Management and 5-year outcome of patients with coronary artery disease in different periods of stent technology.

BACKGROUND: The availability of bare metal stents (BMS) followed by drug-eluting stents of first- (DES1) and second-generation (DES2) progressively increased the rate of the percutaneous revascularizations [percutaneous coronary intervention (PCI)] with unknown impact on the long-term outcome of real-world patients with established coronary artery disease. We sought to investigate treatments applied in patients with coronary artery disease in BMS, DES1 and DES2 eras and their 5-year outcome. METHODS: A total of 3099 consecutive patients with at least one coronary stenosis more than 50% observed in 2002 (BMS era), 2005 (DES1 era) and 2011(DES2 era) were enrolled at 13 hospitals in Veneto region, Italy. RESULTS: Moving from BMS to DES1 and DES2 eras patients became significantly older, had more comorbidities and received more frequently statins, betablockers, renin-angiotensin modulators and antiplatelets (P < 0.0001 for all). The PCI/conservative therapy ratio increased from 1.9 to 2.2 and 2.3, the PCI/coronary artery by-pass surgery ratio from 3.6 to 4.0 and 5.1. The crude 5-year survival was 84.9, 83.4 and 81.4% (P = 0.20) and survival free of myocardial infarction, stroke or further revascularizations was 62.1, 60.2 and 60.1% (P = 0.68), with cardiovascular mortality accounting for 60.9, 55.6 and 43.4% of deaths. At multivariable analysis cardiovascular mortality was significantly lower in patients enrolled in 2011 vs. 2002 (hazard ratio = 0.712, 95% confidence interval 0.508-0.998, P = 0.048). CONCLUSION: From BMS to DES1 and DES2 eras progressive worsening of patients characteristics, improvement of medical treatment standards and increase in PCI/conservative therapy and PCI/coronary artery by-pass surgery ratios were observed. Five-year outcomes remained similar in the three cohorts, but in the DES2 era cardiovascular mortality was reduced.

The impact of drug eluting stents availability on the treatment choice among medical therapy, percutaneous or surgical revascularisation and on 4-year clinical outcome in patients with coronary artery disease: a cohort study.

OBJECTIVE: To investigate the influence of the availability of drug eluting stents (DES) on treatment choice (TC) among medical therapy (MT), coronary by-pass surgery (CABG) or percutaneous coronary interventions (PCI) and the consequent clinical outcomes in patients hospitalised because of coronary artery disease (CAD). DESIGN: Observational study comparing two cohorts hospitalised immediately before, and 3 years after DES availability. SETTING: Thirteen hospitals with cardiology facilities. PATIENTS: 2131 consecutive patients with at least one coronary stenosis >50% at coronary angiography (CA) after exclusion of those with acute myocardial infarction or previous CABG or associated relevant valvular disease. MAIN OUTCOME MEASURES: Treatment choice after CA and 4-year clinical outcomes. RESULTS: TC among MT (27% vs 29.2%), PCI (58.6% vs 55.5%) and CABG (14.5% vs 15.3%) was similar in the DES and bare metal stent (BMS) periods (p = 0.51). At least one DES was implanted in 57% of patients treated with PCI in 2005. After 4 years, no difference in mortality (13.8% vs 13.2%, p = 0.72), hospital admissions for myocardial infarction (6.6% vs 5.2%, p = 0.26), stroke (2.2% vs 1.7%, p = 0.49) and further revascularisations (22.3% vs 19.7%, p = 0.25) were observed in patients enrolled in the DES and BMS periods. Only in patients with Syntax score 23-32 a significant change of TC (p = 0.0002) occurred in the DES versus BMS period: MT in 17.4% vs 31%, PCI in 62.2% vs 35.8%, CABG in 20.3% vs 33.2%, with similar 4-year combined end-point of mortality, stroke, myocardial infarction and further revascularisations (45.3% vs 34.2%, p = 0.087). CONCLUSIONS: Three years after DES availability, the TC in patients with CAD has not changed significantly as well as the 4-year incidence of death, myocardial infarction, stroke and further revascularisations. In subgroup with Syntax score 23-32, a significant increase of indications to PCI was observed in the DES period, without any improvement of the 4-year clinical outcome.

Anatomical and electrophysiological approach to atrial fibrillation ablation: technical limitations.

OBJECTIVE: Pulmonary vein (PV) disconnection by radiofrequency (RF) catheter ablation has been reported to cure atrial fibrillation (AF). Different techniques have been proposed. The aim of this study was to evaluate the technical limitations of both anatomical and electrophysiological approaches. METHODS: A total of 110 PVs were ablated in 26 consecutive patients (23 male, 3 female, mean age 51 +/- 9.5 years) with paroxysmal (n = 19, 73%), persistent (n = 3, 12%) or permanent (n = 4, 15%) AF. Accurate reconstructions of the PV ostia were obtained using fluoroscopy, electrophysiology, and the CARTO mapping system. Electrophysiological mapping was attempted in all PVs by means of a decapolar circular catheter. RF ablation was performed in a single-blind fashion in order to anatomically create circumferential lines around each PV. Completeness of anatomically-guided, circumferential RF lesions around the PVs was established by the physician using the CARTO system, who was unaware of the decapolar circular catheter electrophysiological recordings of the PVs. If PV potentials persisted, RF delivery was targeted to the electrophysiological breakthroughs. RESULTS: All PV ostia were anatomically ablated by performing circumferential RF lesions. Among 110 PVs, 73 (66%) were fully mapped by use of circular catheters. After anatomical ablation, electrical disconnection was achieved in 44/73 PVs (60%). In the remaining 29 PVs (40%), a median of one RF pulse (mean 1.8 +/- 1.4) was necessary to achieve complete PV disconnection. Total procedure duration, fluoroscopy time, and RF delivery time were 232 +/- 29, 50 +/- 16 and 39 +/- 11 min, respectively. Pericardial effusion occurred in one patient after the procedure. After 10.5 +/- 6.4 months, 21 patients (81%) were in stable sinus rhythm and 13 of them (62%) discontinued all drugs after 6 months. Only 4 patients (15%) required two procedures. CONCLUSIONS: Electrical PV disconnection cannot be achieved in many PVs by means of a pure anatomical approach. On the other hand, electrophysiological mapping cannot be performed in many PVs owing to anatomical variations. An integrated approach might overcome these limitations.

Pulmonary embolism: diagnostic algorithms.

In 90% of cases the clinical suspicion of pulmonary embolism (PE) is raised by clinical signs and symptoms, while in only 10% of cases PE is suspected on the basis of electrocardiographic, arterial blood gas analysis or radiological findings. The combination of clinical signs and symptoms and the results of first-level diagnostic tests (electrocardiography, gas analysis and chest X-ray) allows a fairly accurate classification of patients with "clinical suspicion of PE" into three categories of clinical (or pre-test) probability: low, intermediate and high. The clinical diagnosis of PE is very often inaccurate making the use of additional tests, including imaging techniques, mandatory. The choice and the combination (= diagnostic algorithms) of second- and third-level diagnostic tests (D-dimer, venous ultrasound, echocardiography, lung scintigraphy, helical computed tomography and pulmonary angiography) depend primarily on the clinical conditions of patients and their pre-test probability. We propose two diagnostic algorithms: 1) a diagnostic algorithm for patients with clinically suspected PE and critical clinical conditions (unstable patients), 2) a diagnostic algorithm for patients with clinically suspected PE and non-critical clinical conditions (hemodynamically stable patients).

Comparison between anatomical and integrated approaches to atrial fibrillation ablation: adjunctive role of electrical pulmonary vein disconnection.

INTRODUCTION: The aim of this study was to compare the outcome of anatomical pulmonary vein (PV) radiofrequency (RF) ablation with that of an integrated approach (anatomical with electrophysiological confirmation of PV disconnection). METHODS: Sixty consecutive patients affected by drug-refractory paroxysmal (39), persistent (13), and permanent (8) atrial fibrillation (AF) were assigned to an anatomical (group A: 30 patients; 25 male, 5 female, mean age: 55 +/- 7 years) or integrated approach (group B: 30 patients; 26 male, 4 female, mean age: 52 +/- 9 years). In all cases, RF ablation was performed by means of the Carto system in order to anatomically create circumferential lines around PVs. In group B, the persistence of PV potentials was then assessed with a multipolar circular catheter. If PV potentials persisted, RF pulses targeting the electrophysiological breakthroughs were delivered to disconnect PVs. RESULTS: Total procedure duration, fluoroscopy time, and RF delivery time were similar in both groups: 227 +/- 43, 50 +/- 23, and 43 +/- 16 minutes (group A); 232 +/- 32, 55 +/- 15, and 42 +/- 10 minutes (group B), respectively (ns). One asymptomatic PV stenosis and one pericardial effusion occurred in group A and B, respectively. After 15.4 +/- 7.4 months, 17 (57%) group A patients and 25 (83%) group B patients were in stable sinus rhythm (P = 0.02) (RR 1.78; 95% CI: 1.7-2.9). CONCLUSIONS: PV ablation by means of an integrated anatomical and electrophysiological approach seems more effective than a purely anatomical RF ablation approach. Electrophysiological confirmation of PV disconnection could be a useful marker of successful RF treatment of AF.

Usefulness of dipyridamole stress echocardiography for predicting graft patency after coronary artery bypass grafting.

Noninvasive techniques often provide controversial results in patients who have coronary artery bypass grafts (CABGs). Vasodilator stress echocardiography allows semi-simultaneous imaging of CABG flow and segmental left ventricular wall motion. To assess the comparative and additive value of regional flow and function for noninvasive evaluation of graft patency status, we evaluated 110 consecutive patients who underwent CABG and who were scheduled for coronary angiography. All patients underwent stress echocardiography with dipyridamole (0.84 mg/kg) and atropine (1 mg), including wall motion analysis by 2-dimensional echocardiography and Doppler evaluation of flow reserve of each CABG. Echocardiographic findings were compared with angiographic data. Four patients had inadequate acoustic windows. The remaining 106 patients had 226 grafts performed. Stress echocardiography showed 67% sensitivity, 91% specificity, and 71% accuracy for identification of 50% to 100% stenosis in the graft or in the recipient coronary vessel. There was a fair agreement with angiography (kappa coefficient 0.60). Identification of impaired coronary bypass flow reserve (i.e., <1.9 for internal mammary grafts and <1.6 for saphenous vein grafts) by Doppler had 91% sensitivity, 88% specificity, and 89% accuracy for graft stenosis. There was good agreement with angiographic findings (kappa 0.77). The combination of the 2 techniques achieved 93% sensitivity, 93% specificity, and 93% accuracy, showing a very good agreement with the patency status of the grafts as evaluated at angiography (kappa 0.85). The combined assessment of wall motion and flow reserve in patients who underwent CABG is feasible and provides an accurate estimate of graft patency status by increasing sensitivity of stress echocardiography and specificity of Doppler flow reserve.

Left atrial radiofrequency ablation during cardiac surgery in patients with atrial fibrillation.

INTRODUCTION: Intraoperative left atrial radiofrequency (RF) ablation recently has been suggested as an effective surgical treatment for atrial fibrillation (AF). The aim of this study was to verify the outcome of this technique in a controlled multicenter trial. METHODS AND RESULTS: One hundred three consecutive patients (39 men and 65 women; age 62 +/- 11 years) affected by AF underwent cardiac surgery and RF ablation in the left atrium (RF group). The control group consisted of 27 patients (6 men and 21 women; age 64 +/- 7 years) with AF who underwent cardiac surgery during the same period and refused RF ablation. Mitral valve disease was present in 89 (86%) and 25 (92%) patients, respectively (P = NS). RF endocardial ablation was performed in order to obtain isolation of both right and left pulmonary veins, a lesion connecting the previous lines, and a lesion connecting the line encircling the left veins to the mitral annulus. Upon discharge from the hospital, sinus rhythm was present in 65 patients (63%) versus 5 patients (18%) in the control group (P < 0.0001). Mean time of cardiopulmonary bypass was longer in the RF group (148 +/- 50 min vs 117 +/- 30 min, P = 0.013). The complication rate was similar in both groups, but RF ablation-related complications occurred in 4 RF group patients (3.9%). After a mean follow-up of 12.5 +/- 5 months (range 4-24), 83 (81%) of 102 RF group patients were in stable sinus rhythm versus 3 (11%) of 27 in the control group (P < 0.0001). The success rate was similar among the four surgical centers. Atrial contraction was present in 66 (79.5%) of 83 patients in the RF group in sinus rhythm. CONCLUSION: Endocardial RF left atrial compartmentalization during cardiac surgery is effective in restoring sinus rhythm in many patients. This technique is easy to perform and reproducible. Rare RF ablation-related complications can occur. During follow-up, sinus rhythm persistence is good, and biatrial contraction is preserved in most patients.