Routine CT angiography to detect severe coronary artery disease prior to transcatheter aortic valve replacement.

Patients undergoing TAVR undergo routine CT angiography (CTA) to assess aorto-iliac pathology and annular dimensions. While coronary CTA may exclude severe CAD in younger patients, its efficacy in defining CAD severity prior to TAVR may be limited. We retrospectively studied 50 consecutive patients undergoing both invasive coronary angiography (ICA) and routine pre-TAVR CTA. Severe CAD was defined as ≥50% stenosis by quantitative coronary angiography and compared to a blinded CTA visual estimation of ≥50% stenosis. The analysis was confined to four segments: left main and three proximal to mid major coronaries to maximize myocardial territory at risk. Coronary assessment was performed using standard reconstructed ECG phases from pre-TAVR chest CTA on a Philips 256 iCT scanner. Nearly ¾ of patients were ≥75 years old, 57% were female, half were diabetic and 45% had prior PCI. By ICA, 49% had significant coronary calcification. The incidence of severe proximal to mid vessel CAD by ICA was 39%. Similarly, a third of patients required PCI prior to TAVR. CTA was unable to exclude severe proximal to mid vessel CAD in 88% of patients in all four segments: non-diagnostic CTA readings were mainly due to calcification (60%) or motion artifact (28%). Non-diagnostic coronary CTA readings ranged from 25 to 72% according to segment analyzed: only the left main segment had diagnostic quality CTA in the majority of patients (p < 0.01). PCI is performed frequently prior to TAVR based upon invasive coronary angiographic assessment. Routine chest CTA algorithms do not provide adequate diagnostic information to exclude severe CAD, primarily due to severe coronary calcification in the TAVR population.

Platelet functions beyond hemostasis.

Although their central role is in the prevention of bleeding, platelets probably contribute to diverse processes that extend beyond hemostasis and thrombosis. For example, platelets can recruit leukocytes and progenitor cells to sites of vascular injury and inflammation; they release proinflammatory and anti-inflammatory and angiogenic factors and microparticles into the circulation; and they spur thrombin generation. Data from animal models suggest that these functions may contribute to atherosclerosis, sepsis, hepatitis, vascular restenosis, acute lung injury, and transplant rejection. This article represents an integrated summary of presentations given at the Fourth Annual Platelet Colloquium in January 2009. The process of and factors mediating platelet-platelet and platelet-leukocyte interactions in inflammatory and immune responses are discussed, with the roles of P-selectin, chemokines and Src family kinases being highlighted. Also discussed are specific disorders characterized by local or systemic platelet activation, including coronary artery restenosis after percutaneous intervention, alloantibody-mediated transplant rejection, wound healing, and heparin-induced thrombocytopenia.

Current treatment options for patients undergoing rescue coronary intervention.

The benefit of rescue angioplasty after failed thrombolysis was questionable after early studies demonstrated high rates of abrupt infarct artery closure and bleeding complications. Nevertheless, the lack of other good treatment options for patients failing thrombolytic therapy has led to persistent use of this treatment option. Fortunately, there have been significant improvements in the technology and pharmacology available for rescue interventions. In this review article, we describe the prior limitations of rescue angioplasty as well as the significant angiographic and clinical improvements seen in the current era of rescue coronary stenting.

Radiation-associated valvular heart disease in Hodgkin's disease is associated with characteristic thickening and fibrosis of the aortic-mitral curtain.

Radiation-associated valvular dysfunction is characterized by variable aortic and mitral valve thickening. A review of three patients assessed echocardiographically revealed that radiation-associated valvular dysfunction after radiation treatment for Hodgkin's disease may be characterized by a unique and consistent pattern of thickening of the aortic and mitral valves involving the aortic-mitral curtain.

Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective.

OBJECTIVES: The goal of this study was to examine long-term trends in the incidence, in-hospital and long-term mortality patterns in patients with an initial non-Q-wave myocardial infarction (NQWMI) as compared with those with an initial Q-wave myocardial infarction (QWMI). BACKGROUND: Limited data are available describing trends in the incidence and mortality from an initial QWMI and NQWMI from a multi-hospital community-wide perspective. METHODS: Our study was an observational study of 5,832 metropolitan Worcester, Massachusetts residents (1990 census = 437,000) hospitalized with validated initial acute MI in all greater Worcester hospitals during 11 annual periods between 1975 and 1997. RESULTS: The incidence of QWMI progressively decreased between 1975/78 (incidence rate = 171/100,000 population) and 1997 (101/100,000 population). In contrast, the incidence of NQWMI progressively increased between 1975/78 (62/100,000 population) and 1997 (131/100,000 population). Hospital death rates were 19.5% for patients with QWMI and 12.5% for those with NQWMI. After controlling for various covariates, patients with QWMI remained at significantly increased risk for hospital mortality (adjusted odds ratio = 1.63; 95% confidence interval: 1.35, 1.97). While the hospital mortality of QWMI has progressively declined over time (1975/78 = 24%; 1997 = 14%), the in-hospital mortality for NQWMI has remained the same (1975/78 = 12%; 1997 = 12%). These trends remained after adjusting for potentially confounding prognostic factors. The multivariable adjusted two-year mortality after hospital discharge declined over time for patients with QWMI and NQWMI. CONCLUSIONS: Despite impressive declines in the incidence, in-hospital and long-term mortality associated with QWMI, NQWMI is increasing in frequency and has the same in-hospital mortality now as it did 22 years ago.

Evaluation of CoaguChek Pro ACT in cardiac catheterization laboratory.

The objective of this study was to assess the analytical performance of CoaguChek Pro ACT assay versus Hemochron Celite ACT assay concerning activated clotting time (ACT) values and the correlations versus heparin. Enrolled were 158 patients and 101 normal subjects from five cardiac catheterization laboratories (cathlabs). Two different CoaguChek Pro ACT lots were compared to different lots of Hemochron Celite ACT. All sites used arterial blood and one site also used venous blood. Determinations were carried out before and directly after heparinization, and 1-4 h later. Besides the ACT values, hematocrit, platelet counts and factor Xa levels were also determined. The correlations between the Hemochron Celite lots and the two different CoaguChek Pro lots for arterial and venous blood for all sites were good (r=0.88 and 0.84). The agreement between both CoaguChek Pro ACT lots was excellent (r=0.99). The correlations between heparin and CoaguChek Pro ACT were similar to those for the Hemochron Celite lots. There was no influence of the hematocrit and the platelets. The imprecision of the method was very good (CV<6%). This demonstrates that the CoaguChek Pro ACT assay is especially useful for monitoring heparin in cathlabs.

Outcomes and early revascularization for patients > or = 65 years of age with cardiogenic shock.

Hospital survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock has improved during recent years. It is unclear whether this mortality benefit also applies to elderly patients with cardiogenic shock. Elderly residents (age > or = 65 years) of the Worcester, Massachusetts metropolitan area (1990 census population = 437,000) hospitalized with confirmed AMI and cardiogenic shock in all metropolitan Worcester, Massachusetts hospitals between 1986 and 1997 constituted the sample of interest. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in a cohort of 166 cardiogenic patients treated early in the reperfusion era (1986 to 1991) compared with 144 patients with AMI treated approximately 1 decade later (1993 to 1997). There was a significant increase in the use of an early revascularization strategy over time (2% vs 16%, p <0.001). Marked increases in use of antiplatelet therapy, beta blockers, and angiotensin-converting enzyme inhibitors were also observed over the decade-long experience. In-hospital case fatality declined significantly over time, from 80% (1986 to 1991) to 69% (1993 to 1997) in elderly patients who developed cardiogenic shock (p = 0.03). After adjusting for differences in potentially confounding prognostic characteristics between patients hospitalized in the 2 study periods, an even more pronounced reduction in hospital mortality (42%) was observed for the most recently hospitalized cohort. The most powerful predictor of in-hospital survival was use of an early revascularization approach to treatment. Thus, hospital mortality has declined for patients > or = 65 years of age with AMI complicated by cardiogenic shock, and this decline has occurred in the setting of broader use of early revascularization and adjunctive medical therapy for this high-risk population.

Rotational atherectomy or balloon angioplasty in the treatment of intra-stent restenosis: BARASTER multicenter registry.

The BARASTER registry was formed to evaluate the initial success and long-term results of rotational atherectomy in the management of in-stent restenosis. Rotational atherectomy was used in 197 cases of in-stent restenosis: 46 with stand-alone rotational atherectomy or at most 1 atmosphere of balloon inflation (Rota strategy), and 151 with rotational atherectomy and adjunctive balloon angioplasty <1 atmosphere (Combination strategy). These were compared with 107 episodes of in-stent restenosis treated with balloon angioplasty alone. In this observational study, the use of Combination therapy was associated with a slightly higher initial success rate (95% vs. 87% with the Rota strategy and 89% with Balloons, P = 0.08). There was a reduction in one year clinical outcomes (death, myocardial infarction or target lesion revascularization) in the combination group (38% vs. 60% with Rota and 52% with balloons, P = 0.02). These data support a benefit of the strategy of debulking with rotational atherectomy followed by adjunctive balloon angioplasty, in the management of in-stent restenosis.

The impact of the stent era on the management strategy for acute myocardial infarction: A population-based perspective.

We determined trends in the use of invasive diagnostic and revascularization strategies from a multihospital community-wide perspective for patients suffering acute myocardial infarction (AMI). Comparing 3,824 patients treated in the prestent era (1986-1993) to 1,915 patients hospitalized during the stent era (1995-1997), there was a significant increase in the use of invasive procedures and revascularization techniques across a broad spectrum of AMI patients during their index hospitalization. This resulted in a higher-risk profile of patients referred for invasive management of AMI in the stent era. Cathet. Cardiovasc. Intervent. 51:255-258, 2000.

Ten-year trends in the incidence, treatment, and outcome of Q-wave myocardial infarction.

The benefits of coronary reperfusion and antiplatelet therapy for patients with Q-wave acute myocardial infarction (Q-AMI) are well established in the context of randomized, controlled trials. The use and recent impact of these and other therapies on the broader, community-wide population of patients with Q-AMI is less well established. Residents of the Worcester, Massachusetts, metropolitan area (1990 census population 437,000) hospitalized with confirmed Q-AMI in all metropolitan Worcester, Massachusetts, hospitals in 4 1-year periods between 1986 and 1997 comprised the sample of interest. We examined the rates of occurrence, use of reperfusion strategies, and hospital mortality in a cohort of 711 patients with Q-AMI treated early in the reperfusion era (1986 and 1988) in comparison to 669 patients with Q-AMI treated a decade later (1995 and 1997). The percentage of Q-AMI among all hospitalized patients with AMI decreased over the decade of reperfusion therapy: 52% in 1986 and 1988 versus 35% in 1995 and 1997 (p < 0.001). Use of reperfusion therapy for patients with Q-AMI increased from 22% to 57%, with a marked increase in the use of primary angioplasty over time (1% vs 16%). The profile of patients receiving reperfusion therapy also changed significantly over the study period. Marked increases in use of antiplatelet therapy, beta blockers, angiotensin-converting enzyme inhibitors, and decreased use of calcium channel blockers, were observed over time. The crude in-hospital case fatality rate declined from 19% (1986 and 1988) to 14% (1995 and 1997) in patients with Q-AMI. Results of a multivariable regression analysis showed lack of reperfusion therapy, older age, anterior wall AMI, and cardiogenic shock to be independent predictors of in-hospital mortality in patients with Q-AMI. Thus, the percentage of all AMI's presenting as Q-AMI, and hospital mortality after Q-AMI, has decreased significantly in the past 10 years. The decrease in mortality occurs in the setting of broader use of reperfusion and adjunctive therapy (including primary angioplasty).

Predictors of bleeding complications after rescue coronary interventions.

The purpose of this study was to determine predictors of bleeding complications after current rescue coronary interventions including stenting and adjunctive platelet inhibitors. Previous studies of rescue angioplasty for thrombolytic failure have identified variable rates of bleeding complications with balloon angioplasty alone. Although coronary stents and glycoprotein 2b/3a inhibitors have been shown to improve outcome in a wide variety of coronary interventions, the impact of these therapies on bleeding complications after rescue coronary intervention has not been determined. From 1996 through 1998, we treated 108 consecutive patients with rescue coronary intervention (defined as attempted coronary intervention within 12 hours of thrombolysis for ongoing symptoms or electrocardiogram [ECG] changes) including conventional percutaneous transluminal coronary artery (PTCA), stenting (n = 45), and glycoprotein 2b/3a inhibitor use (n = 31). In-hospital clinical outcomes were obtained in all patients, and univariate and multivariate predictors of bleeding complications were identified. In hospital, moderate to severe bleeding complications occurred in 17.6% of the cohort, but the rate of severe bleeding complications (2.7%) and vascular repair (1.9%) were low. Independent predictors of bleeding complications were age > 60y, female gender, cardiogenic shock, and streptokinase use. Neither the delayed use of abciximab (on average 4 hours after thrombolytic therapy initiation) nor the use of rescue stenting were predictors of increased moderate to severe bleeding complications. Current rescue coronary intervention, including stents and platelet inhibitors, is associated with a low rate of severe bleeding complications. Moderate to severe bleeding complications were more common in selected subgroups of patients but not increased significantly by stenting or delayed abciximab use.

Angiographic and clinical outcomes after rescue coronary stenting.

The role of coronary stenting in improving outcomes after failed thrombolysis has not been well described. This study represents a registry of rescue coronary interventions performed during a 3 year period in which interventional treatment was changing for this high risk population. We analyzed acute angiographic results and clinical outcomes in 108 consecutive patients treated for thrombolytic failure with either balloon angioplasty (n = 63) or coronary stenting (n = 45). The overall in-hospital mortality rate was 5.5%, and there was no increase in complications in the stent group. Coronary stenting was associated with improved angiographic results including lower residual stenosis in the culprit artery (15 +/- 10% vs. 31 +/- 22%, P < 0.001) without increasing bleeding complications. The rate of in-hospital and long term target vessel revascularization in the stent group was significantly lower than in the unmatched PTCA group. Rescue coronary stenting is safe, improves acute angiographic results compared to PTCA alone and leads to excellent in-hospital and long term outcomes.

Outcome of patients with acute myocardial infarction who are ineligible for primary angioplasty trials.

We determined acute outcome in 148 consecutive patients with ST segment elevation myocardial infarction undergoing angioplasty including 72 patients (48.7%) considered ineligible for primary angioplasty trials. Overall, in-hospital mortality for acute infarct angioplasty was 12%, with fivefold higher mortality in the trial-ineligible group (21% vs. 4%, P = 0.003). Thus, primary angioplasty trials continue to exclude nearly 50% of acute infarction patients and reported mortality rates of primary angioplasty trials are likely to be significantly lower than the unselected in-hospital mortality rates. Cathet. Cardiovasc. Intervent. 49:237-243, 2000.

Treatment options for acute myocardial infarction complicated by cardiogenic shock.

Hospital survival of patients with acute myocardial infarction complicated by cardiogenic shock has improved during recent years. Before the 1990s, emphasis on a medical and supportive approach to treatment of these high-risk patients (including thrombolytic therapy) was not clearly associated with improving outcomes. However, in the past decade, the interventional approach to treatment of acute myocardial infarction complicated by cardiogenic shock (mainly acute infarct angioplasty) has led to an improving prognosis across a broad spectrum of patients with cardiogenic shock.

Treatment options for coronary stent restenosis.

Treatment of in-stent restenosis with balloon angioplasty alone is adequate for focal lesions but is associated with a 50% recurrence rate for diffuse lesions. For diffuse in-stent restenosis, debulking with atherectomy or laser can significantly reduce the recurrence rate.

Mechanical debulking versus balloon angioplasty for the treatment of true bifurcation lesions.

OBJECTIVES: The purpose of this study was to compare the immediate angiographic and long-term results of debulking versus balloon angioplasty for treatment of true bifurcation lesions. BACKGROUND: Previous studies have shown true bifurcation lesions to be a high risk morphological subset for percutaneous transluminal coronary angioplasty (PTCA). Although atherectomy devices have been used to treat bifurcation lesions, no studies have compared the outcomes of these alternative treatment modalities. METHODS: Between January 1992 and May 1997, we treated 70 consecutive patients with true bifurcation lesions (defined as a greater than 50% stenosis in both the parent vessel and contiguous side branch) with conventional PTCA (n = 30) or debulking (with rotational or directional atherectomy) plus adjunctive PTCA (n = 40). Paired angiograms were analyzed by quantitative angiography, and clinical follow-up was obtained in all patients. RESULTS: Acute procedural success was 73% in the PTCA group and 97% in the debulking group (p = 0.01). Major in-hospital complications occurred in two patients in the PTCA group and one in the debulking group. Treatment with atherectomy plus PTCA resulted in lower postprocedure residual stenoses than PTCA alone (16+/-15% vs. 33+/-17% in the parent vessel, and 6+/-15% vs. 39+/-22% in the side branch; p < 0.001 for both comparisons). At 1 year follow-up, the incidence of target vessel revascularization (TVR) was 53% in the PTCA group as compared with 28% in the debulking group (p = 0.05). Independent predictors of the need for repeat TVR were side branch diameter >2.3 mm, longer lesion lengths, and treatment with PTCA alone. CONCLUSIONS: For the treatment of true bifurcation lesions, atherectomy with adjunctive PTCA is safe, improves acute angiographic results, and decreases target vessel revascularization compared to PTCA alone. The benefits of debulking for bifurcation lesions were especially seen in lesions involving large side branches.

Mechanical debulking versus balloon angioplasty for the treatment of diffuse in-stent restenosis.

Previous studies have shown a high rate of repeat intervention after treating diffuse in-stent restenosis with percutaneous transluminal coronary angioplasty (PTCA) alone. It is not clear whether debulking with atherectomy is more effective in this condition. Between January 1994 and February 1997, we treated 60 consecutive patients with diffuse in-stent restenosis of a native coronary artery using conventional PTCA (n=30) or debulking (with rotational or directional atherectomy) plus adjunctive PTCA (n=30). Paired angiograms were analyzed by quantitative angiography, and clinical follow-up was obtained in all patients at 1 month, 6 months, and 1 year after revascularization. The mean lesion lengths were 13.5+/-8.3 and 18.4+/-13.2 mm in the debulking and PTCA groups, respectively (p=0.09). Acute procedural success was 100% in both cohorts, with no major complications in either group. Treatment with atherectomy plus adjunctive PTCA resulted in lower postprocedure stenoses (18+/-10 vs 26+/-13%, p=0.01) than treatment with balloon angioplasty alone. At 1-year follow-up, repeat target vessel revascularization was required in 28% of patients in the debulking group compared with 46% in the PTCA group (p=0.18). Independent predictors of the need for repeat target vessel revascularization were longer lesion lengths, diabetes mellitus, and smaller postprocedure lumen diameter. Thus, the strategy of atherectomy and adjunctive PTCA for diffuse in-stent restenosis is safe, improves acute angiographic results compared with PTCA alone, and may decrease the need for target vessel revascularization.

Rotational atherectomy for the treatment of restenotic ostial side branches jailed by prior stent placement.

This report describes the treatment by rotational atherectomy of three restenotic ostial diagonal lesions that originated within stented segments of the left anterior descending artery. Excellent results were obtained without complications to stent architecture.