Visual-functional mismatch and results of fractional flow reserve guided percutaneous coronary revascularization.

OBJECTIVE: To identify mismatches in the significance ofcoronary artery stenosis determined by physician 's visual estimation (VE) vs. quantitative coronary angiography (QCA), by VE vs. fractional flow reserve (FFR), and independent predictors for mismatch between VE and FFR. Second objective was to evaluate the clinical outcomes ofpatients receiving FFR-guided percutaneous coronary intervention (PCI). MATERIAL AND METHOD: Two hundreds eighty consecutive patients (338 coronary lesions including non-left main (non-LM) 316 lesions and left main (LM) 22 lesions) underwent coronary angiography, offline edge detection QCA, and FFR measurement between August 2011 and December 2013 were included in the present study. Baseline patient data, lesion characteristics, and clinical outcomes were recorded and analyzed. Coronary lesions were then divided into four groups according to FFR results and treatment (FFR <0.75 and PCI, FFR 0.75-0.80 and PCI, FFR 0.75-0.80 and defer PCI, FFR >0.80 and defer PCI). Mismatches in the significance of coronary artery stenosis determined by VE vs. QCA, VE vs. FFR, independent predictors of VE-FFR mismatch, and clinical outcomes after FFR-guided treatment were reported. RESULTS: Lesions with VE-QCA mismatch were seen in 64% of non-LM lesions and in 87% of the LM lesions. Conversely, lesions with VE-QCA reverse mismatch were seen in 13% of non-LM lesions and in 0% of the LM lesions. Lesions with VE-FFR mismatch were seen in 42% of non-LM lesions and in 53% of the LM lesions. Lesions with VE-FFR reverse mismatch were seen in 15% of non-LM lesions and in 14% of the LM lesions. The independent predictors for VE-FFR mismatch in non-LM lesions were shorter lesion and greater minimal lumen diameter. After FFR guided-treatment and dividing coronary lesions into four groups, all patients were followed-up for a median period of 11.6 (IQR; 7.3, 17.6) months. Major adverse cardiovascular events (excluded one death) of 338 lesions were not significantly different in the four groups (1.7% vs. 5.1% vs. 5.3% vs. 2.7%, p = 0.717). The median cost ofprocedure of lesions undergone FFR plus additional PCI was significantly higher than lesions undergone FFR only (140,000 vs. 137,000 vs. 45,000 vs. 45,000 Baht, p<0.001). CONCLUSION: Mismatches between visually-estimated significance of angiographic coronary stenosis and QCA or FFR are frequently encountered. Visual estimation of coronary angiography alone cannot entirely predict functional significance of coronary stenosis. FFR measurement provides a helpful strategy for decision making before further revascularization.

Benefit of serum-effusion albumin gradient in congestive heart failure patients.

OBJECTIVE: To compare between light's criteria and serum-effusion (S-E) albumin gradient in diagnosis of transudate effusion in congestive heart failure (CHF) patients. MATERIAL AND METHOD: Eighty-six patients who had pleural effusion and suspected CHF were enrolled in the present study between October 2008- September 2010. Suspected CHF was defined by clinical or echocardiography. Inform consents were given by all volunteers. Exclusion criteria was previous thoracotomy or coronary bypass graft 3 months before present study. Thoracocentesis was done to evaluate transudate effusion by light's criteria and S-E albumin gradient > 1.2 mg/dl. RESULTS: 12 (13.95%), 56 (65.11%), 17 (19.76%) of all were pure pleural disease, pure CHF, combination of pleural disease and CHF. Sensitivity/specificity/accuracy of S-E albumin gradients and light's criteria in diagnosis of CHF (both pure and combined) were 90.1/33.3/80.2%, 64.7/80.0/67.4%. No correlation between amount of diuretic drug and "exudate" criteria from lights' (p = 0. 66). 25 (27.2%) patients were previous post thoracotomy or coronary bypass graft. 7 of 25 patients had loculated effusion. There was correlation between previous surgery with loculated effusion and effusion from combination of pleural disease and CHF (p = 0.22). CONCLUSION: There is benefit to use S-E albumin gradient > 1.2 mg/dl to diagnosis patients who were suspected CHF with or without pleural disease. The authors recommended to use S-E albumin gradients combined with Light's criteria in suspected CHF patients.

Percutaneous coronary intervention in patients with anomalous origin of coronary artery.

Percutaneous coronary intervention in patients with anomalous origin of right coronary artery from left sinus of Valsalva was performed in Central Chest Institute during 2005-2009. The diagnosis of this type of congenital anomaly is always difficult, since it requires high operator's consideration and experience. Standard catheter curve desired for general coronary angiography is also not suitable for the abnormal origin of artery, especially when coronary intervention is to be performed. The authors report a series of these anomalous coronary patients with atherosclerotic disease who underwent transcatheter coronary intervention using Extra Backup left coronary guiding catheters, which help cannulation of the anomalous ostium and enhance the operation success.

Factors related to in-hospital heart failure are very different for unstable angina and non-ST elevation myocardial infarction.

Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA) resulted in different degrees of damage to the heart muscle, and yet, when factors related to in-hospital outcomes were examined, these two subsets were often lumped together as non-STelevation acute coronary syndrome. Therefore, we investigated predictors of in-hospital heart failure (HF) in UA and NSTEMI separately. Factors related to HF (Killip > or = 2) were analyzed for NSTEMI and UA in a Thai Acute Coronary Syndrome (ACS) registry conducted in 17 institutions between 2002 and 2005. The registry comprised of 9373 single admissions age 65.1 +/- 12.3 years, 40.2% women, and 45.1% with HF. There were 3548 NSTEMI and 1989 UA with HF prevalence of 56.2% and 27.4%, respectively. Heart failure patients were older, more were women, sicker (as shown by more of those with shock, postcardiac arrest, and breathless on admission), more with diabetes mellitus (DM), received less intervention and medication, and showed higher total death (19.3% vs 5.3% for NSTEMI with and without HF; and correspondingly, 5.9% and 1.9% for UA). Independent predictors (at presentation) for the development of HF following NSTEMI or UA were age (not sex), breathlessness, and less prevalence of chest pain. However, shock and DM were risks only for NSTEMI but not UA. Heart failure was found to be a factor for in-hospital death for NSTEMI only, with odds ratio of 2.84 (confidence interval 2.11-3.82) and 3.23 (2.25-4.64) for total and cardiac deaths, respectively. Non-ST-elevation myocardial infarction and UA showed substantial differences in factors related to predictors for in-hospital outcome such that these should be examined separately.

Immediate, short and intermediate results of transcatheter closure of secondum-type atrial septal defect using Amplatzer septal occluder devices.

OBJECTIVES: To study the immediate, short, and intermediate results of transcatheter closure of secondum-type atrial septal defect using Amplatzer septal occluder devices (TCAA) in terms of clinical symptoms and residual lesions and shunts determined by transthoracic two-dimensional (TTE) and three-dimensional echocardiography (TDE). MATERIAL AND METHOD: Thirty-six patients, who underwent successful TCAA at the Chest Disease Institute between August 2002 and August 2007 and were followed up clinically, by TTE and TDE at day 1-3, 4-6 months, and 1-year post TCAA, were analyzed. RESULTS: TCAA was performed in 75 patients during the study period. Of these, 36 patients were completely followed-up. There were 92% female with a mean age of 40 +/- 16 yrs (range 19 to 65) and the mean of maximal size of ASD secondum determined by TTE, transesophageal echocardiography (TTE) and balloon sizing or balloon stretched diameter (BSD)was 18.9 +/- 4.7 mm (range 10-30), 22.6 +/- 5.3 mm (rang 10-32), and 24.3 +/- 5.3 mm (range 12-34) respectively. The size of ASOD was 26.4 +/- 4.9 mm (range 12-34). Fluoroscopic time was 16.4 +/- 7.1 min (range 6.7-35.6). The success rate of TCAA was 84%. No major complications and deaths were found. All of those with successful TCAA apparently improved their functional class. All of them showed complete ASD closure and yet 12 (31%) had Qp/Qs > or = 1.5 at year one. CONCLUSION: TCAA is safe and effective and had resulted in clinical improvement, complete closure of secondum ASD, and good immediate, short, and intermediate outcomes with fewer complications.

Experience of percutaneous mechanical mitral commissurotomy using metallic commissurotome in patients with mitral stenosis at chest disease institute.

BACKGROUND: Percutaneous metallic mitral commissurotomy (PMMC) has been accepted as an alternative to the traditional balloon technique. The advantage of the metallic commissurotome is that it is designed for several reuse and resterization and it is an interesting tool as seen by the authors. OBJECTIVE: To evaluate the efficacy and safety of PMMC among a wide range of patients with severe mitral stenosis. MATERIAL AND METHOD: Between July 2000 and August 2003, patients with severe mitral stenosis who underwent PMMC were enrolled Interatrial septum was punctured under transesophageal echocardiography guidance in all cases. Demographic data and baseline characteristics were collected Mitral valve area (MVA) was evaluated by echocardiography and hemodynamic parameters pre and post PMMC were compared RESULTS: PMMC was performed in 304 patients with a broad range of severe mitral stenosis. Mean age was 38.7 +/- 10. 9 years and 79% was female. Most were in functional class 11 (94%) and 43 patients (14%) had prior commissurotomy. Atrial fibrillation was found in 41%. Twenty-six patients were crossed over to the Inoue balloon technique. The rate of success was 81% in all patients (246/304) and 89% in patients when PMMC was actually done (246/278). The MVA increased from 84 +/- 22 to 170 +/- 36 mm2 (p < 0.0001). Transvalvular gradient decreased from 17 +/- 6 to 7 +/- 4 mmHg (p < 0.0001) and mean left atrial pressure from 26 +/- 7 to 15 +/- 6 mmHg (p < 0.0001). Separation of both commissures was found in 25% and 61% had symptom relief by a reduction in functional class at least one level (p < 0.0001). Complications developed in 16 patients (5.3%) including three serious events, one death caused by severe mitral regurgitation followed by emergency surgery, another survivor after surgical repair of left ventricular free wall rupture and the last one with surgical removal of the malfunctioned device stuck in the left atrium. CONCLUSION: Results of PMMC is not as encouraging as shown in previous studies. The risk of cardiac tamponade is minimized by interatrial septal puncture using transesophageal echocardiography (TEE) monitoring but this technique increased the possibility of crossover. Deterioration of the metallic commissurotome after a few procedures is demonstrated in the author's real practice.

Transjugular approach as a challenging access in PTMC: case report.

Advantage of transjugular approach in percutaneous mitral commissurotomy (PTMC) of severe mitral stenotic patients with venous drainage anomalies was obtained as the authors' first case experience. This approach should be considered whenever difficulties are encountered in the femoral approach in PTMC case before valve surgery.