Non-invasive characterization of pancoronary inflammation by computed tomography angiography in patients with recent spontaneous coronary dissection

Background

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction of unclear aethiology. Histopathological analyses have identified increased coronary inflammation in patients with SCAD [1]. Recently the peri-coronary adipose tissue attenuation (PCAT) derived from standard computed tomography angiography (CTA) has been established as a reproducible method for measuring vascular inflammation which enhances risk stratification in patients with coronary atherosclerosis [2].

Purpose

To characterize the pancoronary and vessel-specific inflammation by means of CTA-derived PCAT in patients with recent SCAD compared with individuals without prior SCAD.

Methods

Patients with confirmed SCAD referred to a tertiary center between 2017 and 2021 who underwent CTA as a routine cardiac evaluation were included in this retrospective study. Subjects were matched 1:1 with individuals with no prior SCAD who underwent CTA within the same timespan, using the same scanner and imaging protocol, with coronary arteries free of obstructive disease and similar clinical characteristics (Table 1). PCAT was analyzed on end-diastolic CTA reconstructions with a semi-automated software using standard methodology (Figure 1A) [3]. Proximal 40 mm of all major coronary vessels >2 mm in diameter as well as the SCAD-related vessel were included. The primary outcome was pancoronary PCAT defined as mean PCAT in the right (RCA), left anterior descending (LAD) and circumflex (LCX) artery. Secondary outcome was vessel-specific PCAT defined as PCAT in RCA and averaged PCAT in LAD and LCX (PCAT LCA).

Results

The final cohort comprised 35 patients with recent SCAD (median 6.1 mo. [4.0–16.8] since SCAD, 94.3% female) and 35 patients in the non-SCAD group. Pancoronary PCAT was higher in patients with SCAD compared with non-SCAD group (−80.1 [IQR: −74.5, −84.6] vs. −83.4 HU [−78.7, −88.0], P=0.008) suggestive of increased coronary inflammation. Vessel-specific PCAT was higher for the RCA (−80.7 [−70.4, −86.9] vs. −85.3 [−80.4, −90.6] HU, P<0.001) and borderline higher for the LCA (−79.2 [−73.9, −83.2] vs. −83.4 [−78.0, −88.3] HU, P=0.056) in patients with SCAD compared with non-SCAD respectively (Figure 1B). In patients with SCAD, PCAT in previously dissected vessel was not significantly different from averaged PCAT in unaffected vessels (−78.4 [−73.7, −89.0] vs. −80.9 [−74.9, −83.3], P=0.77; Figure 1C). While PCAT numerically decreased with time since SCAD, the association was not statistically significant when patients were stratified into tertiles according to time from SCAD (Figure 1D).

Conclusions

Patients with recent SCAD have higher pericoronary adipose tissue attenuation compared with non-SCAD patients suggesting increased perivascular inflammatory activity. This association is not restricted to the dissected vessel, nor reflected in routine serum inflammatory analysis and persists over time.

Funding Acknowledgement

Type of funding sources: None.

Intravascular ultrasound for valve frame expansion and orifice area measurement as well as paravalvular leak assessment during transcatheter aortic valve replacement

Introduction

Valve frame expansion (measured outer valve frame area/nominal valve dimension), but not oversizing (nominal valve dimension/annulus area, %) determines pattern of restored blood flow after transcatheter aortic valve replacement (TAVR). There is no online measure of frame expansion, and error in current echocardiographic assessment of effective orifice area (EOA) and paravalvular leak (PVL) are common.

Purpose

To evaluate large imaging field intravascular ultrasound (IVUS) during TAVR for measuring valve geometry [frame expansion, minimal geometric orifice area (min GOA), and mechanism of PVL] with transthoracic echo and angio-CT serving for comparative measures, along with the nominal EOA as established by Hahn et al.

Methods

After successful TAVR either a 10MHz Vision PV 0.035" (60mm imaging field) or 20MHz Vision PV 0.018" (24mm imaging field plus Chr omaFlo) IVUS catheter (Philips) was slowly pulled from the left ventricle outflow (LVOT) to the aorta with continuous imaging of the aortic root.

Results

There were 16 pts (80.8±7.1 yrs, 8 female) treated for de novo aortic stenosis (n=15) or failed bioprosthesis (n=1), 7 of whom were treated with balloon-expandable TAVR. PV 0.35" catheters were used in 8 pts (including valve-in-valve) and allowed complete geometry assessment of 26.6±2.7mm nominal prosthesis Ø (Figure 1A) whereas PV 0.018" allowed complete geometry assessment in only 4 of 8 pts with nominal prosthesis Ø of 26.1±2.8mm (Figure 1B). Actual % valve inflow expansion (IVUS outer frame/valve nominal dimension) was significantly smaller than % valve oversizing (80%±19% vs 125±19%, p=0.005). Min GOA was substantially bigger than corresponding nominal EOA and EOA calculated using the post-procedural LVOT diameter (272±84mm2 vs 174±25mm2 vs 181±59mm2, p=0.001 correspondingly). However, min GOA was similar to EOA calculated using baseline LVOT area (272±84mm2 vs 230±90mm2; r=0.713, p=0.009). IVUS and angio-CT measurements of outer prosthesis frame area were similar for inflow, coaptation site, and outflow (460±143mm2 vs 454±134mm2 and 455±134mm2 vs 447±114mm2 and 722±174mm2 vs 725±180; p≤0.001 for all paired correlations). Inflow expansion (IVUS outer frame/baseline CT annulus area) tended to be smaller among valves with ≥mild vs no PVL (95±14% vs 107±11%, p=0.156), with clear ChromaFlo signal seen in the space between the aortic annulus wall and outer-valve frame surface (Figure 1C).

Conclusions

Large imaging field IVUS during TAVR allows for peri-procedural assessment of actual valve geometry that differs substantially from nominal. IVUS offers online tomographic perspective and highest accuracy in anatomy evaluation corresponding with valve function.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Impact of annular and cusps calcification on occurrence of paravalvular leak after transcatheter aortic valve replacement with intra- versus supra-annular devices

Introduction

Severe annular and valve cusps calcification is frequent among patients treated with transcatheter aortic valve replacement (TAVR). Severe annular calcification increases the risk of paravalvular leak (PVL) and was associated with worse outcomes. Whether it is accompanied by an independent effect of calcifications localized on cusps and whether the impact of cusps/annular calcification depends on supra vs intra-annular valve design is unknown.

Purpose

To assess the impact of cusps/annular calcifications on occurrence of moderate PVL after successful TAVR with devices of either intra- or supra-annular design.

Methods

282 consecutive patients (80.3±7.6 yrs, 63% female) with baseline 384-slice CT scan were successfully treated with TAVR between Jul 2012 and Oct 2017, either with intra-annular or supra-annular devices. Severe annular calcification (clear protrusion) and severe cusps calcification (Rosenhek 4 score) were identified using a Syngo Via.

Results

138 (48.9%) patients were treated with intra-annular and 144 (51.15) with supra-annular devices. Whereas severe annular calcification was similar (23.9% vs 20.1%), there was more severe cusps calcification among intra-annular valves (52.9% vs 41.7%, p=0.073). Intra-annular devices were used less frequently among bicuspid aortic valves, were also of smaller diameter, less frequently deployed after pre-dilation, and less frequently post-dilated. Post-procedure mean aortic gradient tended to be higher among intra-annular devices. Moderate PVL was less frequent among intra- vs supra-annular valves (14.5% vs 34.0%, p<0.001). However, PVL occurrence was higher (30.3%) among those (33/138, 23.9%) treated with an intra-annular valve who had severe annular calcification vs 9.5% in pts treated with an intra-annular TAVR who did not have severe annular calcification (p=0.008) unlike in patients treated with a supra-annular valve who had a high frequency of PVL with or without severe annular calcium (37.9% vs 33.0%). After excluding patients with severe annular calcium (n=62, 22%), moderate PVL was similar between those with vs without severe cusp calcification whether treated with intra- or supra-annular valves (11.8% vs 7.4% and 29.3% vs 35.1%, respectively). Combined VARC-2 safety endpoints plus 2-yr mortality occurrence were lower for intra- vs supra-annular devices (30.4% vs 43.8%, p=0.026).

Conclusions

Moderate PVL after intra-annular TAVR device deployment occurs in 30% of patients with protruding annular calcification. Severe cusps calcification unaccompanied by annular calcium was not associated with PVL occurrence. Higher frequency of moderate PVL (34%) seen after supra-annular valve deployment appears to be related to other parameters rather than presence of severe annular or cusps calcification.

Funding Acknowledgement

Type of funding source: None

Inter-ethnic differences in normal coronary anatomy between Caucasian (Polish) and Asian (Korean) populations

PURPOSE

Little is known about ethnic differences in the size of coronary arteries in disease-free individuals. Our aim was to compare coronary artery dimensions between Asian and Caucasian population without atherosclerosis.

METHODS

One hundred and twelve Caucasian patients without any discernible atherosclerosis detected on coronary computed tomography angiography were matched with 112 Asian patients using sex, age, coronary dominance pattern and body surface area (BSA). Maximal and minimal lumen areas (LA) and diameters (LD) of proximal and middle coronary segments were measured, and the mean values were used for analyses.

RESULTS

Caucasians had larger LA and LD than Asian patients in all proximal coronary segments. Overall, the mean difference in LA and LD was 11.4 % and 5.2 %, respectively. Significant differences were observed for all proximal segments (left anterior descending: 13 % and 6%, left circumflex 14 % and 8% and right coronary artery 8% and 4% for LA and LD), but not for mid segments. The greatest difference between Caucasians and Asians was found in left main coronary artery (LMCA) LA (21.2 ± 6.5 vs.16.8 ± 5.4 mm², p < 0.01 respectively). The independent predictors of larger LA and LD of LMCA and proximal coronary segments were male sex (p < 0.05), Caucasian ethnicity (p < 0.05), and left dominance pattern (p < 0.05).

CONCLUSION

In subjects without atherosclerosis, Asians have smaller dimensions of all proximal coronary arteries, most prominently displayed in LMCA, than the Caucasians regardless of age, sex, or body size.

Comparison of Computed Tomography Angiography Versus Invasive Angiography to Assess Medina Classification in Coronary Bifurcations

The Medina classification is used to determine the presence of significant stenosis (≥50%) within each of the 3 arterial segments of coronary bifurcation in invasive coronary angiography (ICA). The utility of coronary computed tomography angiography (coronary CTA) for assessment of Medina classification is unknown. We aimed to compare the agreement and reproducibility of Medina classification between ICA and coronary CTA, and evaluate its ability to predict side branch (SB) occlusion following percutaneous coronary intervention (PCI). In total 363 patients with 400 bifurcations were included, and 28 (7%) SB occlusions among 26 patients were noted. Total agreement between CTA and ICA for assessment of Medina class was poor (kappa = 0.189), and discordance between both modalities was noted in 253 (63.3%) lesions. Larger diameter ratio between main vessel and SB in CTA, and larger bifurcation angle in ICA were independently associated with discordant Medina assessment. Whereas the interobserver agreement on Medina classification in CTA was moderate (kappa = 0.557), only fair agreement (kappa = 0.346) was observed for ICA. Finally, Medina class with any proximal involvement of main vessel and SB (1.X.1) on CTA or ICA was the most predictive of SB occlusion following PCI with no significant differences between both modalities (area under the curve 0.686 vs 0.663, p = 0.693, respectively). In conclusion, Medina classification was significantly affected by the imaging modality, and coronary CTA improved reproducibility of Medina classification compared with ICA. Both CTA and ICA-derived Medina class with any involvement of the proximal main vessel and SB was predictive of SB occlusion following PCI.

Accuracy of RESOLVE score derived from coronary computed tomography versus visual angiography to predict side branch occlusion in percutaneous bifurcation intervention

INTRODUCTION

Visually estimated angiographic V-RESOLVE score was developed as a simple and accurate prediction tool for side branch (SB) occlusion in patients undergoing coronary bifurcation intervention. Data on the use of coronary computed tomography angiography (coronary CTA) for guiding percutaneous coronary intervention in bifurcation lesions is scarce.

OBJECTIVES

We aimed to validate the ability of quantitative CTA-derived RESOLVE score for predicting SB occlusion in coronary bifurcation intervention and to compare its predictive value with that of the angiography-based V-RESOLVE score.

METHODS

We included 363 patients with 400 bifurcation lesions. Angiographic V-RESOLVE score and CTA-derived RESOLVE score were calculated utilizing the weights from the QCA-based RESOLVE score. The scoring systems were divided into quartiles, and classified as the non-high-risk group and the high-risk group. Accuracy was assessed using areas under the receiver-operator characteristic curve (AUC). SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction flow grade (including the absence of flow) in the SB after main vessel stenting.

RESULTS

In total, 28 SB occlusions (7%) occurred. CTA-derived RESOLVE and V-RESOLVE scores achieved comparable predictive accuracy (0.709 vs. 0.752, respectively, p = 0.531) for predicting SB occlusion, and the analysis of AUC for each constituent element of the scores did not show any significant difference between CTA and visual angiography. The total net reclassification index was -18.6% (p = 0.194), and there were no significant differences in the rates of SB occlusion in the non-high-risk group (4.9% vs. 3.8%, p = 0.510) and the high-risk group (13.8% vs. 18.6%, p = 0.384) between CTA-derived RESOLVE and V-RESOLVE scores.

CONCLUSIONS

The quantitative CTA-derived RESOLVE score is an accurate and reliable alternative to the visually estimated angiographic V-RESOLVE score for prediction of SB occlusion in coronary bifurcation intervention.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03709836.

P3738Clinical outcomes after early vs new generation TAVR device deployment

Background

Whether newer generation devices influence early and long-term outcomes post-TAVR in a real life setting is unknown.

Aim

To assess impact of an early vs a new generation transcatheter heart valves (THV) on clinical outcomes (30-day and -years) in a real life scenario.

Methods

Out of 445 consecutive pts treated between 8/2009 and 10/2017 within the single-center, prospective TAVR Registry, there were 432 [median 83.0 years of age, 63.4% female] with device success (97.1%) as per VARC-2. Early generation THV included: CoreValve; Edwards SAPIEN or SAPIEN XT. Newer generation devices included: Evolut-R/-Pro; Acurate neo; Engager, SAPIEN 3; or Lotus Edge Aortic Valve System.

Results

Median follow-up was 29.3 (15.8–53.1) months with 100% 1-year follow-up. Early generation devices were deployed in 60.6% (n=262) and new devices in 39.4% (n=170). Pts treated with newer devices had more peripheral arterial disease (PAD) and more frequent PCI history (17.1% vs 8.8%, p=0.015, and 35.3% vs 26.7%, p=0.068 respectively); other demographic and clinical data were alike. Baseline aortic valve area and LV ejection fraction were similar between early and newer devices. Pre-dilation was less frequent with newer devices (41.8% vs 70.6%, p<0.001), whereas THV size, contrast volume, fluoroscopy time, radiation dose, and post-procedure aortic valve gradients were similar. Moderate PVL assessed early post-TAVR was recognized with same frequency between earlier vs newer devices (28.2% vs 28.6%). An VARC-2 safety endpoint was recognized more often among pts treated with early vs new devices (30.5% vs 21.8%, p=0.028, respectively), with more frequent: 30-day death (3.8% vs 1.8%, p=0.177), life-threatening or disabling bleeding (8.4% vs 5.3%, p=0.181), major vascular complications (20.2% vs 15.3%, p=0.121), and new permanent pacemaker implantation (22.9% vs 10.0%, p=0.001) with early devices, but similar frequencies of stroke and acute kidney injury (1.9% vs 1.8% and 3.8% vs 5.9%, respectively). The 1-year mortality rates were similar (13.4% vs 13.5%, respectively), with similar estimated midterm (1–2 years) prognosis, but worse estimated very long-term follow-up for newer THV devices (fig 1).

Figure 1

Conclusions

Newer TAVR devices with smaller delivery system size, although deployed in pts with more PAD and PCI history, are associated with less frequent occurrence of an VARC-2 safety endpoint and less frequent permanent pacemaker implantation. The 1-year and midterm (1–2 years) prognosis are similar for early and newer devices, whereas the longer follow-up could have been influenced by intrinsic pt characteristics (more frequent PAD and history of PCI).

Acute Hemodynamic Changes Achieved With Successful MitraClip Procedure for Severe Mitral Regurgitation

An 85-year-old, symptomatic man with severe chronic mitral regurgitation MR, left ventricular ejection fraction of 30%, permanent atrial fibrillation, and EuroScore II of 13% qualified for MitraClip procedure. TEE and electrocardiography documented acute hemodynamic changes throughout the procedure.

P1855Multiple and posterior location of moderate paravalvular leaks are associated with worse long-term outcome after successful TAVR

Background

Posterior location of a paravalvular leak (PVL) affects left ventricle fluid dynamics in a more unfavorable way than leaks of the other locations.

Purpose

To assess impact of the PVL location and its grade on subsequent long term mortality after successful TAVR.

Methods

Out of 445 consecutive patients treated between 8/2009 and 10/2017 within the single-center, prospective TAVR Registry, there were 432 pts [median 83.0 years of age, 63.4% female] with device success (97.1%) as per VARC-2. Post-procedural TTE studies done within 7 days post-TAVR were analyzed for PVL location (anterior vs posterior vs medial vs lateral) and grade (none/trace/mild vs moderate). Long-term mortality was assessed.

Results

Median follow-up was 29.3 (15.8–53.1) months with 1-year follow-up in all pts. The 30-day and 1-year mortality rates were 3.0% (n=13) and 13.4% (n=58) with an estimated 4-year mortality of 35.5%. Moderate PVL was reported in 28.5% (n=123) of pts, with 12.0% (n=52) having multiple locations (>1 PVL). Among moderate PVLs (n=184), most were of anterior (33.2%), 29.3% were posterior, 25.2% were lateral, and the least common location was medial (12.0%). Whereas moderate PVL alone was not associated with worse long-term outcome, the 1-year mortality rates tended to be higher for pts with PVL found at multiple or posterior locations (19.2% vs 12.6% among the rest of the subjects, p=0.20, and 18.5% vs 12.7%, p=0.28, respectively). The KM curves suggest mid-term clinical importance of multiple or posterior PVLs (Fig 1A and 1B).

Figure 1

Conclusions

Moderate PVL found in multiple locations or recognized in the posterior location tend to be associated with worse midterm (1–2 years) prognosis after successful TAVR.

Prevalence and Anatomic Characteristics of Single Coronary Artery Diagnosed by Computed Tomography Angiography

Single coronary artery (SCA) is a rare congenital anomaly. We assessed the prevalence and anatomic characteristics of SCA diagnosed with coronary computed tomography angiography and compared the dimensions of the proximal SCA trunk with a reference group of 199 subjects with normal coronary arteries. We screened 30,230 patients who underwent coronary computed tomography angiography from 2008 to 2018 to identify 17 with SCA (age 55 ± 19.0 years, 8 men [47%]). The prevalence of SCA was 0.056%. SCA originated from the right sinus of Valsalva in 11 patients (65%) and from the left sinus of Valsalva in 6 subjects. According to Lipton's classification, the 17 SCAs were L1 (n = 5, 29%), L2-A (n = 1, 6%), R2-A (n = 2, 12%), R2-B (n = 6, 35%), R2-P (n = 2, 12%), and R3 (n = 1, 6%). (Lipton's classification consists of 3 groups and the division is based on the site of origin of SCA ["R" - right, "L" - left sinus of Valsalva] and its anatomical course relating to the ascending aorta and pulmonary trunk ["A" - anterior to the pulmonary trunk, "B" - between the aorta and pulmonary trunk, "P" - posterior to the aorta].) As compared with the reference group, SCA patients had shorter proximal trunks (5.0 ± 3.6 mm vs 8.6 ± 4.8 mm, p = 0.0012). The lumen area (LA) and lumen diameter of the proximal trunk in patients with SCA were larger than the LA and lumen diameter of the left main coronary artery from the reference group (49.5 ± 18.0 mm2 vs 21.3 ± 6.5 mm2, p <0.0001, and 7.8 ± 1.6 mm vs 5.1 ± 0.75 mm, p <0.0001, respectively). Moreover, the LA of the proximal SCA trunk was larger than the sum of respective measurement performed in left main coronary artery and proximal right coronary artery segments in the control group (49.5 ± 18.0 mm2 vs 34.0 ± 7.9mm2, p = 0.0001). In conclusion, the incidence of SCA is very low; but this condition is associated with significant enlargement of the proximal vessel segment.

Measurements of Lumen Areas and Diameters of Proximal and Middle Coronary Artery Segments in Subjects Without Coronary Atherosclerosis

There are plenty of data on morphology and lumen dimensions of diseased coronary arteries. However, information on normal coronary vessel anatomy is scarce. We provided computed tomography angiography-derived reference values of lumen dimensions in proximal and middle coronary segments in a healthy population with respect to gender and vessel dominance. Consecutive 2,849 computed tomography angiography examinations were reviewed to identify 201 subjects (77 men, patient age 50 ± 13 years) whose coronary arteries were free from any sign of atherosclerosis (calcium score 0, no detectable plaque). For all proximal and middle coronary segments, lumen areas (LAs) and lumen diameters were measured. Coronary vessel segmentation and dominance pattern were defined using the Syntax Score. Normal values of LAs and lumen diameters were significantly smaller for women compared with men except for the proximal right coronary artery and the left main coronary artery (LMCA) (20.2 ± 6.6 mm² vs 23.0 ± 6.1 mm², p = 0.0003, and 5.0 ± 0.8 mm vs 5.4 ± 0.7 mm, p = 0.0001). The lower limit of normal for the LMCA (defined as mean LA - 2 standard deviations) equaled 7.0 and 10.8 mm² for women and men, respectively. Subjects with left (vs right) coronary dominance had significantly larger areas and diameters of the LMCA (26.2 ± 9.2 mm² vs 20.7 ± 6.0 mm², p = 0.0017, and 5.7 ± 1.0 mm vs 5.1 ± 0.7 mm, p = 0.0017, respectively) and proximal left circumflex (13.8 ± 2.7 mm² vs 10.4 ± 3.8 mm², p = 0.0001, and 4.2 ± 0.4 mm vs 3.6 ± 0.7 mm, p = 0.0001, respectively) and smaller areas and diameters of the proximal right coronary artery (7.1 ± 2.0 mm² vs 13.3 ± 3.6 mm², p <0.0001, and 3.0 ± 0.4 mm vs 4.1 ± 0.6 mm, p <0.0001, respectively). In conclusion, gender and coronary artery dominance pattern significantly impact normal LAs and dimensions in subjects without coronary atherosclerosis.

Serial intravascular ultrasound analysis of stent strut distribution and fracture: an integrated analysis of the taxus IV, V, and VI trials

AIMS

Non-uniform distribution of drug-eluting stent struts may cause uneven drug deposition associated with an adverse neointimal response and clinical events. This study assesses circumferential stent strut distribution in bare-metal (BMS) and paclitaxel-eluting (Taxus) stents post implantation and at 9-month follow-up, as well as its impact on intimal hyperplasia (IH).

METHODS AND RESULTS

In the current analysis, intravascular ultrasound (IVUS) substudies of the Taxus IV, V, and VI trials were combined. Among them, 242 stents (117 BMS and 125 Taxus) had paired IVUS images post procedure and at 9-month follow-up that were reassessed at 1 mm intervals. Post implantation, the maximum interstrut angle (71.5 ± 17.7° vs 70.0 ± 19.6°; P=.53) and minimum number of stent struts (7.1 ± 1.0 vs 7.2 ± 0.8; P=.32) were similar in Taxus vs BMS subgroups, respectively. At 9-month follow-up, the maximum angle increased (92.8 ± 22.1° and 81.7 ± 20.6°) and stent strut numbers decreased (6.1 ± 0.9 and 6.5 ± 1.0) for both Taxus and BMS, respectively, as compared to immediately post implantation (all P<.001). The increased stent angle was more pronounced for Taxus compared with BMS (P<.01). Non-uniform strut distribution did not affect IH pattern or clinical outcomes in either stent population. No complete stent fractures were identified.

CONCLUSION

Stent strut distribution changed from implantation to follow-up with an increased interstrut angle and fewer visible stent struts. These changes were more pronounced for Taxus as compared to BMS; however, non-uniform strut distribution was unrelated to increased IH or clinical outcomes.

Prevalence and characteristics of coronary anomalies originating from the opposite sinus of Valsalva in 8,522 patients referred for coronary computed tomography angiography

Although coronary computed tomographic angiography has the ability to depict potentially malignant features of anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS), there are limited data on the significance of ACAOS in the computed tomography population. The aims of this study were to assess the prevalence of ACAOS and to correlate its anatomic features with patients' symptoms among 8,522 consecutive subjects who underwent coronary computed tomographic angiography from February 2008 to May 2012. The ACAOS proximal course was classified into anterior, interarterial, septal, and retroaortic subtypes. Malignant ACAOS was recorded if a slitlike ostium, an acute angle of takeoff, an intramural course, and significant compression between the aorta and pulmonary trunk were present simultaneously. The prevalence of ACAOS was 0.84% (72 of 8,522), including right-sided origins of the left main coronary artery (n = 11), left anterior descending coronary artery (n = 9), and left circumflex coronary artery (n = 33) and left-sided origin of the right coronary artery (n = 20). Of the 24 ACAOS (0.28%) with an interarterial course, 12 (0.14%) showed significant vessel compression, of which 6 (0.07%) were classified as malignant. The presence of significant interarterial compression and malignant ACAOS type were observed in left-sided right coronary arteries only, and interarterial compression correlated with patients' symptoms at a median of 15-month follow-up. In conclusion, the computed tomographic prevalence of ACAOS seems to be comparable with that of previous angiographic studies. The malignant features of ACAOS in the adult computed tomography population might be exclusively associated with left-sided right coronary arteries.

Comparison of stent length reported by the stent's manufacturer to that determined by quantitative coronary angiography at the time of implantation versus that determined by coronary computed tomographic angiography at a later time

The aim of this study was to assess whether coronary computed tomographic angiography (CCTA) would allow accurate length measurements that may help select optimal stent length. In 19 patients who underwent stent implantation and CCTA, the lengths of 30 implanted stents were assessed independently using quantitative coronary angiography (QCA) at the time of implantation and CCTA during follow-up. Measurements on CCTA and QCA were compared with the actual lengths of the implanted stents. The mean actual stent length was 17.3 ± 6.3 mm; the mean length of the stents measured using CCTA was 17.25 ± 5.54 mm, and the mean length of the stents measured using QCA was 15.92 ± 5.86 mm. There was a stronger positive correlation between measurements on CCTA versus actual stent lengths (R = 0.99, p = 0.0001) than between measurements on QCA versus actual stent lengths (R = 0.82, p = 0.0001) (p <0.0001 for the difference between correlation coefficients). In conclusion, the length measurements obtained with CCTA correlate better with an anatomic gold standard (actual stent lengths) than those obtained using QCA.

Coronary computed tomographic angiography for prediction of procedural and intermediate outcome of bypass grafting to left anterior descending artery occlusion with failed visualization on conventional angiography

Conventional coronary angiography (CCA) has considerable limitations regarding visualization of distal vessel segments in chronic total occlusion. We assessed the ability of coronary computed tomographic angiography (CCTA) to predict the success of coronary artery bypass grafting (CABG) to the chronically occluded left anterior descending coronary artery (LAD) incompletely visualized on CCA. Thirty symptomatic patients rejected for CABG on the basis of the CCA findings underwent preoperative CCTA before intended transmyocardial laser revascularization. The LAD was explored operatively in all patients, and CABG to the LAD was attempted if the distal vessel was suitable for anastomosis. The procedural outcome of CABG and the 6-month patency of the left internal mammary artery graft at follow-up CCTA were defined as the primary and secondary end point, respectively. The primary and secondary end points were achieved in 80% and 77% of patients, respectively. We found a significant correlation between the intraoperative and computed tomographic measurement of distal LAD diameter (R = 0.428, p = 0.037). On multivariate analysis, the maximum diameter of the distal LAD by CCTA (odds ratio 8.16, p = 0.043) was the only independent correlate of procedural success of CABG. A cutoff value of 1.5 mm for the mean distal LAD diameter predicted left internal mammary artery graft patency with 100% specificity and 83% sensitivity. Successful CABG resulted in significant improvements in angina class and left ventricular function in LAD segments at 6 months of follow-up. In conclusion, CCTA predicted both the procedural and the intermediate outcome of CABG to chronic LAD occlusion with failed visualization on CCA.

Comparison of usefulness of percutaneous coronary intervention guided by angiography plus computed tomography versus angiography alone using intravascular ultrasound end points

The aim of our study was to assess the impact of coronary computed tomographic angiographic (CTCA) guidance on outcomes of percutaneous coronary intervention (PCI). The study was a randomized single-center trial. Consecutive eligible patients with CTCA-detected significant coronary lesions who were scheduled for PCI were randomized to an angiographically guided versus an angiographically plus computed tomographically guided (ACTG) group. In the ACTG group the operator preliminarily planned PCI based on computed tomographic angiogram. The coprimary end points were minimal stent area and minimal reference lumen area assessed in all patients with intravascular ultrasound performed after achieving optimal angiographic results. Seventy-one patients (50 men, mean age 65 ± 8 years) were randomized. After invasive angiography, PCI of 32 lesions (30 patients) in the ACTG and in 32 lesions (30 patients) in the angiographically guided group was performed. A stented segment length was longer and nominal stent diameter tended to be larger in the ACTG group (23.8 ± 6.7 vs 19.5 ± 6.5 mm, p = 0.01; 3.27 ± 0.44 vs 3.09 ± 0.41 mm(2), p = 0.110). Minimal stent area tended to be larger (6.62 ± 2.01 vs 5.80 ± 2.02 mm(2), p = 0.100) and the smallest peri-stent reference lumen area was significantly larger in the ACTG group (6.76 ± 3.01 vs 5.0 ± 1.62 mm(2), p = 0.006) with a smaller plaque burden (50 ± 16% vs 58 ± 13%, p = 0.025). In conclusion, CTCA analysis before PCI significantly influences treatment strategy and results in better lesion coverage as defined by intravascular criteria.

Thrombus aspiration followed by direct stenting: a novel strategy of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Results of the Polish-Italian-Hungarian RAndomized ThrombEctomy Trial (PIHRATE Trial)

BACKGROUND

Previous studies with thrombectomy showed different results, mainly due to use of thrombectomy as an additional device not instead of balloon predilatation. The aim of the present study was to assess impact of aspiration thrombectomy followed by direct stenting.

METHODS

Patients with ST elevation myocardial infarction (STEMI) <6 hours from pain onset and occluded infarct-related artery in baseline angiography were randomized into aspiration thrombectomy followed by direct stenting (TS, n = 100) or standard balloon predilatation followed by stent implantation (n = 96). The primary end point of the study was the electrocardiographic ST-segment elevation resolution >70% (STR > 70%) 60 minutes after primary angioplasty (percutaneous coronary intervention [PCI]). Secondary end points included angiographic myocardial blush grade (MBG) after PCI, combination of STR > 70% immediately after PCI and MBG grade 3 (optimal myocardial reperfusion), Thrombolysis In Myocardial Infarction flow after PCI, angiographic complications, and in-hospital major adverse cardiac events.

RESULTS

Aspiration thrombectomy success rate was 91% (crossing of the lesion with thrombus reduction and flow restoration). There was no significant difference in STR ≥ 70% after 60 minutes (53.7% vs 35.1%, P = .29). STR > 70% immediately after PCI (41% vs 26%, P < .05), MBG grade 3 (76% vs 58%, P < .03), and optimal myocardial reperfusion (35.1% vs 11.8%, P < .001) were more frequent in TS. There was no difference in between the groups in 6-month mortality (4% vs 3.1%, P = .74) and reinfarction rate (1% vs 3.1%, P = .29).

CONCLUSIONS

Aspiration thrombectomy and direct stenting is safe and effective in STEMI patients with early presentation (<6 hours). The angiographic parameters of microcirculation reperfusion and ECG ST-segment resolution directly after PCI were significantly better in thrombectomy group despite the lack of the difference in ST-segment resolution 60 minutes after PCI.

Sodium level on admission and in-hospital outcomes of STEMI patients treated with primary angioplasty: the ANIN Myocardial Infarction Registry

BACKGROUND

Hyponatremia is a common electrolyte disorder reported to be a predictor of poor prognosis among hospitalized patients, but individuals with high levels also tend to have less favorable outcomes. This study investigated whether sodium level on admission is predictive of in-hospital outcome in patients with ST-elevation myocardial infarction (STEMI) treated with primary angioplasty.

MATERIAL/METHODS

Included were 1858 patients admitted with STEMI for primary angioplasty. Sodium level was measured on admission and analyzed as hypo- versus normonatremia and by grouping patients into sodium quintiles. The relationships between sodium level and in-hospital mortality as well as the composite of death or heart failure were assessed.

RESULTS

Ninety-six patients had hyponatremia on admission. The hypo- and normonatremic groups were comparable with respect to baseline characteristics and in-hospital management. Hyponatremics had higher rates of in-hospital mortality (13.5% vs. 3.8%, p<0.001) composite of death and heart failure (27.8% vs. 18.4%, p=0.022). After adjustment for covariates, hyponatremia independently correlated with in-hospital mortality (HR: 3.89, 95%CI: 1.59-9.56, p=0.003) and the combined endpoint (HR: 1.73, 95%CI: 1.01-2.99, p=0.047). Patients in the lowest and highest sodium quintiles were 3.27 (95%CI: 1.34-8.02, p=0.009) and 2.65 (95%CI: 1.07-6.60, p=0.036) times more likely to die during hospitalization than those in the 2nd quintile (best survival). In the adjusted model, only patients in the lowest quintile had significantly increased risk of in-hospital death (HR: 6.35, 95%CI: 1.83-21.72, p=0.004).

CONCLUSIONS

Hyponatremia is a simple laboratory marker independently associated with increased risk of death in STEMI patients treated with primary angioplasty.

Impact of different re-stenting strategies on expansion of a drug-eluting stent implanted to treat bare-metal stent restenosis

We used intravascular ultrasound (IVUS) to compare the expansion of drug-eluting stents (DES) implanted to treat bare-metal stent (BMS) restenosis after 3 common re-stenting strategies. A total of 80 consecutive BMS restenotic targets were re-stented either directly (n = 30, group 1) or after low-pressure (<8 atm) pre-dilation with an undersize regular balloon (n = 16, group 2) or after high-pressure (>12 atm) pre-dilation with a semicompliant balloon the same or greater diameter as the original BMS diameter (n = 34, group 3). More patients from groups 2 and 3 had diabetes mellitus. The targets in group 1 were more proximal and focal. Lesions from groups 2 and 3 were more severe. The size and deployment pressure of the DESs and the achieved angiographic results were all similar. The post-intervention minimum stent area and the percentage of expansion of DES (minimum stent area/distal reference lumen area x 100%) were, however, both significantly larger in group 3 (6.4 +/- 1.5 mm(2) in group 3 vs 5.6 +/- 1.6 mm(2) in group 1 vs 4.4 +/- 1.4 mm(2) in group 2, p <0.001; and 88 +/- 30% in group 3 vs 74 +/- 14% in group 1 vs 73 +/- 23% in group 2, p = 0.021). A post-intervention minimum stent area <5.0 mm(2) was seen in only 3 lesions in group 3 (8.8%) versus 14 in group 1 (46.7%) and 11 in group 2 (68.8%; adjusted odds ratio 0.11, 95% confidence interval 0.03 to 0.38, p <0.001). Overall, the acute lumen gain was mainly from BMS re-expansion; however, the BMS volume increased the most in group 3 (p <0.001). In conclusion, high-pressure pre-dilation leads to superior post-intervention expansion of DESs implanted to treat BMS restenosis, regardless of the original expansion because of the greater BMS re-expansion.

Relation of drug-eluting stent strut distribution to stent thrombosis in coronary arteries

The distribution of stent struts is critical to drug deposition and, therefore, may affect the amount of neointima and the risk of thrombosis after drug-eluting stent (DES) implantation. The aim of our study was to evaluate stent strut distribution in the setting of a drug-eluting stent thrombosis (ST). We retrospectively analyzed postprocedural intravascular ultrasound (IVUS) images of 13 patients who subsequently developed ST (14 DES thrombotic lesions) and a control group of 27 patients (30 DES lesions) matched for stent type and presence of chronic renal failure. In addition to standard IVUS measurements, visible struts were counted and maximum interstrut angle was measured at 1-mm intervals. Early ST was defined as < or =30 days after DES deployment and late ST as >30 days after DES deployment. Compared with DES controls, the ST group had a larger maximum interstrut angle (60.8 +/- 8.3 degrees vs 55.7 +/- 4.8 degrees , p = 0.014) and a similar number of stent struts (8.4 +/- 0.6 vs 8.7 +/- 0.6, p = NS). Maximum interstrut angle tended to be larger in late ST than in early ST (66.1 +/- 10.8 degrees vs 57.8 +/- 5.0 degrees , p = 0.071). The incidence of maximum interstrut angles > or =90 degrees and > or =120 degrees observed continuously for > or =2 mm of stent length was higher in the ST group (p = 0.009 and p = 0.096, respectively). In conclusion, DES-treated lesions leading to ST had larger maximum interstrut gaps distributed circumferentially and longitudinally, but a similar number of struts at the time of DES implantation compared with DES controls.

Hemoglobin, leukocytosis and clinical outcomes of ST-elevation myocardial infarction treated with primary angioplasty: ANIN Myocardial Infarction Registry

BACKGROUND

Hemoglobin (Hb) levels may interact with inflammatory activation, but it is unknown whether the interaction has any impact on clinical outcomes in acute coronary syndromes. The aim of this study was to assess the relationship between admission Hb levels, leukocytosis and clinical outcomes of ST-elevation myocardial infarction (STEMI) treated with primary angioplasty. Methods and Results The study group comprised 1,904 (1,380 men) patients with STEMI treated with primary percutaneous coronary intervention, enrolled in a prospective registry. The primary endpoint of in-hospital death occurred in 90 (4.7%) patients. According to univariate analysis, extreme values of Hb (for 1(st) and 5(th) vs mid quintiles respectively: hazard ratio (HR) =7.1, P<0.001 and HR =3.2, P=0.024) and leukocytosis above median (HR =2.09, P=0.001) significantly correlated with in-hospital death. After dividing patients into high and low white blood cell (WBC) count groups, a U-shaped relationship of Hb levels and mortality was observed for patients with higher leukocytosis (1(st) and 5(th) vs mid quintiles respectively: HR =8.1, P=0.001 and HR =4.4, P=0.022), whereas in patients with lower WBC count higher mortality was related solely to the lowest Hb quintile (HR =6.9, P=0.010 vs mid quintile). Conclusion Higher mortality associated with higher Hb levels in STEMI patients treated with primary angioplasty is limited to patients with increased leukocytosis.

Enhanced level of micronuclei in peripheral blood lymphocytes of patients treated for restenosis with 32P endovascular brachytherapy

BACKGROUND

Restenosis is the complete occlusion of the blood vessel leading to such complications as ischemia/angina, myocardial infarction, and death. It can be managed by endovascular brachytherapy with both gamma and beta sources. Endovascular brachytherapy is performed worldwide on several thousands of cases per year. The gamma-emitter 192Ir as well as the beta-emitters 32P and 90Sr are mainly used. The dose to the occluded endothelial wall is 20 Gy. Interestingly, no information with respect to the dose absorbed by the blood during the course of the treatment exists. The aim of the present investigation was to verify if the micronucleus test is suitable to detect the dose absorbed by lymphocytes in the course of endovascular brachytherapy with 32P.

MATERIALS AND METHODS

Blood was drawn from 16 patients immediately before and 1 day after the treatment. Frequencies of micronuclei were assessed. In order to ensure that the micronuclei did not arise due to fluoroscopy or reperfusion, we analyzed lymphocytes of 16 control patients who underwent interventional cardiology with balloon angioplasty only.

RESULTS AND CONCLUSIONS

Enhanced frequencies of micronuclei were observed in lymphocytes of some donors following brachytherapy. No correlation could be detected between the level of induced micronuclei and the absorbed dose. Also, no effect of fluoroscopy or reperfusion was seen. Thus, although brachytherapy of restenosis with 32P leads to weak enhancement of the micronucleus frequency in lymphocytes, the effect was not seen in all patients; the reason for this heterogeneous response remains to be elucidated.

Repeated stenting of recurrent in-stent restenotic lesions: intravascular ultrasound analysis and clinical outcome

BACKGROUND

Stents are used to treat the first and even successive episodes of in-stent restenosis (ISR).

METHODS

In 18 patients (19 lesions), intravascular ultrasound (IVUS) was performed after placement of a stent for a nonrestenotic lesion after the second stent was used to treat the first episode of ISR and after the third stent was used to treat the second episode of ISR. The duration between the first and second stent was 355 +/- 374 days, and between the second and third stent was 330 +/- 279 days. The duration of follow up after the third stent was 307 +/- 145 days. High-pressure inflation (> 14 atm) was performed for 69% (11/16) of patients when treating the first episode of ISR, and all patients when treating the re-ISR (p = 0.018).

RESULTS

Nevertheless, vessel area and final minimal stent area (MSA) did not increase with successive restenting, and the ratio of minimum stent diameter to nominal stent size suggested that chronic stent underexpansion persisted. MSA > 5 mm2 was noted in 54% after the first stent, 35% after the second stent, and 42% after the third stent (p = 0.6). After the third stent, the rate of target lesion revascularization was 26% (5/19) and target vessel revascularization was 37% (7/19); there was 1 nonfatal myocardial infarction. Thus, the overall rate of major adverse cardiac events was 42%.

CONCLUSION

While serial restenting a recurrent ISR lesion was not associated with progressive decrease in MSA, it was still associated with chronic stent underexpansion and a high rate of adverse events. Attention should be directed to achieving better stent expansion to minimize subsequent recurrences.

Serum tissue inhibitor of metalloproteinases-1 and higher risk features of coronary plaque

AIMS

The purpose of this study was to determine the relationship between higher-risk features of coronary plaque and serum levels of matrix metalloproteinase (MMP) family enzymes in the stable angina patients.

METHODS AND RESULTS

In 36 patients, 75 coronary lesions were assessed by intravascular ultrasound. For each of the plaques remodelling index, mean calcium arc and plaque burden were measured. Positive remodelling and the values of the calcium arc and plaque burden above the respective medians were regarded as the higher-risk features and summarised for each lesion. Serum levels of MMP-2, -3, -7, -9, and tissue inhibitor of MMP (TIMP)-1 and -2 were measured in all patients. TIMP-1 level was the independent predictor of presence of a lesion with positive remodelling (OR 1.032; 95% CI: 1.004-1.061) and of a lesion with higher plaque burden (OR 1.026; 95% CI: 1.003-1.049) in a given patient. Whereas, MMP-2 level was an independent predictor of presence of a lesion with higher calcium arc (OR 1.035; 95% CI: 1.001-1.071). TIMP-1 level (p=0.003) was also an independent predictor of a number of higher-risk features in the highest-risk plaque in a given patient.

CONCLUSIONS

TIMP-1 level correlates with clustering of plaque features associated with higher risk of complications in stable angina patients.

Intravascular ultrasonic study of gender differences in ruptured coronary plaque morphology and its associated clinical presentation

Coronary plaque rupture is a phenomenon underlying most acute coronary events. Although gender is an important determinant of the incidence and clinical course of coronary atherosclerosis, its relation to plaque rupture is unknown. Therefore, we assessed gender differences in native artery plaque rupture characteristics and their related clinical presentations. There were 468 intravascular ultrasound (IVUS) preintervention images of ruptured plaques retrospectively identified. There were 328 men (81.6%) with 387 plaque ruptures and 74 women (18.4%) with 81 plaque ruptures. Patient demographics, angiographic characteristics, and qualitative and quantitative IVUS analyses of ruptured plaques were assessed. On average women were older than men (67.6 +/- 11.8 vs 62.6 +/- 11.4 years, p = 0.001) and more often presented with an acute coronary syndrome (89.2% vs 72.9%, p = 0.003). Older women had smaller vessel areas at the rupture site (p = 0.001), minimum lumen site (p = 0.002), and reference segments (p = 0.002) and smaller lumen areas at the rupture site (p = 0.026) and reference segments (p = 0.03). Ruptured plaques in older women were more often associated with IVUS-evident thrombus (48.1% vs 34.6%, p = 0.022). Independent predictors of acute clinical presentation were female gender (p = 0.006), smoking (p = 0.013), and presence of thrombus (p = 0.049). Independent predictors of the presence of thrombus were female gender (p = 0.025), smaller lumen area (p = 0.023) and larger plaque area (p = 0.008) at the rupture site, longer plaque ruptures (p = 0.016), and smoking (p = 0.045). In conclusion, coronary plaque ruptures are more often associated with thrombus and acute presentations in women than in men.

Comparison of different methods of ST segment resolution analysis for prediction of 1-year mortality after primary angioplasty for acute myocardial infarction

BACKGROUND

Resolution of ST segment elevation corresponds with myocardial tissue reperfusion and correlates with clinical outcome after ST elevation myocardial infarction. Simpler method evaluating the extent of maximal deviation persisting in a single ECG lead was an even stronger mortality predictor. Our aim was to evaluate and compare prognostic accuracy of different methods of ST segment elevation resolution analysis after primary percutaneous coronary intervention (PCI) in a real-life setting.

METHODS

Paired 12-lead ECGs were analyzed in 324 consecutive and unselected patients treated routinely with primary PCI in a single high-volume center. ST segment resolution was quantified and categorized into complete, partial, or none, upon the (1) sum of multilead ST elevations (sumSTE) and (2) sum of ST elevations plus reciprocal depressions (sumSTE+D); or into the low-, medium-, and high-risk groups by (3) the single-lead extent of maximal postprocedural ST deviation (maxSTE).

RESULTS

Complete, partial, and nonresolution groups by sumSTE constituted 39%, 40%, and 21% of patients, respective groups by sumSTE+D comprised 40%, 39%, and 21%. The low-, medium-, and high-risk groups constituted 43%, 32%, and 25%. One-year mortality rates for rising risk groups by sumSTE were 4.7%, 10.2%, and 14.5% (P = 0.049), for sumSTE+D 3.8%, 9.6%, and 17.6% (P = 0.004) and for maxSTE 5.1%, 6.7%, and 18.5% (P = 0.001), respectively. After adjustment for multiple covariates only maxSTE (high vs low-risk, odds ratio [OR] 3.10; 95% confidence interval [CI] 1.11-8.63; P = 0.030) and age (OR 1.07; 95% CI 1.02-1.11; P = 0.002) remained independent predictors of mortality.

CONCLUSIONS

In unselected population risk stratifications based on the postprocedural ST resolution analysis correlate with 1-year mortality after primary PCI. However, only the single-lead ST deviation analysis allows an independent mortality prediction.

Significance of Aspirin and Clopidogrel Resistance in Patients Undergoing Percutaneous Coronary Interventions

Dual antiplatelet therapy (aspirin plus clopidogrel) is mandatory in patients treated with coronary stent implantation. This strategy is highly effective in prevention of stent thrombosis until its struts are covered with endothelium. However, a substantial number of patients still suffer from recurrent ischemic coronary events despite adequate antiplatelet therapy. These events fall into three categories: stent thrombosis, in stent restenosis and events related to other non-stented coronary lesions. Some data suggest that beside other local and systemic factors resistance to aspirin and clopidogrel may be a possible cause of stent thrombosis and ischemic events in patients after coronary interventions. Several mechanisms of antiplatelet drug resistance have been reported including poor compliance, interactions with other drugs, genetic polymorphism or increased platelet turnover. More research is needed to adequately assess the clinical significance and prognostic value of antiplatelet drug resistance detected by laboratory tests in patients undergoing percutaneous intervention. We review published data on mechanisms and the clinical significance of aspirin and clopidogrel resistance in patients after coronary interventions.

Is there room for improvement in technical design and thereby a better facilitation of mechanical reperfusion with intracoronary thrombectomy systems?

This letter includes a case study, which shows the safety and efficacy of the intended use of Judkins guiding catheter for aspiration of excessive thrombus from the infarct-related vein graft, which is however made off-label. Guiding catheter thrombectomy offers optimal facilitation of primary angioplasty without device-related delay in time-to-treatment. Consistently, the negative results of the EMERALD are related to the significantly longer door-to-balloon time while use of the dedicated but complex devices. Interestingly, the current report is in line with the REMEDIA trial, demonstrating superior myocardial tissue reperfusion after the intracoronary thrombectomy in an unselected patient population treated with the dedicated but manual and of a large aspiration lumen catheters.

Comparison of prognostic value of epicardial blood flow and early ST-segment resolution after primary coronary angioplasty. ANIN--Myocardial Infarction Registry

BACKGROUND

TIMI scale is commonly used for angiographic assessment of reperfusion effectiveness and early risk stratification in patients treated with primary angioplasty for ST-elevation myocardial infarction (STEMI). Since ST-resolution analysis allows a noninvasive insight into the reperfusion status at the myocardial tissue level, it may be a better predictor of outcome after primary angioplasty.

AIM

To compare the prognostic value of the reperfusion effectiveness evaluation based on either the epicardial blood flow assessment according to the TIMI scale, or ST-segment resolution analysis in patients treated with primary coronary angioplasty for STEMI.

METHODS

324 consecutive patients treated within 12 hours from the pain onset were studied. Based on the analysis of maximal ST-segment elevation/depression identified in a single ECG lead recorded after the procedure (maxSTE), patients were classified into groups of high versus medium/low risk. Independently, distinguished were groups with restored normal (TIMI 3) and abnormal (TIMI 0-2) final blood flow in infarct related artery.

RESULTS

The 30-day and one-year mortality rates were higher in the high-risk maxSTE group (25% of all patients) than in the other patients (14.8% vs. 2.5%, p<0.001 and 18.5% vs. 5.4%, p<0.001 respectively). In subjects (82%) with restored TIMI grade 3 blood flow, mortality at one-month and one-year was lower than in the group with abnormal final blood flow (3.1% vs. 15.6%, p=0.001 and 6.2% vs. 18.8%, p=0.005). Comparison in multivariate analysis revealed that maxSTE stratification but not final TIMI grade assessment remained an independent predictor of both, 30-day and one-year mortality (high vs. medium/low-risk category; OR 5.3, 95% CI 1.6-16.7, p=0.005, and OR 3.3, 95% CI 1.4-7.8, p=0.007, respectively). Furthermore, maxSTE proved to stratify the risk of death even in subgroup of patients with restored normal blood flow (OR 6.2, 95% CI 1.4-27.8, p=0.016, and OR 3.0, 95% CI 1.1-8.7, p=0.039, respectively).

CONCLUSIONS

Analysis of extent of maximal ST-segment elevation or depression identified in a single ECG lead after primary coronary angioplasty allows better prognosis of subsequent 30-day and one-year mortality than the assessment of final epicardial blood flow, stratifying risk of death even in a subgroup of patients with restored normal blood flow.

Acute lumen overdilation improves outcome after brachytherapy of in-stent restenosis

BACKGROUND

The aim of our study was to test the impact of acute lumen overdilation on neointimal hyperplasia and late lumen size after vascular brachytherapy for in-stent restenosis (ISR).

METHODS

Forty-seven ISR lesions located in 47 coronary arteries in 44 consecutive patients underwent beta brachytherapy with serial intravascular ultrasound studies. Vessel, lumen, and stent cross-sectional area were measured at 1-mm steps. Based on an interpolated reference cross-sectional area, each cross section was assessed as overdilated (lumen cross-sectional area>interpolated reference cross-sectional area) or not overdilated (lumen cross-sectional area <interpolated reference cross-sectional area).

RESULTS

Overall, 502 sections were overdilated and 673 sections were not. Overdilated sections had a larger final lumen cross-sectional area (8.02+/-1.98 vs. 6.90+/-2.23 mm2, P<.001) and more recurrent neointimal hyperplasia (1.59+/-2.17 vs. 0.31+/-1.79 mm2, P<.001), but a smaller follow-up area stenosis (-1.03+/-32.99% vs. 22.15+/-20.75%, P<.001). This was especially true in smaller arteries (angiographic reference<3.0 mm) where larger follow-up lumen cross-sectional area and a corresponding smaller area stenosis were present (5.38+/-1.98 vs. 4.84+/-1.88 mm2 and 6.90+/-31.57% vs. 28.61+/-21.86%, P<.01 and P<.001, respectively).

CONCLUSIONS

Especially in small arteries, the strategy of acute lumen overdilation during balloon angioplasty prior to beta vascular brachytherapy treatment of ISR lesions has a favorable long-term result.

The impact of cardiovascular risk factors on subclinical left main coronary artery disease: an intravascular ultrasound study

BACKGROUND

The impact of cardiovascular risk factors on subclinical but measurable left main coronary artery (LMCA) atherosclerosis is not well known.

METHODS

We analyzed 150 consecutive patients with first-time coronary artery disease presentation undergoing intervention of a left anterior descending coronary artery or left circumflex lesion with motorized intravascular ultrasound transducer pullback that included a nonstenotic LMCA. Framingham, PROCAM, and European SCORE risk assessments were determined in 107 patients <65 years of age (because the Framingham, PROCAM, and European SCORE studies excluded patients >65 years old). Intravascular ultrasound measurements were compared in patients with <10% vs 10% to 20% risk of events.

RESULTS

Plaque volumes were greater in patients with higher risk scores: P = .007 in patients with 10% to 20% PROCAM risk, P = .063 in patients with 10% to 20% Framingham risk, and P = .059 in patients with 10% to 20% SCORE risk (P = .059). The mean arc of LMCA calcium (12 degrees +/- 25 degrees overall) correlated with plaque volume (51 +/- 28 mm3, r = 0.30, P = .0001) and with the number of coronary risk factors (P = .048) and ranged from 0.28 degrees +/- 0.74 degrees in patients with 0 to 1 risk factors to 9.95 degrees +/- 21.55 degrees in patients with 2 to 4 risk factors to 19.38 degrees +/- 32.51 degrees in patients with 5 to 7 risk factors. Regression analysis showed obesity and age were the most important factors contributing to LMCA calcium.

CONCLUSION

Intravascular ultrasound measurable atherosclerosis in nonstenotic LMCA correlates with conventional primary coronary risk scores. Left main coronary artery calcium correlates both with LMCA plaque volume and risk factors. Thus, subclinical LMCA atherosclerosis may be a marker for events that are predicted by commonly used primary risk-assessment algorithms.