Alan Schob

Aortic Pressure Augmentation Predicts Adverse Cardiovascular Events in Patients With Established Coronary Artery Disease

Pulse pressure (PP), a marker of arterial stiffness, predicts cardiovascular risk. We aimed to determine whether augmentation pressure (AP) derived from the aortic pressure waveform predicts major adverse cardiovascular events (MACE) and death independently of PP in patients with established coronary artery disease (CAD). We prospectively followed-up 297 males undergoing coronary angiography for 1186±424 days. Ascending aortic pressure tracings obtained during catheterization were used to calculate AP (difference between the second and the first systolic peak). Augmentation index (AIx) was defined as AP as a percentage of PP. We evaluated whether AP and AIx can predict the risk of MACE (unstable angina, acute myocardial infarction, coronary revascularization, stroke, or death) and death using Cox regression. All models evaluating AP included PP to assess whether AP adds to the information already provided by PP. Both AP and AIx significantly predicted MACE. The hazard ratio (HR) per 10 mm Hg increase in AP was 1.20 (95% confidence interval [CI], 1.08 to 1.34; P<0.001); the HR for each 10% increase in AIx was 1.28 (95% CI, 1.11 to 1.48; P=0.004). After adjusting for other univariate predictors of MACE, age, and other potential confounders, AP remained a significant predictor of MACE (HR per 10 mm Hg increase=1.19; 95% CI, 1.06 to 1.34; P=0.002), as did AIx (adjusted HR, 1.28; 95% CI, 1.09 to 1.50; P=0.003). AP was a significant predictor of death (HR per 10 mm Hg increase=1.18; 95% CI, 1.02 to 1.39; P=0.03). Higher AIx was associated with a trend toward increased mortality (HR=1.22; 95% CI, 0.98 to 1.52; P=0.056). Aortic AP predicts adverse outcomes in patients with CAD independently of PP and other risk markers.

Saphenous vein graft aneurysm presenting as a large mediastinal mass compressing the right atrium

A patient with a large saphenous vein graft aneurysm is described. This case illustrates the role of magnetic resonance imaging and cardiac catheterization in patients with a mediastinal mass and history of coronary bypass surgery.

Ability of serum to decrease cellular acylCoA:cholesterol acyl transferase activity predicts cardiovascular outcomes.

Background— We evaluated whether cholesterol efflux activity of serum is associated with the presence of angiographic coronary artery disease (CAD) and the risk of major adverse cardiovascular events (MACE) and death. Methods and Results— We studied 168 men undergoing coronary angiography. Cholesterol efflux activity was measured in vitro by incubation of patient serum with human skin fibroblasts and defined as the ability of serum to decrease the pool of cholesterol available for esterification by the acylCoA:cholesterol acyl transferase (ACAT) reaction. We evaluated whether this activity was associated with the presence of CAD and the risk of MACE and death during a 4.5-year follow-up. Serum-induced changes in ACAT activity did not correlate with HDL levels or the presence of CAD. Patients in the highest tertile of change in ACAT activity had a significantly higher risk for MACE (HR, 2.15; 95% CI, 1.36 to 3.39; P=0.001) and death (HR, 2.23; 95% CI, 1.17 to 4.26; P=0.01). These correlations were independent of other risk markers including LDL, HDL, and C-reactive protein levels. Conclusions— Serum-induced depletion of cellular cholesterol available for esterification by ACAT was a strong, independent predictor of MACE and death. We speculate that the ability of serum to decrease ACAT activity depends on ATP binding cassette transporter A1 (ABCA1)–mediated efflux. Furthermore, serum samples that induce larger changes in ACAT activity contain increased levels of HDL particles that preferentially interact with ABCA1 and that these particles accumulate in the serum of patients because of low activity of ABCA1 in vivo preventing or limiting the extent of apoA-I lipidation.

Iatrogenic coronary septal artery–to–right ventricular fistula complicating percutaneous transluminal coronary angioplasty with spontaneous resolution ☆ ☆☆ ★

and the use of superoinferior sweeps from the high left paras ternal and suprasternal t ransducer positions. These sweeps demonstrate the spatial relationship of the origins and courses of the branch pulmonary arteries. Accurate noninvasive diagnosis of pulmonary artery malpositions can be made with echocardiography. The finding of crossed pulmonary arteries may be a clue for the presence ofassoda ted cardiac and extracardiac anomalies.

ST-alternans alternans

Abstract ST-segment alternans indicates nonuniformity of ventricular repolarization in time and space, and consequently correlates with the occurrence of ventricular fibrillation during cardiac ischemia. 1,2 ST alternans has been observed during spontaneous and induced myocardial ischemia in experimental animals 1,3 and in man during exercise, 4 Prinzmetal angina 5,6 and coronary angioplasty. 7–9 Whereas ST-segment shifts (particularly ST-segment elevation) are frequent during angioplasty, 10 ST-segment alternans is infrequent. We present a patient who on sequential balloon inflations during coronary angioplasty demonstrated a sequence of ST-segment shifts recorded by intracoronary electrocardiography, reflecting the unique effects of repeated short episodes of ischemia on the alternans phenomenon.

Cryoplasty for the Treatment of Coronary Bifurcation Stenoses Following Main Vessel Stenting

OBJECTIVES This retrospective study sought to assess the safety and clinical efficacy of cryoplasty for treatment of side-branch stenoses following main vessel stenting in coronary bifurcation lesions. BACKGROUND Cryoplasty prevents restenosis by reducing smooth muscle proliferation and extracellular matrix synthesis. Clinical effectiveness has been demonstrated in the peripheral circulation. Treatment of coronary bifurcation lesions remains a challenge. We used a novel strategy of main vessel stenting combined with side-branch cryoplasty to treat high-grade stenoses following main vessel stenting. METHODS Eighteen patients with bifurcation lesions had significant plaque shift into a side branch after main vessel intervention. Drug-eluting stents were placed in the main vessel and cryoplasty was performed on the side-branch vessel. Quantitative coronary analysis was performed on all side-branch vessels both pre- and post-main vessel stenting. All patients had clinical follow-up 3 months or more after cryoplasty including either nuclear stress testing or diagnostic coronary angiogram. RESULTS Mean percent stenosis decreased from 80.6% post main vessel stenting to 24.8% following cryoplasty (P < 0.0001). Of the 17 patients who had pre-cryoplasty nuclear stress testing 1 patient had ischemia identified in the distribution of the treated vessel at follow-up. Five patients had follow up angiography. One patient had restenosis, the other 2 were unchanged. There was a low incidence of MACE. CONCLUSIONS In this first report of its use in the coronary circulation, cryoplasty for bifurcation side-branch disease was safe and associated with a low rate of clinical recurrence in carefully selected patients.