Intracoronary pressure measurement differences between anterior and posterior coronary territories.

INTRODUCTION: Intracoronary pressure measurements have improved assessment of angiographic intermediate coronary stenoses. Methodically, pressure equalization and actual measurements are frequently performed at different height levels, depending on the particular coronary territory analyzed. Considering a hypothetical influence of hydrostatic pressure and the supine position of the patient, differences in the results of intracoronary measurements between anterior and posterior vessels seem likely. The purpose of this study was to compare the results of intracoronary pressure measurements between anterior and posterior coronary territories. METHODS: Intracoronary pressure measurements of 214 coronary stenoses in 158 patients were analyzed. Fractional flow reserve (FFR) was measured in all stenosis and instantaneous wave-free ratio (iFR) in 197 stenoses in 144 patients. RESULTS: Both FFR (0.79 vs. 0.87, p < 0.001) and iFR values (0.86 vs. 0.94, p < 0.001) were significantly higher in posterior compared to anterior coronary vessels. Patients with only anterior or posterior lesions did not differ regarding clinical or lesion characteristics, in particular coronary stenosis severity (62.5 vs. 61.6 %, p = 0.27). CONCLUSIONS: Results of intracoronary measurements were systematically higher in the posterior coronary vessels when compared with anterior vessels. This phenomenon was independent of coronary stenosis severity or any clinical characteristics in our study population.

Aortic valve replacement after previous coronary artery bypass grafting: experience with a simplified approach.

AIM: Aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG), particularly in a patent left internal thoracic artery (ITA), is a challenge. Avoidance of injuring the patent graft and ensuring myocardial protection are important issues in the management of these patients. The aim of this study was to evaluate a simplified surgical approach to these reoperations. METHODS: Between January 2003 and June 2005, 19 of 287 AVRs performed at our institution were in a patient subset (mean age 70 years, range: 62-82) who received AVR after previous CABG surgery. The aortic valve gradients were between 50 and 107 mm Hg. Our operation strategy followed the KIS-principle (keep it simple): both femoral vessels were cannulated using the Seldinger technique. Only the area around the ascending aorta and the right atrium was dissected to permit x-clamping, aortotomy, and catheterization for retrograde cardioplegia and a left ventricular vent. The anterior aspect of the heart and the left side, where the ITA was embedded and patent, were left untouched and not clamped. RESULTS: The mean interval between the first and second operation was 6.5 years. Fourteen patients received biological prostheses. Four patients received an additional surgery at the time of AVR. The mean operating time was 267 min; the mean AoX-clamp time was 63 min. One patient died because of severe heart failure. In all others the postoperative course was uneventful. CONCLUSIONS: We believe that the indication for AVR in patients scheduled for CABG should be re-evaluated. In those in which Redo-surgery for new or increased valve stenosis is indicated, a simple and safe surgical option is presented.

[Angiographic assessment of functionally insignificant left main coronary artery stenoses: reliability compared to intracoronary pressure measurement]. / Angiographische Beurteilung funktionell nicht signifikanter Hauptstammstenosen--Zuverlässigkeit im Vergleich zur intrakoronaren Druckmessung.

BACKGROUND AND OBJECTIVE: Left main coronary artery disease (LMCA) is still a widely accepted indication for coronary artery bypass surgery. Intermediate LMCA disease, however, often cannot be evaluated reliably on the basis of clinical and angiographic information alone. The deferral of surgical revascularization based on fractional flow reserve (FFR) measurements has been shown to be safe and feasible when taking an FFR value of (3) 0.75 as cutoff. This study was performed to compare the accuracy of visual angiographic assessment of intermediate LMCA stenoses by experienced interventional cardiologists with functional assessment by FFR in a patient population with excellent long-term outcome after deferral of surgery on the basis of FFR measurements. PATIENTS AND METHODS: 24 of 51 consecutive patients with intermediate LMCA disease were deferred from surgery based on an FFR value of > or = 0.75. Each angiogram was retrospectively reviewed independently by three experienced interventional cardiologists. Reviewers were blinded to initial FFR results, clinical data, and clinical outcome and asked to classify each lesion as SIGNIFICANT (FFR < 0.75), NOT SIGNIFICANT (FFR > or = 0.75), or UNSURE if the observer was unable to make a decision based on the angiogram. RESULTS: Mean follow-up was 29 +/- 13.6 months. No death or myocardial infarction was observed, event-free survival was 69 %. When taking the "unsure" classifications into consideration the individual reviewers achieved correct lesion classification with respect to FFR results on average in 58 % to 82 % of cases. Interobserver variability resulted in only 46 % of cases in concordant lesion classification (3 agreements or 2 agreements and 1 "unsure" evaluation). The number of concordant agreements between the individual pairs of reviewers did not exceed the rate of coincidental agreements that could be expected to result from simple guessing (mean KAPPA coefficient 0.04). More than 50 % of patients with excellent long-term outcome after deferral of surgery would potentially have undergone operative revascularization if consensual decision making had been solely based on angiographic lesion assessment. CONCLUSION: The functional significance of intermediate or equivocal LMCA lesions should not be based on visual assessment alone, even when performed by experienced interventional cardiologists.

Normal angiogram in acute coronary syndrome-preangiographic risk stratification, angiographic findings and follow-up.

BACKGROUND: Coronary angiographies performed during acute coronary syndrome show different coronary morphologies-vessel occlusions, thrombi and various types of stenoses. In a few cases of acute coronary syndrome, angiography reveals normal coronary arteries. It is the purpose of this study to analyze this specific subset of patients who presented with an acute coronary syndrome but had a normal coronary angiogram with respect to the preangiographic diagnostics, risk stratification and clinical follow-up. METHODS AND RESULTS: A total of 897 coronary angiographies were performed as an emergency procedure in our institution. The majority of patients (n = 821) presented with coronary artery disease and the majority was treated by mechanical revascularization (86.3%). In 76 patients (8.5%), no coronary artery stenosis was documented. However, according to the preangiographic risk stratification, coronary artery disease was expected in these patients. Observations documented angiographically included coronary spasms (6.6%) and muscle bridges (5.3%). During a mean follow-up of 11.2 +/- 6.4 months, one patient developed an acute myocardial infarction requiring coronary intervention. All other patients were free of any cardiac event. CONCLUSIONS: In summary, we have to consider that coronary angiography may not always detect the cause of myocardial ischemia in every patient. There is a small group of patients with normal coronary angiograms during acute coronary syndrome. Additional diagnostic procedures like intravascular ultrasound (IVUS) or the assessment of intracoronary physiological parameters may increase the diagnostic value of angiography.

Access-site complications after rescue percutaneous coronary intervention during thrombolysis for acute myocardial infarction.

Aggressive antithrombotic medical therapy may increase the rate of access-site complications after percutaneous coronary intervention. Frequently, emergency coronary interventions have to be performed in a situation when thrombolysis therapy was administered as the first-line therapeutic approach in acute myocardial infarction but failed to achieve stable conditions. We analyzed the rate of femoral bleeding complications after emergency coronary intervention in 76 consecutive patients with unsuccessful thrombolysis in acute myocardial infarction. All invasive procedures were performed in a time period no longer than eight hours after thrombolysis was administered. Additional antithrombotic therapy with heparin and glycoprotein IIb/IIIa-inhibitors was given during intervention in 100% and 38.2% of patients, respectively. In three patients (3.9%) femoral hematomas without therapeutic consequences were documented; one patient (1.3%) developed a hematoma requiring blood transfusion. A pseudoaneurysm, fistula or surgical vascular intervention did not occur. Coronary interventional procedures in rescue situations can be performed with excellent safety with respect to access-site bleeding complications even under conditions of ongoing thrombolysis therapy and aggressive antithrombotic medical regimens.

Strain imaging with intravascular ultrasound array scanners: validation with phantom experiments.

Intravascular Ultrasound (IVUS) is routinely used in interventional cardiology for imaging coronary plaque morphology. However, the use of B-mode images for tissue characterization and detection of vulnerable coronary plaques is limited. Strain imaging with ultrasound is a new modality that provides additional information for tissue characterization by imaging differences in tissue stiffness. The aim is to differentiate between vulnerable (soft) plaques and less dangerous calcified (hard) plaques. In this work, the applicability of a time efficient strain imaging algorithm in conjunction with data from IVUS array transducers is evaluated. Unfocused radiofrequency (rf) data from the transducer array is acquired using custom made hardware. Rf line reconstruction is performed offline by synthetic aperture focusing techniques. Vessel mimicking phantoms of different geometries and material stiffness are made from agar and Polyvinyl Alcohol Cryogel (PVA). Experiments are conducted in a water tank and a water column is used for applying intraluminal pressure differences required for strain imaging. The results show that strain images can be calculated with A-lines reconstructed from unfocused rf raw data. Regions of different stiffness can be identified qualitatively by local strain variations. With the used algorithm strains of up to 2% can be imaged without significant decor-relation.

[Recanalization by percutaneous coronary intervention in occlusion of all coronary vessels]. / Diabetiker mit Verschluss aller Koronarien. Gibt es Alternativen zum Bypass?

The utility of coronary intervention in the treatment of multivessel coronary disease with complex morphology and damage to the myocardium remains controversial. What is certain is that drug treatment is often not adequate and surgical revascularization not always possible. A patient with occlusion of all coronary vessels who underwent a multivessel intervention is presented. Multivessel intervention can improve the left ventricular function and appreciably increase the performance of the patient. In similar cases, consideration should be given to percutaneous coronary intervention as an alternative to bypass surgery.

Coronary artery stenting in diabetes mellitus--unfavourable clinical outcome due to increased rate of myocardial ischemia and percutaneous interventions.

Diabetes mellitus is one of the major risk factors for cardiovascular diseases. The aim of this study was to analyze if diabetic patients, compared to nondiabetic patients, have a worse angiographic and clinical success rate and a reduced clinical and angiographic outcome at three-months follow-up after coronary artery stenting according to postprocedural complications, recurrent angina, myocardial ischemia, restenosis and revascularization. A total of 307 unselected patients with coronary artery disease and myocardial ischemia who underwent intracoronary stenting were included in this study. Diabetes was present in 49 patients. Morphological criteria, angiographic results and clinical in-hospital outcome did not differ significantly between both groups. At follow-up diabetics presented significantly more often recurrent angina and myocardial ischemia. The rate of restenosis and target lesion revascularization was not different. Among diabetics, the rate of percutaneous coronary interventions because of different lesions was significantly increased. Diabetes does not reduce the angiographic result initially and at follow-up after coronary artery stenting. Diabetes mellitus limits the clinical outcome because of recurrent angina, myocardial ischemia and the need of coronary interventions.

[Expectations and satisfaction of patients during inpatient treatment]. / Erwartungen und Zufriedenheit von Patienten während eines stationären Krankenhausaufenthaltes.

PURPOSE: Aim of the study was to examine the expectations of patients at the beginning and the satisfaction at the end of a hospital stay. The hospital settings were standardised. METHODS: 510 patients on the cardiological ward were asked to fill in a questionnaire on the first and last day of their stay. RESULTS: The admitted patients stated clear expectations in respect of the hospital facilities and staff. The most important aspects for the patients were the qualification of staff and the time physicians and nurses would devote to the patient, and the medical and technical equipment of the hospital. Beds per room, food, length and costs of the stay were less important in patients' expectations. On the day of discharge, the patients were very satisfied with the staff and medical equipment, in contrast to a low satisfaction regarding additional fees and the number of beds per room (three). CONCLUSIONS: Since cost-benefit is a basic need in running a hospital today, financial resources should be enhanced in the spheres which are equally medically important for fulfilling the expectations of the patients. Therefore, the number of staff and the qualification of the medical professionals should be financed instead of supporting architectural and room design. Accordingly, the patients' main criteria for choosing a hospital is the medical equipment provided and the qualification of the medical staff. In conclusion, these aspects should be publicized for meaningful decision-making. Medical professionals should be encouraged to inspire competence and to spend as much time as possible with each individual patient.

Efficacy and safety of ticlopidine monotherapy versus ticlopidine and aspirin after coronary artery stenting: follow-up results of a randomized study.

A combined antiplatelet treatment with ticlopidine and aspirin has been accepted as standard pharmacological regimen after coronary artery stenting. No data of a randomized trial are available on ticlopidine monotherapy. This prospective, randomized monocenter trial investigates the role of ticlopidine monotherapy versus combined antiplatelet therapy with ticlopidine and aspirin in unselected patients undergoing coronary artery stenting. After successful placement of 378 coronary artery stents, two hundred and forty-three consecutive patients were randomly assigned to receive antiplatelet therapy with 2 x 250 mg ticlopidine (121 patients) or a combination of 2 x 250 mg ticlopidine plus 100 mg aspirin (122 patients) daily. The primary endpoint included the absence of death, cardiac events and vascular access-site complications during the in-hospital phase. Angiographic and clinical assessment was repeated at the 3-month follow-up exam. Two hundred and thirty-seven patients (97.5%) were free from cardiac and non-cardiac events. Stent thromboses were seen in 2 patients of the combined treatment group, while none were observed in the monotherapy group. No statistically significant differences were found between the 2 groups regarding the primary endpoint. Angiography performed in 210 patients (86.4%) at follow-up revealed a restenosis rate of 29.4% in the combined treatment group and 27.8% in the monotherapy group. Monotherapy with ticlopidine is as safe and effective as a combined regimen of ticlopidine plus aspirin after coronary artery stenting in an unselected patient population. These results need to be confirmed in a larger multicenter trial.

[Health promotion and cardiovascular risk factors. The level of knowledge among 510 inpatients of an acute coronary care unit]. / Gesundheitsförderung und kardiovaskuläre Risikofaktoren. Uber den Wissensstand von 510 Patienten einer kardiologischen Akutklinik.

PATIENTS AND METHODS: A total of 510 patients hospitalized on a cardiologic ward were questioned on cardiovascular disease risk factors using a questionnaire. The knowledge on these risk factors was assessed with a score system. RESULTS: Knowledge of patients on cardiovascular disease risk factors was generally low: One out of 5 did not know about the consequences of obesity, high blood cholesterol or smoking on the coronary vessels. Over 30% did not name hypertension. Only 1 out of 3 patients mentioned diabetes mellitus as a risk factor. There was no change in the knowledge during the hospital stay despite a standardized and intensive information program. The results of the second survey on the day of discharge were equal to the results of the admission day. Hospital stays in the past had no influence on the knowledge. Patients with a diagnosed coronary heart disease had the same results in the survey as patients with other diseases. The presence of risk factors had hardly any influence on the knowledge of these patients. CONCLUSION: The result of this study emphasizes the need for better health information for patients. The repetitive information on health related issues during inpatient treatment does not seem to have a positive effect on patients' knowledge. Therefore other ways of health education have to be introduced and evaluated in acute care.

Hyperfibrinogenemia increases the risk of cardiac events after coronary artery stenting.

Primary success rates, and the angiographic and clinical outcome after percutaneous coronary intervention, are influenced by many different factors. Clinical features and morphologic characteristics of the target lesion are important. Also, interventionally caused endothelial trauma may trigger atherogenetic and procoagulatory factors leading to intraluminal thrombosis. The study population consisted of 228 consecutive, unselected patients with symptomatic coronary artery disease or exercise-induced myocardial ischemia and coronary artery stenoses eligible for percutaneous intervention. We analyzed different clinical, morphological, and laboratory (total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, triglycerides, fibrinogen) features in those patients with adverse cardiac events (stent thrombosis, myocardial infarction, urgent target vessel revascularization, death) after primary successful coronary artery stenting, compared with a control group without adverse events. In the group with adverse cardiac events we found a significantly higher level of fibrinogen compared with the control group. Other laboratory data and clinical characteristics were not significantly different between the two groups. The study shows a possible association between hyperfibrinogenemia and adverse cardiac events after intracoronary stenting. In clinical practice, the potential role of elevated levels of fibrinogen in an unfavorable outcome after percutaneous coronary interventions should be considered when planning coronary artery stenting.