Value of the American College of Cardiology/American Heart Association angiographic classification of coronary lesion morphology in patients with in-stent restenosis. Insights from the Restenosis Intra-stent Balloon angioplasty versus elective Stenting (RIBS) randomized trial.

BACKGROUND: The implications of the American College of Cardiology/American Heart Association (ACC/AHA) lesion classification in patients with in-stent restenosis (ISR) are unknown. METHODS: Four hundred fifty patients included in the RIBS randomized study were analyzed. A centralized core laboratory assessed ISR classifications including ACC/AHA, the classification of Mehran et al (Circulation 1999;100:1872-8), diffuse/focal, and a new quantitative ISR index (lesion length/stent length). Logistic regression models were constructed for prespecified outcome measures including (1) unsatisfactory acute results and (2) recurrent restenosis rate. RESULTS: Complex (B2/C) lesions (78%) more frequently obtained unsatisfactory acute results (20% vs 8%, P = .007), smaller minimal lumen diameter after the procedure (2.45 +/- 0.5 vs 2.73 +/- 0.5 mm, P = .001) and at follow-up (1.48 +/- 0.8 vs 1.94 +/- 0.8 mm, P = .0001), and had a higher restenosis rate (43 vs 24%, P = .001) than simple (A/B1) lesions. On logistic regression analysis, all classification schemes were useful to predict unsatisfactory initial results (area under the curve: 0.63, 0.61, 0.59, and 0.62) and recurrent restenosis (area under the curve: 0.60, 0.64, 0.61, and 0.63). The predictive ability of these schemes persisted despite adjustment for potential confounders. Although the ACC/AHA classification was a better predictor of acute results, the classification of Mehran was superior to predict restenosis. CONCLUSIONS: The ACC/AHA classification provides a useful tool to determine acute procedural results and the long-term angiographic outcome of patients with ISR.

A randomized comparison of repeat stenting with balloon angioplasty in patients with in-stent restenosis.

OBJECTIVES: This randomized trial compared repeat stenting with balloon angioplasty (BA) in patients with in-stent restenosis (ISR). BACKGROUND: Stent restenosis constitutes a therapeutic challenge. Repeat coronary interventions are currently used in this setting, but the recurrence risk remains high. METHODS: We randomly assigned 450 patients with ISR to elective stent implantation (224 patients) or conventional BA (226 patients). Primary end point was recurrent restenosis rate at six months. Secondary end points included minimal lumen diameter (MLD), prespecified subgroup analyses, and a composite of major adverse events. RESULTS: Procedural success was similar in both groups, but in-hospital complications were more frequent in the balloon group. After the procedure MLD was larger in the stent group (2.77 +/- 0.4 vs. 2.25 +/- 0.5 mm, p < 0.001). At follow-up, MLD was larger after stenting when the in-lesion site was considered (1.69 +/- 0.8 vs. 1.54 +/- 0.7 mm, p = 0.046). However, the binary restenosis rate (38% stent group, 39% balloon group) was similar with the two strategies. One-year event-free survival (follow-up 100%) was also similar in both groups (77% stent vs. 71% balloon, p = 0.19). Nevertheless, in the prespecified subgroup of patients with large vessels (> or =3 mm) the restenosis rate (27% vs. 49%, p = 0.007) and the event-free survival (84% vs. 62%, p = 0.002) were better after repeat stenting. CONCLUSIONS: In patients with ISR, repeat coronary stenting provided better initial angiographic results but failed to improve restenosis rate and clinical outcome when compared with BA. However, in patients with large vessels coronary stenting improved the long-term clinical and angiographic outcome.

[Congenital apical left ventricular aneurysm]. / Aneurisma congénito apical ventricular izquierdo.

Congenital ventricular aneurysm is an infrequently occurring disease entity that usually affects the left ventricle. Its etiopathology is unknown. Clinical presentation is variable, and the condition is potentially lethal in some cases. Various imaging techniques are useful in diagnosis and enable the condition to be differentiated from congenital left diverticulum. We present a patient with a calcified congenital ventricular aneurysm who presented with supraventricular and ventricular arrhythmias and who was treated by surgical resection.

[Relationship between coronary flow and viability in patients with myocardial infarction submitted to revascularization with stent. Assessment by Doppler guidewire]. / Relación entre flujo coronario y viabilidad en pacientes con infarto que reciben angioplastia con stent. Análisis con guía intracoronaria Doppler.

UNLABELLED: Introduction and objectives. Intracoronary Doppler guidewire measurement provides information about the state of the myocardial microcirculation. Our aim was to assess the relationship between the pattern of coronary flow and myocardial viability. Patients and method. The study included 19 patients who had had a recent myocardial infarction (< 1 month), who underwent percutaneous revascularization of the responsible vessel, and who agreed to angiographic follow-up. Patients were divided into two groups according to the extent of the akinetic area observed at follow-up responsible (149 [40] days) in the myocardial region supplied by the responsible artery: one group (n=11) had preserved regional contractility (i.e., an akinetic area less than 30%); the other group (n=8) had impaired regional contractility (i.e., an akinetic area equal to or greater than 30%). Coronary flow in the artery was responsible assessed after revascularization and at follow-up using the Doppler guidewire method. RESULTS: After revascularization, patients with preserved regional contractility had a higher diastolic deceleration half-time than those with impaired regional contractility (628 [188] ms vs 376 [131] ms, P=.02). At follow-up, the difference in coronary flow between the groups had disappeared. Patients in whom regional contractility was preserved demonstrated a significant increase in coronary flow reserve at follow-up (1,8 [0,5] vs 2,3 [0,5], P=.01). CONCLUSIONS: After timely revascularization (within one month) of the vessel responsible for a myocardial infarction, the pattern of coronary flow observed in patients with viable myocardium differed from that in those with non-viable myocardium. The differences disappeared during follow-up.

Validation of 4 French catheters for quantitative coronary analysis: in vivo variability assessment using 6 French guiding catheters as reference scaling devices.

UNLABELLED: Although numerous studies have established the utility of 4 F catheters for routine coronary angiography, its adequacy for automatic quantitative coronary analysis has not been previously assessed. METHODS: In 32 consecutive patients, coronary angiography was performed sequentially with 4 F diagnostic catheters and 6 F guiding catheters after intracoronary nitroglycerin. A total of 43 lesions were evaluated for quantitative analysis using both types of catheter as scaling devices. Possible differences in the reference diameter, minimal luminal diameter and percent diameter stenosis were evaluated. All measurements were performed offline by the same operator and intraobserver variability estimation was performed by repeating the evaluation in 12 lesions randomly selected after 1 month. RESULTS: The mean reference diameter was 2.98+/-0.48 mm, mean minimal luminal diameter was 1.00+/-0.52 mm and percent diameter stenosis was 67.1+/-15.3%. Accuracy (mean difference of values) was 0.009 mm for reference diameter, 0.005 mm for minimal luminal diameter and 0.25% for percent diameter stenosis. Precision (mean standard deviation of the differences) was 0.17 mm for reference diameter, 0.19 mm for minimal luminal diameter and 5.93% for percent stenosis. Linear correlation for these three variables was 0.94, 0.93 and 0.93, respectively. Intraobserver variability analysis showed similar values for accuracy, precision and linear correlation. CONCLUSIONS: Angiography with 4 F catheters allows adequate quantification of luminal diameters as compared to most accepted clinical standards. These results may have implications for the selection of diagnostic catheters for routine follow-up assessment of percutaneous coronary interventions.

[Could fractional flow reserve guide therapeutic strategy in acute coronary syndrome?]. / ¿Puede la reserva fraccional del flujo guiar la estrategia terapéutica en el síndrome coronario agudo?

Fractional flow reserve, as determined with a pressure-wire, was validated in the assessment of the functional severity of intermediate lesions in a population with stable ischemic cardiopathy. The value of pressure-wire analysis in acute coronary syndrome is unknown. We report two patients with acute coronary syndrome, in which the therapeutic approach was guided by the fractional flow reserve. We discuss the utility of this tool in this context.

[ST segment elevation during dipyridamole stress testing in a patient without coronary lesions]. / Elevación del segmento ST durante una tomografía computarizada por emisión de fotones simples con dipiridamol en ausencia de lesiones coronarias.

We describe a patient who presented transient ST-segment elevation and typical chest pain during an ischemia test with dipyridamole and technetium-tetrofosmin. Chest pain and electrical alterations disappeared promptly with sublingual nitroglycerin. Coronary angiography showed no epicardial lesions, and coronary vasospasm was suspected. We discuss possible explanations for this complication.

[Percutaneous coronary intervention for iatrogenic occlusion of the circumflex artery after mitral anuloplasty]. / Intervencionismo coronario en la oclusión iatrogénica de circunfleja tras anuloplastia mitral.

We describe a patient with obstruction of the dominant circumflex artery after surgical repair of the mitral valve, repaired successfully with percutaneous coronary intervention during the immediate postoperative period. We discuss the etiology, prevention and management of this complication with special emphasis on percutaneous intervention.

[Coronary angiography with 4 f catheters by the radial: minimally invasive catheterization]. / Angiografía coronaria con catéteres de 4 F por la vía radial: el "cateterismo mínimamente invasio".

INTRODUCTION AND OBJECTIVES: Experience with 4 F catheters in cardiac catheterization is limited. These devices appear to be more suitable for the radial artery approach than conventional 6 F catheters. METHODS: We analyze our preliminary experience with diagnostic catheterization of the radial artery with 4 F catheters. Angiographic images were evaluated using a predefined scale (1. poor; 2. acceptable; 3. optimal). In a subgroup of patients who underwent coronary angioplasty, the quantitative angiographic data obtained with the 4 F catheter were compared to those obtained with the 6 F guide catheter. In all cases the patients were clinically followed-up at 24 h and 7 days. RESULTS: Two hundred and six studies performed over a 12-month period were reviewed. In 6 cases (2.9%) the femoral vein had to be used instead and in 4 cases (1.9%) the 4 F catheters were replaced by 6 F catheters. The left coronary angiography was graded as optimal in 83% and as acceptable in 15%. Right coronary artery images were considered optimal in 93% and acceptable in 7%. There was an excellent correlation between the reference diameter obtained by quantitative angiography with the 4 F catheter and values obtained with a 6 F guide catheter (r = 0.92; p < 0.01). No major vascular complications occurred. CONCLUSION: 4 F catheters are appropriate for systematic use in diagnostic procedures using the radial access.

[Value of gated-SPECT in defining the post-revascularization prognosis of patients with ischemic cardiomyopathy]. / Valor del gated-SPECT para definir el pronóstico tras la revascularización en una población con cardiopatía isquémica.

INTRODUCTION AND OBJECTIVES: Gated-SPECT simultaneously evaluates perfusion and ventricular function and could provide important prognostic information in ischemic cardiomyopathy. Our aim was to study the value of gated-SPECT performed before revascularization in a cardioischemic population to predict the outcome of revascularization. METHODS: One hundred and ten patients who had undergone percutaneous (n = 100) or surgical revascularization were included. Patients underwent sestamibi gated-SPECT before revascularization. After revascularization, they were followed-up for at least 12 months (mean 23.7 months, maximum 44 months). We recorded deaths and a combined clinical event of death, non-fatal infarction, and hospital re-admission for cardiac reasons. We analyzed the prognostic value of clinical, angiographic, and gated-SPECT variables. RESULTS: During follow-up, there were 14 deaths (6.4%/ year) and 36 cases of combined events (16.5%/year). Multivariate analysis showed that depressed gated-SPECT ejection fraction (threshold 0.30) was the only variable independently related to death (OR = 4.8; 95%CI, 1.6-14.6) and combined event (OR = 2.5; 95%CI, 1.2-4.8). Survival analysis showed that patients with ejection fraction < or = 0.30% had a significantly shorter period of time free of death (33 months [28-38] versus 42 months [40-44]; p = 0.002) and combined events (28 months [23-32] versus 36 months [33-39]; p = 0.007). CONCLUSIONS: Gated-SPECT, due to the information it provides about left ventricular function, predicts the prognosis of patients after coronary revascularization.

Transradial cardiac catheterization in patients with coronary bypass grafts: feasibility analysis and comparison with transfemoral approach.

The objective of this study was to analyze the feasibility and safety of transradial catheterization in patients with remote surgical cardiac revascularization. Selective catheterization of coronary bypass grafts might be more difficult and time-consuming from the radial artery as compared to the femoral route. This special patient subset has been either excluded or underrepresented in previous studies. Retrospective review was made of 304 cardiac diagnostic procedures performed from January 2001 through December 2004 in patients with coronary artery bypass grafts in a single center. Patients had to be considered eligible for both transradial and transfemoral approach to be included. Cases with double internal mammary or gastroepiploic grafts were excluded. Selection of the arterial access was individualized according to operator preferences. Among diagnostic cases, transradial access was attempted as first choice in 151 cases (left radial in 133) and transfemoral in 154. Total procedural time (41 +/- 22 vs. 40 +/- 23 min), fluoroscopy time (15 +/- 10 vs. 18 +/- 13 min), and dye volume (180 +/- 64 vs. 192 +/- 73 ml) were similar. Crossover rates were 4.0% in the transradial group and 1.3% in transfemoral (P = 0.28). Only two patients in transradial group needed transfemoral access because of failure to catheterize a bypass graft. Transradial angiography of coronary bypass grafts can be performed with similar success rates as compared with transfemoral procedures and without a significant time delay.

A randomized comparison of sirolimus-eluting stent with balloon angioplasty in patients with in-stent restenosis: results of the Restenosis Intrastent: Balloon Angioplasty Versus Elective Sirolimus-Eluting Stenting (RIBS-II) trial.

OBJECTIVES: We sought to assess the effectiveness of sirolimus-eluting stents (SES) in patients with in-stent restenosis (ISR). BACKGROUND: Treatment of patients with ISR remains a challenge. METHODS: The Restenosis Intrastent: Balloon Angioplasty Versus Elective Sirolimus-Eluting Stenting (RIBS-II) study is a multicenter randomized trial conducted in 150 patients with ISR (76 allocated to SES and 74 to balloon angioplasty [BA]). The primary end point was recurrent restenosis rate at nine months. Secondary end points included prespecified subgroup analysis, lumen volume on intravascular ultrasound (IVUS), and a composite of major clinical events at one year. RESULTS: Angiographic success was obtained in all patients. At 9-month angiographic follow-up (96% of eligible patients) minimal lumen diameter was larger (2.52 mm [interquartile range (IQR) 2.09 to 2.81] vs. 1.54 mm [IQR 0.91 to 2.05]; p < 0.001) and recurrent restenosis rate was lower (11% vs. 39%; p < 0.001) in the SES group. Prespecified subgroup analyses were consistent with the main outcome measure. Lumen volume on IVUS at 9 months was also larger (279 mm3 [IQR 227 to 300] vs. 197 mm3 [IQR 177 to 230]; p < 0.001) in the SES group. At one-year clinical follow-up (100% of patients), the event-free survival (freedom from death, myocardial infarction, and target vessel revascularization) was significantly improved in the SES group (88% vs. 69%; p < 0.004) as the result of a lower requirement for target vessel revascularization (11% vs. 30%; p < 0.003). CONCLUSIONS: In patients with ISR, the use of SES provides superior long-term clinical, angiographic, and IVUS outcome than BA treatment.

Simultaneous intracoronary pressure and Doppler guidewires to assess coronary stenosis: if one is enough, are two too much?

We report a potential source of erroneous estimation of stenosis severity by pressure guidewire assessment. Simultaneous introduction of pressure and Doppler guidewires can lead to an overestimation of stenosis pressure gradient in the evaluation of intermediate stenosis.

Coronary perforation as a potential complication derived from coronary thrombectomy with the X-Sizer device.

We report a case of coronary perforation after failed atherectomy with a 2 mm X-Sizer catheter in recent totally occluded right coronary artery. The perforation was successfully managed with a polytetrafluoroethylene-covered stent with satisfactory final angiographic results. Possible predictors of this complication with this new device are discussed.