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AIMS: Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken. METHODS AND RESUTS: Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar [percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18]. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older [72 (64-77) vs. 67 (61-73) years, P < 0.001] and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock [adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach [aHR 1.44 (1.01-2.05), P = 0.042], and number of vessels with coronary artery disease [aHR 1.22 (1.01-1.47), P = 0.043] were independently associated with long-term mortality. CONCLUSION: Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.
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Infarto de la Pared Anterior del Miocardio , Defectos del Tabique Interventricular , Infarto del Miocardio , Humanos , Choque Cardiogénico/etiología , Cuidados Posteriores , Resultado del Tratamiento , Alta del Paciente , Defectos del Tabique Interventricular/cirugía , Sistema de Registros , Reino Unido/epidemiología , Estudios RetrospectivosRESUMEN
Acquired ventricular wall ruptures can be life-threatening. Depending on the pathological features and anatomy, surgical repair can be technically challenging and may be associated with high morbidity and mortality. We present 3 successful percutaneous repairs of different ruptures that used a variety of techniques. (Level of Difficulty: Advanced.).
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Tabique Interatrial , Cateterismo Cardíaco/instrumentación , Circulación Coronaria , Oxigenación por Membrana Extracorpórea , Rotura Cardíaca/terapia , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Hemodinámica , Enfermedad Iatrogénica , Insuficiencia de la Válvula Mitral/cirugía , Tabique Interatrial/diagnóstico por imagen , Tabique Interatrial/fisiopatología , Cateterismo Cardíaco/efectos adversos , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/cirugía , Ecocardiografía Transesofágica , Rotura Cardíaca/diagnóstico por imagen , Rotura Cardíaca/etiología , Rotura Cardíaca/fisiopatología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
AIM: Fractional flow reserve (FFR) allows for physiological definition of coronary lesion severity but requires induction of maximal coronary circulation hyperemia with administration of adenosine leading to coronary resistive vessel vasodilatation. However, the hyperemic response to adenosine, and therefore the calculation of FFR, may be affected by dysfunction of the coronary microvasculature. The aim was to define the relationship between basal Pd /Pa and FFR and identify lesion-independent predictors of the change in Pd /Pa with hyperemia. METHODS AND RESULTS: One hundred and sixty-six consecutive patients undergoing FFR measurement were prospectively enrolled (mean age 62.6 ± 10.3 years, 27% females). Basal Pd /Pa , FFR, and delta Pd /Pa (difference between basal Pd /Pa and FFR) were recorded. Independent predictors of delta Pd /Pa included angiographic lesion severity, lesion length, gender, body mass index, and total cholesterol:HDL cholesterol ratio. The best basal Pd /Pa cutoff value to predict lesion physiological significance was 0.87 (positive predictive value of 100% for an FFR value ≤0.80) and the best cutoff for nonsignificance was 0.93 (negative predictive value of 98% for an FFR value >0.80). CONCLUSION: The delta Pd /Pa may be affected by patient gender, body mass index, and cholesterol profile. A basal Pd /Pa value of ≥0.93 is highly predictive of an FFR >0.80. Conversely, a basal Pd /Pa value of ≤0.87 is highly predictive of an FFR ≤0.80. © 2017 Wiley Periodicals, Inc.
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Presión Sanguínea , Cateterismo Cardíaco/métodos , Enfermedad de la Arteria Coronaria/diagnóstico , Estenosis Coronaria/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Reserva del Flujo Fraccional Miocárdico , Adenosina/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Índice de Masa Corporal , Colesterol/sangre , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/fisiopatología , Estenosis Coronaria/sangre , Estenosis Coronaria/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Femenino , Humanos , Hiperemia/fisiopatología , Masculino , Microcirculación , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Factores Sexuales , Vasodilatadores/administración & dosificaciónRESUMEN
BACKGROUND: Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery. METHODS: All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up. RESULTS: Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002). CONCLUSION: Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.
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Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Válvula Mitral/cirugía , Complicaciones Posoperatorias/etiología , Falla de Prótesis/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter , Adulto , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/métodos , Femenino , Insuficiencia Cardíaca/etiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Irlanda , Masculino , Persona de Mediana Edad , Reoperación/métodos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Reino UnidoAsunto(s)
Embolia Paradójica/complicaciones , Foramen Oval Permeable/complicaciones , Infarto del Miocardio/etiología , Trombosis de la Vena/complicaciones , Adulto , Angiografía Coronaria , Embolia Paradójica/diagnóstico , Femenino , Foramen Oval Permeable/diagnóstico , Humanos , Imagen por Resonancia Magnética , Masculino , Infarto del Miocardio/diagnóstico , Ultrasonografía Doppler en Color , Trombosis de la Vena/diagnóstico , Adulto JovenRESUMEN
BACKGROUND: Cardiovascular magnetic resonance (CMR) is the gold standard non-invasive method for determining left ventricular (LV) mass and volume but has not been used previously to characterise the LV remodeling response in aortic stenosis. We sought to investigate the degree and patterns of hypertrophy in aortic stenosis using CMR. METHODS: Patients with moderate or severe aortic stenosis, normal coronary arteries and no other significant valve lesions or cardiomyopathy were scanned by CMR with valve severity assessed by planimetry and velocity mapping. The extent and patterns of hypertrophy were investigated using measurements of the LV mass index, indexed LV volumes and the LV mass/volume ratio. Asymmetric forms of remodeling and hypertrophy were defined by a regional wall thickening ≥ 13 mm and >1.5-fold the thickness of the opposing myocardial segment. RESULTS: Ninety-one patients (61 ± 21 years; 57 male) with aortic stenosis (aortic valve area 0.93 ± 0.32 cm2) were recruited. The severity of aortic stenosis was unrelated to the degree (r2=0.012, P=0.43) and pattern (P=0.22) of hypertrophy. By univariate analysis, only male sex demonstrated an association with LV mass index (P=0.02). Six patterns of LV adaption were observed: normal ventricular geometry (n=11), concentric remodeling (n=11), asymmetric remodeling (n=11), concentric hypertrophy (n=34), asymmetric hypertrophy (n=14) and LV decompensation (n=10). Asymmetric patterns displayed considerable overlap in appearances (wall thickness 17 ± 2mm) with hypertrophic cardiomyopathy. CONCLUSIONS: We have demonstrated that in patients with moderate and severe aortic stenosis, the pattern of LV adaption and degree of hypertrophy do not closely correlate with the severity of valve narrowing and that asymmetric patterns of wall thickening are common.
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Estenosis de la Válvula Aórtica/diagnóstico , Cardiomiopatía Hipertrófica/diagnóstico , Hipertrofia Ventricular Izquierda/diagnóstico , Imagen por Resonancia Cinemagnética/métodos , Función Ventricular Izquierda , Remodelación Ventricular , Anciano , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/fisiopatología , Cardiomiopatía Hipertrófica/complicaciones , Cardiomiopatía Hipertrófica/fisiopatología , Diagnóstico Diferencial , Femenino , Ventrículos Cardíacos/patología , Ventrículos Cardíacos/fisiopatología , Humanos , Hipertrofia Ventricular Izquierda/etiología , Hipertrofia Ventricular Izquierda/fisiopatología , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: To assess the effect of long-acting local anesthetic (levobupivacaine) in addition to lidocaine for the management of femoral artery sheaths during and after percutaneous coronary intervention (PCI). BACKGROUND: Femoral artery sheaths are commonly used during PCI. Sheath removal is often delayed after the procedure by which time short-acting local anesthetic agents may no longer be effective. METHODS: Sixty patients were randomized to either usual care or the administration of local levobupivacaine after PCI. Patients were asked to report their pain experienced on a visual analogue score. RESULTS: Thirty patients received additional levobupivacaine (0.5%) and 30 received standard care. There were no procedural differences between the groups, except that more patients in the control group received intravenous (IV) morphine at the time of sheath removal. There was no difference between the control group and levobupivacaine group in pain scores at the time of sheath insertion. (2.0 +/- 0.4 versus 1.8 +/- 0.3; p = 0.80). Both groups recorded low pain scores while waiting for sheath removal, and the score was slightly (but not significantly) lower in the levobupivacaine group (1.3 +/- 0.2 versus 0.8 +/- 0.2; p = 0.09). Pain scores were lower in the levobupivacaine group during sheath removal 2.2 +/- 0.4 versus 1.1 +/- 0.2; p = 0.02). There were no differences in terms of blood pressure between the groups at any time point. CONCLUSIONS: Levobupivacaine reduced the need for IV opiate and provided better analgesia than lidocaine alone in patients undergoing PCI.
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Anestesia Local/métodos , Anestésicos Locales/uso terapéutico , Angioplastia Coronaria con Balón/métodos , Enfermedad Coronaria/terapia , Arteria Femoral , Dolor/tratamiento farmacológico , Anciano , Bupivacaína/análogos & derivados , Bupivacaína/uso terapéutico , Preparaciones de Acción Retardada/uso terapéutico , Estudios de Seguimiento , Humanos , Periodo Intraoperatorio , Levobupivacaína , Persona de Mediana Edad , Dolor/diagnóstico , Dimensión del Dolor , Periodo Posoperatorio , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Calcific aortic stenosis has many characteristics in common with atherosclerosis, including hypercholesterolemia. We hypothesized that intensive lipid-lowering therapy would halt the progression of calcific aortic stenosis or induce its regression. METHODS: In this double-blind, placebo-controlled trial, patients with calcific aortic stenosis were randomly assigned to receive either 80 mg of atorvastatin daily or a matched placebo. Aortic-valve stenosis and calcification were assessed with the use of Doppler echocardiography and helical computed tomography, respectively. The primary end points were change in aortic-jet velocity and aortic-valve calcium score. RESULTS: Seventy-seven patients were assigned to atorvastatin and 78 to placebo, with a median follow-up of 25 months (range, 7 to 36). Serum low-density lipoprotein cholesterol concentrations remained at 130+/-30 mg per deciliter in the placebo group and fell to 63+/-23 mg per deciliter in the atorvastatin group (P<0.001). Increases in aortic-jet velocity were 0.199+/-0.210 m per second per year in the atorvastatin group and 0.203+/-0.208 m per second per year in the placebo group (P=0.95; adjusted mean difference, 0.002; 95 percent confidence interval, -0.066 to 0.070 m per second per year). Progression in valvular calcification was 22.3+/-21.0 percent per year in the atorvastatin group, and 21.7+/-19.8 percent per year in the placebo group (P=0.93; ratio of post-treatment aortic-valve calcium score, 0.998; 95 percent confidence interval, 0.947 to 1.050). CONCLUSIONS: Intensive lipid-lowering therapy does not halt the progression of calcific aortic stenosis or induce its regression. This study cannot exclude a small reduction in the rate of disease progression or a significant reduction in major clinical end points. Long-term, large-scale, randomized, controlled trials are needed to establish the role of statin therapy in patients with calcific aortic stenosis.
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Estenosis de la Válvula Aórtica/tratamiento farmacológico , Calcinosis/tratamiento farmacológico , Ácidos Heptanoicos/uso terapéutico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Pirroles/uso terapéutico , Anticolesterolemiantes/administración & dosificación , Anticolesterolemiantes/efectos adversos , Anticolesterolemiantes/uso terapéutico , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Atorvastatina , Velocidad del Flujo Sanguíneo , LDL-Colesterol/sangre , Progresión de la Enfermedad , Método Doble Ciego , Ecocardiografía Doppler , Ácidos Heptanoicos/administración & dosificación , Ácidos Heptanoicos/efectos adversos , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Pirroles/administración & dosificación , Pirroles/efectos adversos , Insuficiencia del TratamientoRESUMEN
OBJECTIVE: Arterial stiffness is an emerging major risk factor for cardiovascular morbidity and mortality. The aim of the present study was to assess if coronary artery plaque load correlates with non-invasive measures of arterial stiffness. DESIGN: Prospective investigational study. SETTING: Tertiary university hospital centre. PATIENTS: Patients undergoing elective diagnostic coronary angiography. INTERVENTIONS AND MAIN OUTCOME MEASURES: Coronary artery plaque burden was assessed using a 30 MHz intravascular ultrasound catheter during an automated pullback. Proximal coronary artery plaque volume was determined using a validated edge-detection algorithm following three-dimensional computerized reconstruction. Central arterial stiffness was assessed in each patient using applanation tonometry to radial, carotid and femoral pulses, with derivation of aortic pressure augmentation and pulse wave velocity using pulse wave analysis. RESULTS: In 35 patients (61 +/- 2 years), proximal coronary arterial plaque volume was 5.9 +/- 0.6 mm3/mm of vessel. Plaque volume correlated positively with carotid-radial pulse wave velocity (r = 0.47, P = 0.008) and appeared to correlate with carotid-femoral pulse wave velocity (r = 0.34, P = 0.07). Aortic augmentation (r = 0.24, P = 0.16), augmentation index (r = 0.3, P = 0.08), and pulse pressure (r = 0.22, P = 0.2) did not correlate significantly with proximal coronary artery plaque volume. CONCLUSIONS: Non-invasive measures of carotid-radial pulse wave velocity correlate with the extent of coronary artery plaque volume and may be a useful non-invasive surrogate marker for the extent of coronary atherosclerosis. Our findings are consistent with the suggestion that central aortic stiffness may promote the development of coronary atherosclerosis and ischaemic heart disease.
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Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/fisiopatología , Pulso Arterial , Ultrasonografía Intervencional , Anciano , Algoritmos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Femenino , Arteria Femoral/fisiopatología , Humanos , Procesamiento de Imagen Asistido por Computador , Imagenología Tridimensional , Masculino , Manometría , Persona de Mediana Edad , Estudios Prospectivos , Arteria Radial/fisiopatologíaRESUMEN
OBJECTIVES: To assess the effect of tissue harmonic imaging (THI) on assessment of left ventricular mass index (LVMI) measurements by M-mode trans-thoracic echocardiography, when compared with magnetic resonance imaging (MRI). METHODS: 20 hypertensive male subjects were studied. LVMI was measured in all subjects by both gradient-echo MRI (Lscelsint Prestige 1.9 T) and by transthoracic echocardiography (ATL HDI 5000). M-mode echocardiography recordings were taken for each patient, two with fundamental imaging (FI) and two using THI in a randomised order and the images unlabelled. Recordings were analysed off-line, by a blinded observer. LVMI by MRI was calculated using Simpson's rule on serial short axis slices of 8 mm thickness. Data are expressed as mean +/- SD. RESULTS: There was a difference in LVMI measurements between FI and THI (LVMI) (79 +/- 20 vs. 93 +/- 25 g2; p < 0.001). A lower mean difference was obtained by THI, compared to FI, when compared with MRI (2 +/- 15 vs. -32 +/- 22 g2; p < 0.001) suggesting that FI underestimates LVMI. Inter-observer variability was similar between THI and FI (4.5 +/- 15 vs. 6.4 +/- 15 g2; p = 0.46). CONCLUSION: In hypertensive males, M-mode echo derived from FI underestimated LVMI. These results imply that widely accepted reference ranges for LVMI using FI are not applicable when THI is used.
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Hipertrofia Ventricular Izquierda/diagnóstico , Aumento de la Imagen , Adulto , Ecocardiografía , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/patología , Humanos , Hipertensión/diagnóstico , Hipertensión/epidemiología , Hipertrofia Ventricular Izquierda/epidemiología , Imagen por Resonancia Magnética , Masculino , Variaciones Dependientes del Observador , RadiografíaRESUMEN
We aimed to characterise and to identify the predominant plaque type in vivo using unprocessed radiofrequency (RF) intravascular ultrasound (US) backscatter, in remodelled segments of human atherosclerotic coronary arteries. A total of 16 remodelled segments were identified using a 30-MHz intravascular ultrasound (IVUS) scanner in vivo. Of these, 9 segments were classified as positively remodelled (>1.05 of the total vessel area in comparison with the proximal and distal reference segments) and 7 as negatively remodelled (<0.95 of reference segment area). Spectral parameters (maximum power, mean power, minimum power and power at 30 MHz) were determined and plaque type was defined as mixed fibrous, calcified or lipid-rich. Positively remodelled segments had a larger total vessel area (16.5 +/- 1.1 mm2 vs. 8.7 +/- 0.9 mm2, p<0.01) and plaque area (7.3 +/- 1.1 mm2 vs. 4.4 +/- 0.8 mm2, p=0.05) than negatively remodelled segments. Both positively and negatively remodelled segments had a greater percentage of fibrous plaque (p<0.01) than calcified or lipid-rich plaque. Comparing positively and negatively remodelled segments, there was no significant difference between the proportion of fibrous, calcified or lipid-rich plaque. We have been able to characterise and to identify plaque composition in vivo in human atherosclerotic coronary arteries. Our data suggest that remodelled segments are predominantly composed of fibrous plaque, as identified by RF analysis, although plaque composition is similar, irrespective of the remodelling type.
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Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Adaptación Fisiológica/fisiología , Anciano , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ondas de Radio , UltrasonografíaRESUMEN
Observer variability may limit assessment of aortic stenosis by Doppler echocardiography. This study aimed to assess whether echocardiographic contrast agent improves reproducibility of aortic valve area (AVA) measurements for patients with aortic stenosis. In all, 20 patients with aortic stenosis (67 +/- 10 years old) underwent noncontrast and contrast Doppler echocardiography on 2 occasions, 3 weeks apart. Intraobserver and interobserver coefficients of reproducibility were 0.36 and 0.20 cm for left ventricular outflow tract (LVOT) diameter, and 0.38 and 0.24 cm(2) for AVA, respectively. Although intraobserver reproducibility was unaffected, contrast improved interobserver reproducibility for LVOT diameter (mean of differences -0.02 +/- 0.07 cm vs 0.01 +/- 0.10 cm, P <.05) and AVA (mean of differences 0.02 +/- 0.10 cm(2) vs 0.07 +/- 0.12 cm(2), P <.05). Prevalve and postvalve velocities were increased with contrast compared with noncontrast imaging (prevalve, 1.07 +/- 0.20 vs 0.94 +/- 0.19 m/s, P <.01; postvalve, 3.76 +/- 0.87 vs 3.47 +/- 0.78 m/s, P <.01). We conclude that contrast significantly increases Doppler velocities and produces modest improvements in reproducibility of LVOT diameter and AVA. We suggest that, when assessing patients with aortic stenosis, contrast agents should be considered in patients who are difficult to image with poor baseline LVOT images or Doppler studies, or where there is poor interobserver reproducibility.
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Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Velocidad del Flujo Sanguíneo/efectos de los fármacos , Medios de Contraste/administración & dosificación , Ecocardiografía Doppler , Anciano , Estenosis de la Válvula Aórtica/epidemiología , Ecocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Reproducibilidad de los ResultadosRESUMEN
OBJECTIVES: Arterial remodeling may increase or decrease the luminal encroachment of atherosclerotic plaques in the coronary circulation. However, the factors determining the nature and consequences of the remodeling process remain poorly characterized. The study aims were to assess whether the pattern of vascular remodeling influences the physical and vasomotor responses of the coronary arteries in vivo in man. METHODS: Coronary vessel area, distensibility and stiffness were determined in positively, negatively and non-remodeled arterial segments using intravascular ultrasound and Doppler flow measurement. Epicardial vasomotor responses were determined following intracoronary boluses of acetylcholine (10(-6) and 10(-4) M), adenosine (24-30 microg) and nitroglycerin (200 microg). RESULTS: Fifty-six coronary arterial segments were studied in 25 patients. In comparison to non- and positively remodeled segments, negatively remodeled segments had a higher stiffness index (67+/-16 vs. 33+/-5 and 38+/-8, respectively; P<0.02) and appeared to have lower compliance and distensibility (0.66+/-0.17 vs. 1.65+/-0.54 and 0.94+/-0.18/mmHg; P=NS). Non-remodeled segments had a greater change in vessel area with 10(-6) M acetylcholine (4.9+/-0.8%), compared to positively and negatively remodeled segments (0.6+/-1.8% and -4.9+/-1.8%, respectively, P<0.05). A significant degree of preservation of vasodilatation to 10(-6) M acetylcholine was evident in positively remodeled compared with negatively remodeled segments (P<0.05). Nitroglycerin caused greater vasodilatation in non-remodeled segments (7.2+/-3.8%) than either positively or negatively remodeled segments (4.7+/-0.9 and 3.7+/-0.6%, respectively, P<0.05). CONCLUSIONS: Vascular remodeling is an important and major determinant of local epicardial vasomotor responses. Both structural and functional abnormalities are associated with negative remodeling that may contribute to the adverse effects of such lesions.
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Enfermedad Coronaria/patología , Vasos Coronarios/patología , Endotelio Vascular/patología , Acetilcolina , Adenosina , Análisis de Varianza , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Endotelio Vascular/diagnóstico por imagen , Endotelio Vascular/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nitroglicerina , Ultrasonografía Doppler , Ultrasonografía Intervencional , VasodilatadoresRESUMEN
BACKGROUND: Following percutaneous transluminal coronary angioplasty (PTCA), the extent of vascular injury is underestimated by angiographic assessment. Conventional intracoronary ultrasound (ICUS) imaging provides additional information with regard to the extent of dissections but requires mental reconstruction of consecutive images. Three-dimensional ICUS reconstruction overcomes this limitation and may provide more accurate assessment of the extent of vascular injury. This study compares conventional two-dimensional ICUS imaging to combined two- and three-dimensional ICUS information in the assessment of vascular injury following PTCA. METHODS: Atherosclerotic, human coronary arteries (n=24) were studied in a specially constructed flow system. Balloon dilatation of significant stenoses was performed followed by assessment using two- and three-dimensional ICUS imaging methods. Treated arteries were submitted for histological assessment after pressure fixation. Dissection depth and length measurements were made from obtained images and compared to histomorphometric assessments. RESULTS: Of the 20 arterial segments confirmed histologically to contain dissection, 11 (55%) and 18 (90%) were identified by two-dimensional ICUS and combined two- and three-dimensional ICUS respectively. The kappa values for correlation of dissection type were 0.29 (0.23-0.35) and 0.64 (0.57-0.71) respectively indicating better agreement using combined two- and three-dimensional ICUS. Two-dimensional ICUS consistently underestimated dissection length (3.52+/-1.75 mm compared with 6.54+/-2.42 mm, P<0.001) and depth (0.61+/-0.24 mm compared with 0.92+/-0.32 mm, P=0.001). Combined two- and three-dimensional ICUS produced accurate dissection length (6.13+/-2.29 mm compared with 6.54+/-2.42 mm, P=0.09) and depth (0.86+/-0.32 mm compared with 0.92+/-0.32 mm, P=0.28) estimations. CONCLUSION: Computerized three-dimensional reconstruction of ICUS images provides improved accuracy compared to conventional ICUS imaging in the detection and quantitation of arterial dissection. This technique would be a useful adjunct to angiography for the precise assessment of vascular injury following PTCA.
Asunto(s)
Angioplastia Coronaria con Balón , Imagenología Tridimensional , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Ultrasonografía Intervencional , Enfermedades Vasculares/diagnóstico , Enfermedades Vasculares/etiología , Disección Aórtica/diagnóstico , Disección Aórtica/etiología , Disección Aórtica/patología , Arterias/diagnóstico por imagen , Arterias/patología , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/patología , Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patología , Humanos , Complicaciones Posoperatorias/patología , Índice de Severidad de la Enfermedad , Estadística como Asunto , Resultado del Tratamiento , Enfermedades Vasculares/patologíaRESUMEN
Premature cardiovascular disease (CVD) is the leading cause of mortality and of graft loss in renal transplant recipients. However, the pattern of cardiovascular risk factors (specifically modifiable risk factors) is not well established and may be different from the general population. In this study we investigated the importance of electrocardiographic abnormalities and conventional cardiovascular risk factors present at the time of first renal transplantation in a longitudinal follow-up study of 515 patients. Overall, 45.8% were cigarette smokers, 13.0% were diabetic, 75.1% had "hypertension", 12.2% had symptoms of angina pectoris and 9.1% had a past history of myocardial infarction or stroke. Two thirds of ECG tracings were abnormal. 58.7% of men and 37.5% of women had left ventricular hypertrophy (LVH). Overall, 28.2% had simple LVH, 20.5% had LVH with repolarisation changes ('strain'). 434 patients had complete data for multivariate analyses of patient and graft survival. A Cox multivariate analysis of patient survival (patients whose graft failed were censored in the analysis) identified: age (hazard ratio 1.03/year), diabetes (2.72), smoking (1.81) and family history of premature CVD (2.17) as independent risk factors for patient survival. An abnormal ECG was also independently associated with outcome, with the exception of isolated left ventricular hypertrophy. Left ventricular hypertrophy with strain, or ischaemic changes were associated with adverse outcome with a hazard ratio of 1.96 and 3.30 respectively. A similar analysis of the determinants of graft survival (patients who died with a functioning graft were censored in the analysis) identified: acute rejection (hazard ratio 2.38), cigarette smoking (1.48) and age (1.04/year) as independent predictors of graft failure. These data demonstrate a high prevalence of ECG abnormalities and CV risk factors in renal transplant recipients. Moreover, ECG abnormalities and "conventional" cardiovascular risk factors are associated with poor graft and patient outcome and represent potentially remediable risk factors for renal transplant recipients.