Value of intravascular ultrasound imaging in following up patients with replacement of the ascending aorta for acute type A aortic dissection.

BACKGROUND: The value of intravascular ultrasound (IVUS) imaging in patients with replacement of the ascending aorta for acute type A aortic dissection (AD) is unknown. The purpose of this study was to assess the potential use of IVUS imaging in this setting. METHODS: From September 2002 to July 2005, IVUS imaging with a 9 MHz probe was performed in a series of 16 consecutive patients with suspected or established AD. This study focused on 5 of them with replacement of the ascending aorta for acute type A AD. Among these 5 patients, other imaging modalities including aortography, spiral computed tomography, magnetic resonance imaging and transesophageal echocardiography were performed in 5, 3, 3 and 1 patients, respectively. RESULTS: There were no complications related to IVUS imaging. For the replaced graft, as other imaging modalities, IVUS could identify all 5 grafts, the proximal and the distal anastomoses, and the ostia of the reimplanted coronary arteries. In 2 cases, IVUS detected 2 peri-graft pseudo-aneurysms (1 per case), which were also detected by magnetic resonance imaging but omitted by aortography. For the residual dissection, IVUS had similar findings as other imaging modalities in detecting the patency (5/5), the longitudinal and the circumferential extent, the thrombus (4/5), the recurrent dissection (1/5) and an aneurysm distal to the graft (5 in 4 patients). However, it detected more intimal tears and side branch involvements than other imaging modalities (15 vs 10 and 3 vs 1, respectively). CONCLUSIONS: In following-up patients with replacement of the ascending aorta for acute type A AD, IVUS imaging can provide complete information of the replaced graft and the residual dissection. So, IVUS imaging may be considered when the four current frequently used imaging modalities can not supply sufficient information or there are some discrepancies between them.

Management of unsuccessful thrombolysis in acute massive pulmonary embolism.

BACKGROUND: The management of patients with acute massive pulmonary embolism (PE) who do not respond to fibrinolytic therapy remains unclear. We aimed to compare rescue surgical embolectomy and repeat thrombolysis in patients who did not respond to thrombolysis. METHODS: We conducted a prospective single-center registry of PE patients who underwent thrombolytic therapy. Lack of response to thrombolysis within the first 36 h was prospectively defined as both persistent clinical instability and residual echocardiographic right ventricular dysfunction. Patients underwent surgical embolectomy or repeat thrombolysis, at the discretion of the attending physician. The clinical end point was a combined end point including recurrent PE, bleeding complications, or PE-related death, which was defined as death from recurrent PE or cardiogenic shock. Long-term adverse outcomes included death, recurrent thromboembolic events, and congestive heart failure. RESULTS: From January 1995 to January 2005, 488 PE patients underwent thrombolysis, of whom 40 (8.2%) did not respond to thrombolysis. Fourteen patients were treated by rescue surgical embolectomy, and 26 were treated by repeat thrombolysis. There was no significant difference in baseline characteristics between the two groups. The in-hospital course was uneventful in 11 of the surgically treated patients (79%) and in 8 patients (31%) treated by repeat thrombolysis (p = 0.004). There was a trend for higher mortality in the medical group than in the surgical group (10 vs 1 deaths, respectively; p = 0.07). There were significantly more recurrent PEs (fatal and nonfatal) in the repeat-thrombolysis group (35% vs 0%, respectively; p = 0.015). While no significant difference was observed in number of major bleeding events, all bleeding events in the repeat-thrombolysis group were fatal. The rate of uneventful long-term evolution was the same in the two groups. CONCLUSION: Rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in patients with massive PE who have not responded to thrombolysis. The transfer of patients who have not responded to thrombolysis to tertiary cardiac surgery centers could be considered as an alternative option.

Impact of renal dysfunction on 1-year mortality after acute myocardial infarction.

BACKGROUND: Survival after acute myocardial infarction (MI) is linked to multiple factors, including mild or severe chronic kidney dysfunction. The aim of this study was to determine to what extent a reduction in glomerular filtration rate (GFR) influences 1-year mortality when risk level at admission and quality of care are taken into account. METHODS: A prospective registry was carried out in a geographically delimited area, including all patients admitted with a diagnosis of acute MI over a 6-month period. The GFR was calculated from serum creatinine levels, and patients were stratified into 3 groups: GFR1 >59 mL/min per 1.73 m2, GFR2 >29 and <60 mL/min per 1.73 m2, and GFR3 <30 mL/min per 1.73 m2. A risk index based on initial presentation was calculated. Inhospital and discharge treatments were recorded, taking into account possible contraindications. Patients were followed up for 1 year to assess all-cause mortality rate. RESULTS: A total of 754 patients were included, 333 ST-elevation MI and 421 non-ST-elevation MI. Overall 1-year mortality was 11.5%. Patients with impaired GFR were older, with more comorbidities, and received fewer effective therapies (less reperfusion, glycoprotein IIb/IIIa receptor inhibitors, early angiography, beta-blockers, and statins). One-year mortality increased as GFR decreased: GFR1 2.3% (5/215), GFR2 9.4% (31/328), and GFR3 24.2% (51/211) (P < .001 for trend). By multivariable logistic regression, a significant association was found between 1-year mortality and risk index (odds ratio [OR] 1.41, 95% CI 1.16-1.71 per 10% increase in risk index), GFR (OR 0.97, 95% CI 0.95-0.98 per additional GFR unit), use of beta-blockers (OR 0.15, 95% CI 0.05-0.50 for users), and early coronary angiography (OR 0.26, 95% CI 0.32-0.66 for patients submitted to angiography). CONCLUSIONS: In patients with acute MI, decreased GFR is associated with higher mortality, and this relation remains strong after adjustment for the level of risk at admission and the effective treatments used.

The value of intravascular ultrasound imaging in diagnosis of aortic penetrating atherosclerotic ulcer.

BACKGROUND: Aortic penetrating atherosclerotic ulcer (PAU) is one of the causes of acute aortic syndrome. Few studies have evaluated the value of intravascular ultrasound (IVUS) imaging in the diagnosis of PAU. OBJECTIVES: We aimed to evaluate the value of IVUS imaging in diagnosis of PAU. METHODS AND RESULTS: From September 2002 to May 2005, a consecutive series of 15 patients with suspected aortic dissection underwent both IVUS imaging and spiral Computed Tomography (CT).CT documented 4 PAUs in three patients. There were no complications related to IVUS imaging. The common IVUS features of these four PAUs appeared as a crescentic, localized, outpouching thickened aortic wall with heterogeneous echoic density that communicated with the lumen via a discontinuous intima. By using these features, IVUS detected five other PAUs in four patients, which were overlooked by CT. The width of PAU detected by CT was significantly wider than that of PAU not detected by CT (1.33+/-0.67cm vs 0.43+/-0.27cm, P=0.027). Two of five PAUs omitted by initial CT were confirmed by follow-up CT or magnetic resonance imaging (MRI). During follow up, three PAUs, including two of those overlooked by CT, developed into aneurysms. CONCLUSION: IVUS imaging is a safe examination, and more sensitive than spiral CT to diagnose PAU.

One-year outcome of patients submitted to routine fractional flow reserve assessment to determine the need for angioplasty.

AIMS: In patients submitted to coronary angiography, fractional flow reserve (FFR) assessment by a pressure wire can be used to guide the decision for revascularization. Routine application of FFR assessment and 1-year outcome of patients are poorly documented. The aim of this study was to report a 4-year single-centre experience where the use of FFR for decision making in equivocal lesions is encouraged. METHODS AND RESULTS: A prospective registry was designed to collect clinical and angiographic characteristics, as well as 1-year clinical follow-up for all patients submitted to FFR assessment. The decisional cut-off point for revascularization was 0.80. Over a 4-year period, out of 6415 coronary angiographies, FFR was measured in 407 (6.3%) patients (469 lesions). FFR was assessed through 4 or 5 Fr diagnostic catheters in 330 (81%). Median FFR value was 0.87 (0.80; 0.93). On the basis of FFR results, 271 (67%) patients were treated with medical therapy alone. A subset of 71 (17%) patients were not treated in accordance with the results of FFR. All patients but four (i.e. 99%) had 1-year clinical follow-up. Three hundred and forty four (85%) were free from clinical event, six (1.5%) patients died, five (4%) had an acute coronary syndrome, and 20 (5%) underwent target-vessel revascularization. Event-free survival was comparable in patients with vs. without revascularization (0.94 +/- 0.02 and 0.93 +/- 0.01, respectively). Patients had significantly better 1-year outcome when treated in accordance with the results of the FFR assessment. CONCLUSION: In routine practice, FFR assessment during diagnostic angiography was performed in 6.3%. On the basis of FFR, two-thirds of patients with 'intermediate' lesions were left unrevascularized, with a favourable outcome, when FFR was above 0.80. These data suggest that routine use of FFR during diagnostic catheterization is feasible, safe, and provide help to guide decision making.

Compliance with guidelines and 1-year mortality in patients with acute myocardial infarction: a prospective study.

AIMS: In patients with acute myocardial infarction (MI), mortality can be predicted by risk scoring systems, but the impact of therapy recommended by guidelines is poorly documented. The aim of this study was to determine, taking into account the patient's condition at admission, to what extent the degree of guideline compliance influences the 1-year survival of patients admitted for acute MI. METHODS AND RESULTS: A 6-month registry was carried out in a geographically limited area, prospectively including all patients with acute MI. A risk score based on initial presentation, and a compliance index based on patient characteristics, type of MI, in-hospital management (including revascularization strategies and use of recommended drugs) were established. Patients were clinically followed at 1 year. A total of 754 patients, 333 ST elevation MI and 421 non-ST elevation MI, were included. The median compliance index (percentage of optimal compliance with guidelines) was 0.66 (95% CI 0.5;8.3). One-year mortality rate was 11.5%. By logistic regression, three variables were independently related to mortality: type of MI [OR=2.6 (1.5;4.3)], risk score [OR=2.4 (1.9;3.1) per additional 10%], and compliance index [OR=0.8 (0.7;0.9) per additional 10%]. CONCLUSION: A clear relationship between the extent of guideline implementation, and 1-year mortality was shown and this relationship remained strong after stratification on the risk score at admission and the type of MI. These data emphasize the need for thorough implementation of guidelines to improve the outcome of patients suffering from acute MI.

In-hospital and long-term outcome after sub-massive and massive pulmonary embolism submitted to thrombolytic therapy.

BACKGROUND: From a registry of 249 confirmed pulmonary embolism (PE) patients submitted to thrombolytic therapy (TT), we analysed predictors of in-hospital course and long-term mortality. METHODS AND RESULTS: The combined clinical end point of in-hospital course associated death, recurrent PE, repeat thrombolysis, surgical embolectomy or bleeding complications. The long-term follow-up included analysis of survival, and occurrence of PE-related events, defined as recurrent deep vein thrombosis, recurrent PE, occurrence of congestive heart failure or change of New York Heart Association functional class to class III or IV in patients who survived the acute phase.In-hospital clinical course was uneventful in 165 (66.3%) patients. Initial right ventricular (RV) dysfunction was reversible in 80% within 48 h following TT. Initial pulmonary vascular obstruction >70% (RR=5.3 [2.1; 13.6]); haemodynamic instability at presentation (RR=2.6 [1.1; 6]); persistence of septal paradoxical motion after TT (RR=5.9 [1.4; 25.9]); and insertion of intracaval filter (RR=3.7 [1.4; 9.4]) were independent predictors of poor in-hospital course. Mean follow-up was 5.3+/-2.6 years. Of the 227 patients alive after the hospital stay, the probability of survival was 92% at 1 year, 79% at 3 years and 56% at 10 years. Multivariate predictors of long-term mortality were age >75 years (RR=2.73 [2.18; 3.21]; P=0.0002), persistence of vascular pulmonary obstruction >30% after thrombolytic treatment (RR=2.22 [1.69; 2.74]; P=0.003), and cancer (RR=2.03 [1.40; 2.65]; P=0.04). CONCLUSION: The recovery of RV function should be considered as a marker of thrombolysis efficacy, while residual pulmonary vascular obstruction and cancer are independent predictors of long-term mortality. These results advocate the identification of high-risk patients by means of systematic lung-scan and echocardiography pre- and post-thrombolysis, and raise the question of the need for thromboendarterectomy in patients with residual pulmonary vascular obstruction.

Medical costs of intravascular ultrasound optimization of stent deployment. Results of the multicenter randomized 'REStenosis after Intravascular ultrasound STenting' (RESIST) study.

OBJECTIVE: Intravascular ultrasound (IVUS) can be used to optimize the deployment of stents. The aim of this study was to assess the acute and long-term medical costs of the use of IVUS through the results of the 'REStenosis after Intravascular ultrasound STenting' (RESIST) study. METHODS: One hundred and fifty-five patients were randomized to routine stent deployment with (n = 79) versus without (n = 76) IVUS guidance, with clinical follow-up over 18 months. The medical costs (hospitalization plus procedural costs) were calculated using a cost accounting system at the time of stent implantation and for all repeat lesion revascularizations. (At the time of writing the exchange rate was 1 Euro = 1 US dollar.) RESULTS: Because of the cost of IVUS catheters and the need for more balloons, acute procedural costs were 18% higher in the group with IVUS guidance (2934 +/- 670 Euros vs 2481 +/- 911 Euros). Clinical events (death, myocardial infarction, unstable angina or lesion revascularization) occurred in 28/76 (37%) in the group without IVUS, versus 20/79 (25%) (OR = 1.7; 95%CI = [0.82; 3.63]) in the group with IVUS. There was a higher number of revascularization procedures in the control group (31 in the control group vs 20 in the IVUS group). The cumulative medical costs at 18 months were only slightly higher in the IVUS group (4535 +/- 2020 Euros vs 4679 +/- 1471 Euros in the IVUS group), as the higher acute costs in the group with IVUS guidance were partially offset by the lower cost for revascularization procedures. Sensitivity analysis using variations of the unit costs as well as variations in the number of revascularization procedures and length of hospital stay showed that the overcost remained in a range between 1% and 7.6%. CONCLUSIONS: Over 18 months of followup, despite higher acute costs, IVUS optimization of stent deployment did not considerably increase the medical costs.