Arun Kalyanasundaram

A Preoperative Echocardiographic Predictive Model for Assessment of Cardiovascular Outcome after Renal Transplantation

OBJECTIVE Major adverse cardiac events (MACE) frequently determine the outcome of renal transplantation (RT). Stress testing is advocated for preoperative risk assessment, but limited information is available on the prognostic value of these tests. We aimed to retrospectively assess the value of preoperative dobutamine stress echocardiography (DSE) in predicting MACE in patients undergoing RT. METHODS A total of 185 patients (age 56 +/- 11 years, 64% were men, creatinine level of 7.3 +/- 2.9 mg/d, 27% were smokers, 86% had hypertension, 54% had diabetes, 57% were dyslipidemic) with end-stage renal disease (ESRD) underwent DSE before RT. A standard DSE protocol was used with the administration of 5-50 mug/kg/min incremental doses in 3-minute intervals and up to 1 mg of atropine if needed to reach prespecified end points. RESULTS Regional left ventricular wall motion abnormality (WMA) at rest (fixed), with stress (inducible), or both were present in 54, 35, and 18 patients, respectively. In 38 patients who underwent coronary angiography, the sensitivity, specificity, and positive and negative predictive values of inducible WMA for predicting angiographic coronary artery disease (> or = 70% luminal diameter reduction) were 88%, 62%, 65%, and 87%, respectively. Cox regression analysis identified the presence of combined fixed and inducible WMA (ie, resting WMA that did not change during DSE, accompanied by new WMA evident during DSE; hazard ratio [HR] 5.6, P = .012), left atrial enlargement (HR 4.2, P = .002), and aortic valve sclerosis (HR 3.9, P = .013) as independent predictors of 48-month MACE (cardiac death, nonfatal acute myocardial infarction, and coronary revascularization after RT). Patients with all 3 predictors had a 48-month MACE of 60% compared with 5% in those with none (P = .007). Compared with those without WMA, patients with both fixed and inducible WMA had a higher rate of MACE at 48 months (7% vs 33%, P = .004). CONCLUSION In RT candidates, DSE can effectively identify those at low and high risk of MACE.

Thrombus predicts ischemic complications during percutaneous coronary intervention in saphenous vein grafts: Results from TARGET (do tirofiban and reopro give similar efficacy trial?)

Background: Saphenous vein graft (SVG) percutaneous coronary intervention (PCI) carries a high risk of ischemic complications. However, there are scant recent data to identify which SVG lesions carry particularly high risk in recent years. We studied demographic and angiographic factors associated with ischemic complications after SVG PCI without distal protection in the TARGET (do tirofiban and reopro give similar efficacy trial?) study. Methods: TARGET was a multicenter double‐dummy, double‐blinded study randomizing 4,809 PCI patients to tirofiban or abciximab. Of these, 254 patients underwent PCI involving an SVG lesion. The primary endpoint of this analysis was major adverse cardiac events (MACEs) at 30 days, including death, nonfatal myocardial infarction (MI), and urgent target vessel revascularization. Results: No demographic characteristic was associated with 30‐day MACE. Lesion length > 20 mm (odds ratio [OR] = 2.7, P = 0.03), thrombus (OR = 3.9, P = 0.003), eccentricity (P = 0.001), thrombolysis in myocardial infarction flow < 3 postprocedure (OR = 5.6, P = 0.037), and >1 target lesion (OR = 2.5, P = 0.035) were univariate variables associated with 30‐day MACE. Multivariate analysis associated only thrombus (OR = 3.8, P = 0.015) with 30‐day MACE. No difference in outcomes was noted between patients receiving abciximab and tirofiban. SVG patients had lesser angiographic success (95.6% vs. 98%, P = 0.04) and increased 30‐day Q‐wave MI (2.5% vs. 0.9%, P = 0.039) compared with non‐SVG patients, but a similar incidence of death (0% vs. 0.4%), non‐Q‐MI (5.9% vs. 4.5%), and target vessel revascularization (0.5% vs. 1%). Conclusion: In the era of routine stenting and GpIIb/IIIa inhibitors, thrombus is the angiographic characteristic most closely associated with adverse outcomes of SVG PCI

Simultaneous massive pulmonary embolism and impending paradoxical embolism through a patent foramen ovale.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 66-year-old obese woman presented with shortness of breath over 8 weeks. She was hemodynamically stable. D-dimer was elevated at 2.14. Transthoracic (Online Video [1][5]) followed by transesophageal

Safety and efficacy of the hybrid approach in coronary chronic total occlusion percutaneous coronary intervention: The Hybrid Video Registry

The aim of the Hybrid Video Registry (HVR) is to assess the acute safety and efficacy of the Hybrid Approach in comparison to other contemporary methods of CTO‐PCI. Background: Recently, multiple techniques in Percutaneous Coronary Intervention (PCI) for coronary Chronic Total Occlusions (CTO) have been synthesized into a method referred to as the “Hybrid Approach”.

Update on the Management of Chronic Total Occlusions in Coronary Artery Disease

Purpose of the ReviewChronic total occlusions (CTOs) are found in about a third of patients with coronary artery disease (CAD) and can pose a significant challenge during percutaneous revascularization. However, advances in CTO percutaneous coronary intervention (PCI) strategies, devices, and algorithms have led to significant improvements in successful treatment of CTOs. This review summarizes current management of CTOs in the context of modern PCI techniques and current evidence.Recent FindingsThe hybrid algorithm now provides a standardized, teachable approach to CTO PCI, and success rates are approximately 90% in experienced hands. The first randomized controlled trial in patients with CTOs recently reported that patients with ST elevation myocardial infarction (STEMI) and a CTO in the non-culprit vessel showed an improvement in ejection fraction in patients undergoing CTO PCI of the LAD, but not other vessels. Updated data from the SYNTAX trial showed a benefit with complete revascularization in patients with coronary artery disease (CAD). Incomplete revascularization of CTOs in the PCI group may explain some of the benefit seen with CABG over PCI in patients with complex coronary disease. Contemporary CTO registries have reported success rates of approximately 90%, and the OPEN-CTO registry updates our understanding of CTO PCI complication rates and outcomes.SummaryThe available evidence highlights the potential benefits of CTO PCI in patients with an indication for revascularization. Technological advancements have paved the way for success rates approaching 90% at high-volume centers, but further studies evaluating outcomes following CTO PCI are needed, with several currently underway.

Routine Platelet Testing Should Not Be Performed on All Patients Undergoing Percutaneous Coronary Intervention

We all know that clopidogrel reduces thrombotic complications during and after a percutaneous coronary intervention (PCI) procedure. Because clopidogrel is a prodrug and only ≈2% of ingested clopidogrel is ultimately bound to platelets, it is entirely possible, even likely, that small differences in metabolism that lead to a reduction in the formation of the active metabolite could potentially have an enormous clinical impact.1 So, it would seem entirely logical to measure individual patients response to clopidogrel and to alter their therapy in an individualized manner. After all, are we not moving as a profession with great enthusiasm to the practice of “personalized medicine?” And should we not? Does it make sense that patients young or old, tall or short, lightweight or obese, and so on would all require the same dose of clopidogrel and respond to it to the same degree? No, it does not. Response by Price on p 288 Having said that, the truth is that there are scant data to date that the routine use of platelet function testing for all patients to whom clopidogrel is administered would improve clinical outcomes. In fact, the currently available data suggest the opposite. How can we make such a statement in view of all the studies that at first glance might seem to suggest the opposite? The issues suggesting that routine platelet function testing of all patients on clopidogrel ought not yet be routinely used to guide clinical practice can perhaps be most clearly understood by examining the following basic yet fundamental concerns: Clopidogrel resistance, or to use the more appropriate and preferred term, hyporesponsiveness to …

Fractional flow reserve–guided PCI reduced major adverse cardiac outcomes compared with angiography-guided PCI in multivessel CAD

Question In patients with multivessel coronary artery disease (CAD) having percutaneous coronary intervention (PCI), does routine measurement of fractional flow reserve (FFR) using angiography improve cardiac outcomes? Methods Design Randomized controlled trial (Fractional Flow Reserve versus Angiography for Multivessel Evaluation [FAME] study). ClinicalTrials.gov NCT00267774. Allocation {Concealed}.* Blinding Blinded (outcome assessors).* Follow-up period 1 year. Setting 20 medical centers in the USA and Europe. Patients 1005 patients (mean age 64 y, 74% men) with multivessel CAD (coronary artery stenosis 50% of vessel diameter in 2 of 3 major epicardial coronary arteries) who were having PCI. Exclusion criteria included angiographically significant left main CAD, previous coronary artery bypass surgery, cardiogenic shock, extremely tortuous or calcified coronary arteries, and contraindication to drug-eluting stents. Intervention FFR- (n =509) or angiography-guided (n =496) PCI with drug-eluting stents. The FFR group received stents for lesions of FFR 0.8, whereas the angiography group received stents for all lesions. All patients took aspirin and clopidogrel for 1 year after PCI. Outcomes Included major adverse cardiac events (composite of death, myocardial infarction [MI], and repeated revascularization), individual components of the composite endpoint, and health-related quality of life. Patient follow-up 98% (100% included in intention-to-treat analysis). Main results Fewer patients in the FFR group had major adverse cardiac events compared with the angiography group (Table). Groups did not differ for individual components of the composite endpoint (Table) or health-related quality of life. Conclusion Measurement of fractional flow reserve using angiography reduced a composite of death, myocardial infarction, and repeated revascularization compared with angiography alone in patients with multivessel coronary artery disease having percutaneous coronary intervention. Fractional flow reserve (FFR)- vs angiography-guided percutaneous coronary intervention in patients with multivessel coronary artery disease Outcomes FFR Angiography At 1 y RRR (95% CI) NNT (CI) Major adverse cardiac event 13% 18% 28% (4 to 46) 20 (12 to 137) Death 1.8% 3.0% 42% (32 to 74) Not significant Myocardial infarction 5.7% 8.7% 34% (4 to 58) Not significant Repeated revascularization 6.5% 9.5% 32% (5 to 55) Not significant Abbreviations defined in Glossary. RRR, NNT, and CI calculated from control event rates and relative risks in article. Commentary Previously, Pijls and colleagues showed that PCI can be safely deferred in stenoses that are not functionally significant (FFR 0.75) (1). The associated risk for cardiac death or MI was <1%/year and was not reduced by stenting (1). Given that PCI may cause adverse events and is expensive, Tonino and colleagues evaluated whether PCI based on FFR rather than angiography might improve outcomes in multivessel CAD. The results reinforce 3 key concepts: 1) Visual assessment of the functional significance of a borderline lesion based on angiograms is often inaccurate; 2) physiologic assessment of lesions before PCI is generally feasible and often enlightening; 3) medical treatment of borderline lesions that are not physiologically significant seems to have a better outcome than PCI. Yet questions remain about the integration of the study findings into clinical practice. First, does every lesion in multivessel CAD require FFR measurement? Although FFR was measured in all vessels with lesions >50%, certain lesions are clearly so severe on angiography that FFR is unlikely to be educational. Do all lesions between 50% and 70% need FFR measurement? Stenting such lesions is rarely appropriate, with or without functional assessment. Another issue is what to do with borderline positive FFRs of 0.75 to 0.80. Some unfavorable lesions with borderline positive FFRs can and should be managed medically. Such lesions probably lead to angina only at high workloads rarely achieved by many patients. The safety of medical therapy for patients with minimal symptoms has been shown previously (2), and it is appealing for patients with borderline lesions and unfavorable characteristics for PCI. Although further studies may be needed to address some concerns, the landmark study by Tonino and colleagues supports a physiologically guided approach to PCI in some lesions and powerfully argues for deferring PCI in angiographically borderline lesions with negative FFRs.