Bedside quantification of atherosclerosis severity for cardiovascular risk stratification: a prospective cohort study.

OBJECTIVES: We sought to assess the ability of a new noninvasive method to quantify atherosclerosis severity and to examine its power to predict cardiovascular events. BACKGROUND: Drug prevention of cardiovascular events is effective but costly, leading to a debate about who should receive this treatment. Patient selection is often based on surrogate markers, but quantification of atherosclerosis severity is desirable. METHODS: Atherosclerosis severity was quantified by determination of specific aortic wall elastance in transthoracic echocardiography, applying the biomechanics of pulse wave propagation. After validating the method in 52 patients by measuring aortic plaque burden in transesophageal echo directly, another 336 patients were prospectively studied by monitoring atherosclerotic events at one year and comparing the results with conventional risk stratification. RESULTS: Specific aortic elastance was well correlated with plaque burden (p < 0.0001) and largely independent of confounding variables. Specific aortic elastance predicted the primary end point of "atherosclerotic death, myocardial infarction or stroke" at one year (p < 0.0002). Event rate at one year in the lowest specific elastance tertile was 1.8% (CI 0.0% to 4.3%), in the middle tertile 5.4% (CI 1.1% to 9.7%) and in the highest tertile 12.7% (CI 6.3% to 19%). Secondary end points supported these findings. Stepwise multivariate analysis identified specific aortic elastance, prior atherosclerotic events and left ventricular ejection fraction as independent risk predictors. Specific elastance was of incremental value to clinically identified variables. CONCLUSIONS: Bedside measurement of specific aortic elastance allows assessment of atherosclerosis severity. It predicts the risk for future atherosclerotic events beyond conventional risk factors, promising better targeting of pharmacologic prevention and improved cost effectiveness.

Elective ostial left main stenting: a tailored approach.

Elective left main (LM) stenting is increasingly performed as a valuable alternative to coronary artery bypass grafting. Nevertheless, clinical data are limited to registries, and randomized trials have not been published. Intravascular ultrasound (IVUS) has been recognized as an accurate tool for assessing optimal stent deployment. We hereby report the usefulness of IVUS in defining the interventional strategy in four consecutive patients presenting with severe, symptomatic ostial LM disease, and this in the era of drug-eluting stents. The first two patients were treated by a short drug-eluting stent for a critical LM stenosis as IVUS demonstrated a reference diameter < 3.7 mm. The third patient had a larger reference diameter and was treated with conventional stenting with optimization of the result by IVUS. IVUS was particularly helpful in all patients to confirm accurate stent placement in relation to the LM ostium and bifurcation. In another patient, based on IVUS findings, surgery was preferred. This patient with diabetes as a risk factor presented with comparable angiographic features. IVUS, however, showed diffuse disease without any healthy reference segment in the LM. All stented patients are asymptomatic at 15 +/- 7 months follow-up with negative stress testing. The present observation indicates that IVUS is an essential tool for strategic selection and to optimize percutaneous coronary intervention for LM disease.

Direct stenting with a combined intravascular ultrasound-coronary stent delivery platform: a feasibility trial.

IVUS is considered as the most accurate tool for the assessment of optimal stent deployment. Direct stenting has shown to be a safe, efficient, and resource-saving procedure in selected patients. In a prospective 1-month feasibility trial, a new combined IVUS-coronary stent delivery platform (Josonics Flex, Jomed, Helsingborn, Sweden) was evaluated during direct stenting in consecutive patients considered eligible for direct stenting. The feasibility endpoint was successful stent deployment without any clinical adverse event, while the efficacy endpoint was strategic adaptation according to standard IVUS criteria for optimal stent deployment at the intermediate phase (after a result considered angiographically optimal) and at the end of the intervention (after optimization according to IVUS standards). A total of 16 patients were successfully treated with this device without any major clinical complication. At the intermediate phase, optimal stent deployment was achieved in four patients only, while at the end only one patient had nonoptimal IVUS stent deployment. In particular, the minimal in-stent cross-section area increased from 6.3 +/- 1.2 to 8.3 +/- 2.5 mm(2). These preliminary data demonstrate the feasibility of direct stenting with a combined IVUS-stent catheter in selected patients and confirm the results from larger randomized trials on the impact of IVUS on strategic adaptations during coronary stent placement.