiation therapy in rabbit iliac arteries. Circulation 2003; 107:2153-8. [PMID: 12695306 DOI: 10.1161/01.cir.0000062648.39025.09] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Late total occlusion after vascular brachytherapy (VBT) continues to be a serious complication. Delayed reendothelialization was suggested as a pivotal cause, but the time course for complete healing is unknown. METHODS AND RESULTS Seventy-two rabbit iliac arteries underwent stent implantation and were treated with gamma-radiation using 192Ir. The prescribed doses were 0 Gy (controls, n=24 arteries), 15 Gy (n=24), or 30 Gy (n=24) at 2 mm. Animals were killed at 1 month (n=24), 3 months (n=24), or 6 months (n=24) and were analyzed for histomorphometry or scanning electron microscopy. Intimal area was reduced after VBT at 3 months with 15 and 30 Gy (0.66+/-0.07 and 0.66+/-0.04 mm2, respectively) compared with controls (1.01+/-0.11 mm2, P<0.05) and at 6 months with 30 Gy (0.75+/-0.09 versus 1.28+/-0.26 mm2 in controls, P<0.01). Intimal area was similar at 6 months between 15 Gy and controls. At 1 month, 92+/-4% of the control stented segment was covered with endothelial cells, whereas only 37+/-4% and 37+/-8% was covered in the 15- and 30-Gy arteries, respectively. Similarly, at 3 and 6 months, there was a difference in the extent of reendothelialized areas (at 3 months, 95+/-2%, 32+/-12%, and 29+/-13%; and at 6 months, 98+/-2%, 40+/-8%, and 35+/-12% in control, 15-Gy, and 30-Gy arteries, respectively). Excess platelets and leukocytes were seen in irradiated arteries without complete coverage of endothelium. CONCLUSIONS Reendothelialization after VBT is not completed at 6 months after VBT. Special care with prolonged antiplatelet therapy should be considered beyond that time point.
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Affiliation(s)
- Edouard Cheneau
- Cardiovascular Research Institute, Washington Hospital Center, 110 Irving St, NW, Suite 4B-1, Washington, DC 20010, USA
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Waksman R, Cheneau E, Ajani AE, White RL, Pinnow E, Torguson R, Deible R, Satler LF, Pichard AD, Kent KM, Teirstein PS, Lindsay J. Intracoronary radiation therapy improves the clinical and angiographic outcomes of diffuse in-stent restenotic lesions: results of the Washington Radiation for In-Stent Restenosis Trial for Long Lesions (Long WRIST) Studies. Circulation 2003; 107:1744-9. [PMID: 12665490 DOI: 10.1161/01.cir.0000060497.91775.6d] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Washington Radiation for In-Stent Restenosis Trial for long lesions (Long WRIST) was designed to determine the safety and efficacy of vascular brachytherapy for the treatment of diffuse in-stent restenosis. METHODS AND RESULTS A total of 120 patients with diffuse in-stent restenosis in native coronary arteries (lesion length, 36 to 80 mm) were randomized for either radiation with 192Ir with 15 Gy at 2 mm from the source axis or placebo. After enrollment, 120 additional patients with the same inclusion criteria were treated with 192Ir with 18 Gy and included in the Long WRIST High Dose registry. Antiplatelet therapy was initially prescribed for 1 month and was extended to 6 months in the last 60 patients of the Long WRIST High Dose registry. At 6 months, the binary angiographic restenosis rate was 73%, 45%, and 38% in the placebo, 15 Gy, and 18 Gy radiated groups, respectively (P<0.05). At 1 year, the primary clinical end point of major cardiac events was 63% in the placebo group and 42% in the radiated group with 15 Gy (P<0.05). The major cardiac event rate was further reduced with 18 Gy (22%; P<0.05 versus 15 Gy). Late thrombosis was 12%, 15%, and 9% in the placebo group, 15 Gy group with 1 month of antiplatelet therapy, and 18 Gy group with 6 months of antiplatelet therapy, respectively. CONCLUSIONS Vascular brachytherapy with 192Ir is safe and reduces the rate of recurrent restenosis in diffuse in-stent restenosis. The efficacy of vascular brachytherapy on angiographic and clinical outcomes is enhanced with a radiation dose of 18 Gy and prolonged antiplatelet therapy.
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Affiliation(s)
- Ron Waksman
- Washington Hospital Center, 110 Irving St, NW, Suite 4B-1, Washington, DC 20010, USA.
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Sharma AK, Ajani AE, Garg N, Cheneau E, Wolfram R, Chan R, Pinnow E, Canos D, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Usefulness of gamma intracoronary radiation for totally occluded in-stent restenotic coronary narrowing. Am J Cardiol 2003; 91:595-7. [PMID: 12615269 DOI: 10.1016/s0002-9149(02)03315-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Arvind K Sharma
- Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA
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Ajani AE, Waksman R, Cheneau E, Cha DH, McGlynn S, Castagna M, Chan RC, Satler LF, Kent KM, Pichard AD, Pinnow E, Lindsay J. The outcome of percutaneous coronary intervention in patients with in-stent restenosis who failed intracoronary radiation therapy. J Am Coll Cardiol 2003; 41:551-6. [PMID: 12598064 DOI: 10.1016/s0735-1097(02)02859-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study reports the outcome of patients who failed intracoronary radiation therapy (IRT) for the treatment of in-stent restenosis (ISR). BACKGROUND Intracoronary radiation therapy has demonstrated a reduction in the recurrence rate of restenosis for patients with ISR. However, 10% to 30% of these patients require repeat intervention to the irradiated site. METHODS Of 961 patients who were assigned to gamma or beta radiation for the treatment of diffuse ISR, we evaluated the outcome of 282 (29%) consecutive patients who failed IRT and compared them with the 679 (71%) patients who had successful IRT. For patients who failed radiation, the mean time to the first target vessel revascularization (TVR) was 173 +/- 127 days after the index procedure and the total duration of follow-up was 494 +/- 304 days. RESULTS Patients who failed IRT were younger (60 +/- 10 vs. 63 +/- 11 years, p = 0.002) and had a higher incidence of restenting (51% vs. 41%, p = 0.003). The majority (55%) of the restenotic lesions after IRT failure were focal (< or =10 mm), with a mean lesion length of 11.9 +/- 1.9 mm. Of the 257 patients who had subsequent TVR after failed IRT, 68 (26%) underwent coronary artery bypass grafting and 189 (74%) underwent percutaneous coronary intervention using balloon in 61%, restenting in 26%, atheroablation in 11%, and the cutting balloon in 2% of cases. At six months, 6% of patients died, 1% had Q-wave MI, 17% had repeat TVR, and the overall rate of major adverse cardiac events was 21%. CONCLUSIONS The predominant angiographic pattern of lesions in patients who failed IRT is focal restenosis, with these lesions responding well to conventional revascularization methods.
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Affiliation(s)
- Andrew E Ajani
- Division of Cardiology, Washington Hospital Center, 110 Irving Street NW, Washington, D.C. 20010, USA
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