Interaction between the Kansas City Cardiomyopathy Questionnaire and the Pocock's clinical score in predicting heart failure outcomes.

PURPOSE: Heart failure (HF) is a complex syndrome. Its appropriate management should combine several health measurements. We assessed the relationship between the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Pocock's clinical score. METHODS: We conducted a prospective registry of HF outpatients. The main outcome was occurrence of death or hospitalization during a 6-month follow-up. A multivariate logistic regression was performed, including the KCCQ overall summary score, the Pocock's clinical score and their interaction in the model. RESULTS: From January 2008 to December 2010, 143 patients were involved. Mean age of patients was 68 years, and 74% were men. KCCQ's overall summary score and Pocock's clinical score were inversely correlated (r = -0.24, p = 0.026). A total of 61 (42.7%) events occurred. There was a high proportion of events (77.8%) in patients with a Pocock's clinical score > 50%, whatever the KCCQ score value. When the KCCQ score was ≤ 50 %, there was a low increase in risk as the Pocock's clinical score increased (OR 2.0 [0.6; 6.6]). However, when the KCCQ score was between 50 and 75 or ≥ 75 %, there was a high increase in risk as the Pocock's clinical score increased (OR 6.9 [1.2; 38.9] and OR 7.4 [0.8; 69.7], respectively). CONCLUSIONS: Patients with a high Pocock's clinical score are at a high risk of death or hospitalization. For patients with a low Pocock's clinical score, the KCCQ score can identify those at risk of these events.

The evolution of the CTO-PCI landscape in Belgium and Luxembourg: a four-year appraisal.

BACKGROUND: To chart the evolution of the CTO-PCI landscape in Belgium and Luxembourg, the Belgian Working Group on Chronic Total Occlusions (BWGCTO) was established in 2016. METHODS: Between May 2016 and December 2019, patients undergoing a CTO-PCI treatment were prospectively and consecutively enrolled. Twenty-one centres in Belgium and one in Luxembourg participated. Individual operators had mixed levels of expertise in treating CTO lesions. Demographic, angiographic, procedural parameters and incidence of major adverse cardiac and cerebrovascular events (MACCE) were systematically registered. RESULTS: Over a four-year enrolment period, 1832 procedures were performed in 1733 patients achieving technical success in 1474 cases (80%), with an in-hospital MACCE rate of 2.3%. Fifty-nine (3%) cases were re-attempt procedures of which 41 (69%) were successful. High-volume centres treated more complex lesions (mean J-CTO score: 2.15 ± 1.21) as compared to intermediate (mean J-CTO score: 1.72 ± 1.23; p < 0.001) and low-volume centres (mean J-CTO score: 0.99 ± 1.21; p = 0.002). Despite this, success rates did not differ between centres (p = 0.461). Overall success rates did not differ over time (p = 0.810). High-volume centres progressively tackled more complex CTOs while keeping success rates stable. In all centres, the most applied strategy was antegrade wire escalation (83%). High-volume centres more often successfully applied antegrade dissection and re-entry and retrograde techniques in lesions with higher complexity. CONCLUSION: With variable experience levels, operators treated CTOs with high success and relatively few complications. Although AWE remains the most used technique, it is paramount for operators to be skilled in all contemporary techniques in order to be successful in more complex CTOs.

Assessing the landscape of percutaneous coronary chronic total occlusion treatment in Belgium and Luxembourg: the Belgian Working Group on Chronic Total Occlusions (BWGCTO) registry.

Background: Important developments in materials, devices, and techniques have improved outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), and resulted in a growing interest in CTO-PCI. The Belgian Working Group on Chronic Total Occlusions (BWGCTO) working group aims to assess the evolution within the CTO-PCI landscape over the next years. Methods: From May 2016 onwards, patients undergoing CTO-PCI were included in the BWGCTO registry by 15 centres in Belgium and Luxemburg. Baseline, angiographic, and procedural data were collected. Here, we report on the one-year in-hospital outcomes. Results: Over the course of one year, 411 procedures in 388 patients were included with a mean age of 64 ± 11 years. The majority were male (81%). Relatively complex CTOs were treated (Japanese CTO score =2.2 ± 1.2) with a high procedure success rate (82%). Patient- and lesion-wise success rates were 83 and 85%, respectively. Major adverse in-hospital events were acceptably low (3.4%). Antegrade wire escalation technique was applied most frequently (82%). On the other hand, antegrade dissection and re-entry and retrograde strategies were more frequently applied in higher volume centres and successful for lesions with higher complexity. Conclusion: Satisfactory procedural outcomes and a low rate of adverse events were obtained in a complex CTO population, treated by operators with variable experience levels. Antegrade wire escalation was the preferred strategy, regardless of operator volume.

Time-dependent effects on coronary remodeling and epicardial conductance after intracoronary injection of enriched hematopoietic bone marrow stem cells in patients with previous myocardial infarction.

Bone marrow (BM) cells may interact with coronary endothelium and modulate coronary atherosclerosis. We investigated the time course of coronary luminal loss and changes in conductance after intracoronary injection of enriched hematopoietic BM stem cells in patients with previous myocardial infarction (MI). Among 24 patients with acute MI, 13 were randomized to early (<7 days) and 11 to late (4 months) intracoronary injection of CD133+ cells after the infarction. Segmental quantitative coronary angiography and fractional flow reserve (FFR) measurements of the infarct-related (IR) artery (A) and contralateral artery (control) were performed. In the early group, at 4 months, cumulative luminal loss (LL) of the minimal luminal diameter (MLD) of the IRA distal to the stented segment was -0.39 (-0.51-0.10) mm (p < 0.05 vs. control). There was no further change in LL between 4 and 8 months [-0.09 (-0.26-0.15) mm]. In parallel, FFR decreased at 4 months [-0.16 (-0.26-0.001), p < 0.05 vs. control] but slightly increased from 4 to 8 months follow-up [+0.05 (-0.10-0.09)]. In the late group, LL of the MLD of the IRA distal to the stented segments was -0.12 (-0.47-0.07) mm (NS vs. control) at 4 months and further -0.07 (-0.25-0.05) mm (NS) between 4 and 8 months. At 8 months, the total LL of the MLD in the early and late group was only slightly higher compared to control [-0.34 (-0.48--0.16), -0.36 (-0.69--0.09), and -0.12 (-0.39-0.05) mm, respectively, NS]. Early intracoronary administration of hematopoietic BM stem cells in patients with previous MI is associated with accelerated luminal loss and reduced conductance of the infarct-related artery.

Long-term effect of molsidomine, a direct nitric oxide donor, as an add-on treatment, on endothelial dysfunction in patients with stable angina pectoris undergoing percutaneous coronary intervention: results of the MEDCOR trial.

OBJECTIVE: The MEDCOR trial is a double-blind, randomized study aiming at demonstrating the superiority of molsidomine (direct NO donor) over placebo, used as add-on treatments, on improving endothelial function (EF) after 12 months, in stable angina patients undergoing percutaneous coronary intervention. METHODS: EF was assessed by peripheral vasodilator response (i.e. Endoscore) using arterial tonometry and by several biomarkers, in terms of changes versus baseline after a one-year treatment. RESULTS: The change in Endoscore was +75 ± 130% in placebo group and +39 ± 145% in molsidomine group (p = 0.143). There was a decrease in sICAM-1 with molsidomine (-6%) and an increase with placebo (+6%). The MPO activity/antigen ratio slightly increased with placebo (+9%) and strongly decreased with molsidomine (-42%) (p = 0.020). CONCLUSION: The MEDCOR trial was not able to demonstrate significant differences between molsidomine and placebo for all parameters, except the MPO activity/antigen ratio which significantly decreased with molsidomine (p = 0.020 versus placebo).

Double-blind parallel placebo-controlled study to evaluate the effect of molsidomine on the endothelial dysfunction in patients with stable angina pectoris undergoing percutaneous coronary intervention: the MEDCOR Trial.

The effects of molsidomine (a direct nitric oxide donor) on the endothelial dysfunction have never been evaluated using reactive hyperemia peripheral arterial tonometry (RH-PAT). The objective of the MEDCOR double-blind trial will be to demonstrate the superiority of molsidomine (Coruno® 16 mg, once daily) over placebo, on improving the endothelial function (Endoscore by RH-PAT) after 12 months of treatment in stable angina patients undergoing elective percutaneous coronary intervention (PCI). Study design will take care of the real-life situation, in which patients are being offered PCI and stent placement (drug-eluting or bare metal), but also gold standard medical therapy (beta-blockers, statins, angiotensin-converting enzyme inhibitors (ACEIs), and/or calcium antagonists). Demonstrating clinical and statistical superiority of the study drug over placebo will be a real challenge. Therefore, a sequential approach has been designed with a pilot phase aiming at recruiting 50 patients. Upon evaluation of the results by an independent data steering committee, a larger sample size phase will eventually be considered.

Transcriptional fingerprint of human whole blood at the site of coronary occlusion in acute myocardial infarction.

AIMS: Transcriptome patterns associated with acute myocardial infarction at the site of coronary occlusion are largely unknown. The aim of this study was to decipher the angiogenic, atherosclerotic, and inflammatory mRNA profiles in whole blood samples collected at the site of coronary occlusion in patients with ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: In five consecutive patients with STEMI, blood was sampled at the site of occlusion (local) and in the systemic circulation (peripheral) during primary percutaneous coronary intervention. RNA was extracted from whole blood samples. Among 221 genes involved in angiogenesis, inflammation and atherosclerosis, 24 were shown to be differentially modulated locally, by analysis with custom-designed DNA array technology. Validation in 28 distinct STEMI patients using real-time quantitative PCR identified seven out of these 24 genes to be consistently and significantly upregulated in local versus peripheral blood (p<0.05). Three genes were chemokine family members (CCL2, CCL18 and CXCL12), three genes belonged to the cell-cell and cell-extracellular matrix family (FN1, CDH5 and SPP1), and one gene was representative of the lipoprotein family (APOE). CONCLUSIONS: We identified a set of whole blood transcripts induced at the site of coronary occlusion in the acute phase of myocardial infarction. Resolved genes indicate a predominant role for chemokines, cell-extracellular matrix, and lipoprotein alterations in the pathophysiology of acute myocardial infarction and the initial response to myocardial injury.

Direct volumetric blood flow measurement in coronary arteries by thermodilution.

OBJECTIVES: This study sought to validate a new method for direct volumetric blood flow measurement in coronary arteries in animals and in conscious humans during cardiac catheterization. BACKGROUND: Direct volumetric measurement of blood flow in selective coronary arteries would be useful for studying the coronary circulation. METHODS: Based on the principle of thermodilution with continuous low-rate infusion of saline at room temperature, we designed an instrumental setup for direct flow measurement during cardiac catheterization. A 2.8-F infusion catheter and a standard 0.014-inch sensor-tipped pressure/temperature guidewire were used to calculate absolute flow (Q(thermo)) in a coronary artery from the infusion rate of saline, temperature of the saline at the tip of the infusion catheter, and distal blood temperature during infusion. The method was tested over a wide range of flow rates in 5 chronically instrumented dogs and in 35 patients referred for physiological assessment of a coronary stenosis or for percutaneous coronary intervention. RESULTS: Thermodilution-derived flow corresponded well with true flow (Q) in all dogs (Q(thermo) = 0.73 Q + 42 ml/min; R(2) = 0.72). Reproducibility was excellent (Q(thermo,)(1) = 0.96 x Q(thermo,)(2) + 3 ml/min; R(2) = 0.89). The measurements were independent of infusion rate and sensor position as predicted by theory. In the humans, a good agreement was found between increase of thermodilution-derived volumetric blood flow after percutaneous coronary intervention and increase of fractional flow reserve (R(2) = 0.84); reproducibility of the measurements was excellent (Q(thermo,)(1) = 1.0 Q(thermo,)(2) + 0.9 ml/min, R(2) = 0.97), and the measurements were independent of infusion rate and sensor position. CONCLUSIONS: Using a suitable infusion catheter and a 0.014-inch sensor-tipped guidewire for measurement of coronary pressure and temperature, volumetric blood flow can be directly measured in selective coronary arteries during cardiac catheterization.