Clinical outcome in patients with intermediate or equivocal left main coronary artery disease after deferral of surgical revascularization on the basis of fractional flow reserve measurements.

BACKGROUND: Correct assessment of the significance of left main stem lesions is of pivotal importance to the patient with coronary artery disease. On the basis of clinical and angiographic information alone, this evaluation often cannot be done reliably. Limited data suggest that coronary pressure-derived fractional flow reserve (FFR) supports decision making in equivocal left main disease. METHODS: All patients presenting to our institution between June 1999 and June 2004 with intermediate left main coronary artery disease (40%-80% diameter stenosis by angiography), or in whom left main coronary disease was suspected but could not be quantified angiographically, were included in this prospective single-center follow-up study. If FFR was <0.75 along the left main stem, surgical revascularization was recommended; if FFR was >0.80, medical treatment or percutaneous coronary intervention elsewhere in the coronary tree was chosen. If FFR was in the "gray zone," between > or = 0.75 and < or = 0.80 treatment recommendation was dependent on additional individual criteria. Primary end points were freedom from death, myocardial infarction, any coronary revascularization procedure, and stroke. RESULTS: Fifty-one patients (mean age 62.2 +/- 9.6 years, 41 male) were included. In 27 patients (53%), coronary artery bypass surgery was performed. The remaining 24 patients (47%) were treated nonsurgically. Mean follow-up was 29 +/- 16 months. Estimated survival after 4 years of follow-up was 81% among patients in the surgical group and 100% among patients in the nonsurgical group. Event-free survival was 66% in the surgical group and 69% in the nonsurgical group. CONCLUSIONS: Fractional flow reserve is helpful to identify patients with intermediate left main disease in whom deferral of surgical revascularization is associated with excellent survival and low event rates.

Optimizing revascularization strategies in patients with multivessel coronary disease: impact of intracoronary pressure measurements.

OBJECTIVES: In patients with multivessel coronary disease, the functional significance of each lesion is often unclear, and preinterventional stress tests may be inconclusive. In this setting, intracoronary pressure measurements may be helpful to define the optimal revascularization strategy. METHODS: Twenty-five consecutive patients (aged 64 +/- 11 years) with multivessel disease, inconclusive stress tests or not performed stress tests, and an angiographically intermediate coronary artery stenosis in at least 1 major vessel underwent intracoronary pressure measurements. Myocardial fractional flow reserve was measured for the intermediate lesions under the condition of maximum hyperemia induced by intravenous adenosine (140 microg x kg(-1) x min(-1). Revascularization strategies based on angiographic information alone were compared with treatment strategies based on fractional flow reserve results. RESULTS: The original recommendation of the revascularization procedure of choice (bypass operation or angioplasty) was changed in 9 patients (36%) on the basis of the results of fractional flow reserve measurements. In 6 more patients, pressure measurements led to a change in the recommended number of anastomoses to be aimed for during the operation. Within diffusely diseased vessels, fractional flow reserve provided an exact segmental resolution of pathologic vessel resistance for optimal graft placement. Significant left main disease was confirmed in 3 of 6 patients and was detected in 3 angiographically unsuspected cases. CONCLUSIONS: In patients with multivessel disease, coronary pressure-derived fractional flow reserve is a valuable tool to guide clinical decision making and support cardiologists and cardiovascular surgeons in the composition of optimal revascularization strategies.

[Health care quality: medication and prevention in patients with and without coronary heart disease]. / Versorgungsqualität im medikamentösen und präventiven Bereich bei Patienten mit und ohne koronare Herzkrankheit.

BACKGROUND AND PURPOSE: Next to noninvasive-recently also invasive-diagnostics, ambulant care in patients with coronary heart disease (CHD) should focus on optimal medication and prevention. The aim of this study was to evaluate actual health care quality concerning drug prescription and preventive care in patients with CHD. PATIENTS AND METHODS: This prospective study was conducted from March 1999 to February 2002 at the University Hospital Bergmannsheil, Bochum, Germany. 300 patients admitted with a suspected CHD and without previous coronary angiography or myocardial infarction were enrolled. Diagnostic and therapeutic regimen complied with actual guidelines. 248 patients (82.7%) including 116 patients with angiographically confirmed CHD were examined after 1 year. RESULTS: On follow-up, only 70.9% of patients with confirmed CHD received a beta-blocker, 83.6% were treated with platelet aggregation inhibitors. Body mass index, portion of overweight patients, and HbA(1c) in patients with diabetes did not change during observation. After 1 year, 48.0% of the subjects had a systolic blood pressure > 139 mmHg, in 22.6% diastolic pressure level was > 89 mmHg. Blood level of low-density cholesterol exceeded the recommended range in 57.0% of the cases observed with equally high portion of inadequately treated patients in the group with confirmed CHD and in the group without CHD. CONCLUSION: Drug therapy, primary and secondary prevention in the observed subjects were fairly poor. Remarkable deficits in health care quality became obvious. There is no lack in availability of evaluated, effective and efficient measures. Thus, physicians' efforts to implement evidence-based guidelines into clinical practice have to be strengthened.

Short-term effects of transcatheter aortic valve implantation on neurohormonal activation, quality of life and 6-minute walk test in severe and symptomatic aortic stenosis.

OBJECTIVE: This prospective study aimed to determine to what extent clinical symptoms and neurohumoral activation are improved in patients with severe aortic valve stenosis after transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis. METHODS: From June 2008 to June 2009 consecutive patients with symptomatic severe aortic valve stenosis (area<1 cm(2)), age>or=75 years with a logistic EuroSCORE >or=15% or age>60 years plus additional specified risk factors were evaluated for TAVI. Examinations of study patients were performed before and 30 days after TAVI and comprised assessment of quality of life (Minnesota living with heart failure questionnaire, [MLHFQ]) 6-minute walk test, measurement of B-type natriuretic peptide and echocardiography. Aortic valve prosthesis was inserted retrograde using a femoral arterial or a subclavian artery approach. RESULTS: In 44 consecutive patients (mean age 79.1+/-7 years, 50% women, mean left ventricular ejection fraction 55.8+/-8.5%) TAVI was successfully performed. Follow-up 30 days after TAVI showed a significantly improved quality of life (baseline 44+/-19.1 vs 28+/-17.5 MLHFQ Score, p<0.001) and an enhanced distance in the 6-minute walk test (baseline 204+/-103 vs 266+/-123 m, p<0.001). B-type natriuretic peptide levels were reduced (baseline 725+/-837 vs 423+/-320 pg/ml, p=0.005). CONCLUSIONS: Our preliminary results show a significant clinical benefit and a reduction of neurohormonal activation in patients with severe and symptomatic aortic valve stenosis early after TAVI.

Clinical outcome following conservative vs revascularization therapy in patients with stable coronary artery disease and borderline fractional flow reserve measurements.

BACKGROUND: Fractional flow reserve (FFR) measurements in the so-called gray-zone range of > or = 0.75 and < or =0.80 are associated with uncertainty concerning the guidance of patient therapy. It is unclear whether any difference in clinical outcome exists when revascularization treatment of FFR-evaluated lesions in this borderline range is deferred or performed. The objective of this study is to compare the clinical outcome of these patients with respect to their recommended treatment strategy. METHODS: Out of a single center database of 900 consecutive patients with stable coronary artery disease, 97 patients with borderline FFR measurements were identified and included in the study. The rate of major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), coronary revascularization) and the presence of angina were evaluated at follow-up. RESULTS: A total of 48 patients were deferred from revascularization and 49 patients underwent revascularization. There was no difference in risk profile between these groups. At a mean follow-up of 24+/-16 months, event-free survival in the deferred group was significantly better regarding overall MACE, combined rate of cardiac death, and MI, as well as MACE related to the FFR-evaluated vessel. No difference with regard to the presence of angina was observed. CONCLUSIONS: Patients with coronary lesions in the borderline FFR range can be deferred from revascularization without putting them at increased risk for major adverse events. Revascularization may be considered in the course of therapy on an individual basis if typical angina persists or worsens despite maximal medical treatment.

Adenosine-induced maximal coronary hyperemia for myocardial fractional flow reserve measurements: comparison of administration by femoral venous versus antecubital venous access.

BACKGROUND: Maximal hyperemia is a critical prerequisite for correct fractional flow reserve (FFR) measurements. Continuous administration of adenosine by femoral venous access is considered the gold-standard. However, antecubital venous access is used as an alternative route of administration due to the increasing popularity of radial versus femoral access for coronary catheterization. Because of a potentially larger cross sectional venous area in the arm-theoretically associated with slower flow velocities-and the extremely short half-life of adenosine, there are concerns whether this route of administration is truly equivalent to the femoral route. METHODS: Fifty randomly selected patients with coronary artery disease were included. FFR was measured with a pressure monitoring wire and the recording was digitally stored. Hyperemia was successively induced by adenosine via the antecubital vein at a dose of 140 microg kg(-1) min(-1) (A140), via the antecubital vein at a dose of 170 microg kg(-1) min(-1) (A170), and via the femoral vein at a dose of 140 microg kg(-1) min(-1) (F140). RESULTS: Induction of hyperemia by A140 yielded significantly lower hyperemic responses than compared with A170 (P = 0.038) and F140 (P = 0.005). No significant difference was seen between adenosine administration by A170 versus F140. Hyperemic stimulation by A140 underestimated lesion severity near the ischemic threshold of FFR more frequently than the other modalities. There were no differences in side-effects between any of the dosages and routes of administration. CONCLUSIONS: The intravenous application of adenosine via antecubital venous access is feasible but slightly less effective than the femoral approach. In this setting, an antecubital dosage of 170 microg kg(-1) min(-1) is comparable to the standard dosage of 140 microg kg(-1) min(-1) in the femoral vein. In some patients, this regimen might prevent an underestimation of lesion severity.

Renal perforation and retroperitoneal hematoma: an unusual complication following cardiac catheterization.

Retroperitoneal hematoma (RPH) is a well-recognised, albeit rare complication of percutaneous transfemoral cardiac catheterization. We describe an unusual case of renal perforation and RPH following transfemoral cardiac catheterization for endomyocardial biopsy. Diagnosis was made based on multidetector computed tomography (MDCT) which clearly depicted active renal hemorrhage in short acquisition time. The case expands the spectrum of possible complications of percutaneous transfemoral cardiac catheterization and illustrates the usefulness MDCT in quickly and adequately detecting RPH.

How good are experienced interventional cardiologists at predicting the functional significance of intermediate or equivocal left main coronary artery stenoses?

BACKGROUND: Decisions for coronary revascularisation are frequently based on visual assessment of the severity of a stenosis. In patients with intermediate left main stem lesions clinical decision making based on FFR is safe and feasible. This study was performed to assess the accuracy of visual angiographic assessment of intermediate or equivocal left main coronary artery (LMCA) stenoses by experienced interventional cardiologists when taking fractional flow reserve (FFR) measurements as the gold standard. METHODS: Fifty-one patients with intermediate (40-80% diameter stenosis by angiography) or equivocal LMCA disease were evaluated by FFR. Angiograms were then reviewed by 4 experienced interventionalists from different university hospitals blinded to FFR results. Lesions were visually assessed and their significance classified as 'significant', 'not significant', or 'unsure' if the observer was unable to make a decision regarding lesion significance based on the angiogram. RESULTS: Results were compared with two different FFR cutoff values (< 0.75 and < or = 0.80) for hemodynamic significance. The 4 reviewers achieved correct lesion classification in no more than approximately 50% of cases each, regardless of FFR threshold. The interobserver agreement between two reviewers in excess of the agreement expected due to chance was outperformed on average by only 16%. Furthermore, interobserver variability was large resulting in unanimously correct lesion classification in only 29% of all cases. CONCLUSIONS: The functional significance of intermediate and equivocal LMCA stenoses should not be based solely on angiographic assessment even by experienced interventional cardiologists.