Benny Drieghe

Novel X‐ray imaging technology enables significant patient dose reduction in interventional cardiology while maintaining diagnostic image quality

The purpose of this study was to quantify the reduction in patient radiation dose during coronary angiography (CA) by a new X‐ray technology, and to assess its impact on diagnostic image quality.

Screening for pulmonary arterial hypertension in an unselected prospective systemic sclerosis cohort

Screening for pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) improves outcomes. The DETECT screening algorithm is recommended in a high-risk SSc subgroup. This study aims to compare prospectively the positive predictive value of screening using the DETECT algorithm and the 2009 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines, and to compare their cost-effectiveness in an unselected, day-to-day SSc population. Post hoc, screening according to the 2015 ESC/ERS guidelines using echocardiographic parameters alone (“2015 echo screening”) or combined with the DETECT algorithm (“2015 combined screening”) in high-risk subjects was analysed. 195 consecutive SSc patients included in the Ghent University Hospital SSc cohort were screened using different algorithms. The referral rate for right heart catheterisation was 32% (63 out of 195 patients) (46/4/13/34/40 patients using the DETECT algorithm/2009 guidelines/both/2015 echo screening/2015 combined screening). Right heart catheterisation was performed in 53 patients (84%) (36 (78%)/four (100%)/13 (100%)/28 (82%)/32 (80%) patients recommended by the DETECT algorithm/2009 guidelines/both/2015 echo screening/2015 combined screening). PAH was diagnosed in three patients (incidence 1.5%·year–1, 95% CI 0.5–4.4), in whom all algorithms recommended a right heart catheterisation. The positive predictive value was 6% (95% CI 2–17%; three out of 49 patients) for the DETECT algorithm, 18% (95% CI 6–41%; three out of 17 patients) for the 2009 guidelines, 23% (95% CI 8–50%; three out of 13 patients) for both, 11% (95% CI 4–27%; three out of 28 patients) for the 2015 echo screening and 9% (95% CI 3–24%; three out of 32 patients) for the 2015 combined screening. The cost was EUR224/80/90/112 per patient using the DETECT algorithm/2009 guidelines/2015 echo screening/2015 combined screening. Echocardiography may remain a candidate first step for PAH screening in SSc. Echocardiography remains a candidate first step in screening for PAH in an unselected systemic sclerosis population http://ow.ly/nuoh3096nRh

Three‐dimensional rotational X‐ray acquisition technique is reducing patients' cancer risk in coronary angiography

The purpose of this study was to assess patient‐specific organ doses and cancer risk with 3D‐rotational acquisitions versus the current standard of multiple single‐plane coronary angiography (CA).

Influence of central command and ergoreceptors on the splanchnic circulation during isometric exercise

The splanchnic circulation can make a major contribution to blood flow changes. However, the role of the splanchnic circulation in the reflex adjustments to the blood pressure increase during isometric exercise is not well documented. The central command and the muscle chemoreflex are the two major mechanisms involved in the blood pressure response to isometric exercise. This study aimed to examine the behaviour of the superior mesenteric artery during isometric handgrip (IHG) at 30% maximal voluntary contraction (MVC). The pulsatility index (PI) of the blood velocity waveform of the superior mesenteric artery was taken as the study parameter. A total of ten healthy subjects [mean age, 21.1 (SEM 0.3) years] performed an IHG at 30% MVC for 90 s. At 5 s prior to the end of the exercise, muscle circulation was arrested for 90 s to study the effect of the muscle chemoreflex (post exercise arterial occlusion, PEAO). The IHG at 30% MVC caused a decrease in superior mesenteric artery PI, from 4.84 (SEM 1.57) at control level to 3.90 (SEM 1.07) (P = 0.015). The PI further decreased to 3.17 (SEM 0.70) (P = 0.01) during PEAO. Our results indicated that ergoreceptors may be involved in the superior mesenteric artery vasodilatation during isometric exercise.

Transcatheter left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: results from the Belgian registry.

AIMS This study aimed to assess the safety and efficacy at midterm follow-up of left atrial appendage occlusion (LAAO) using different devices, in real life in Belgium. METHODS AND RESULTS Between June 2009 and November 2016, 457 consecutive patients (63% male, 75±12 yrs, CHA2DS2-VASc 4±0.6, HAS-BLED 3.5±0.7) undergoing LAAO were included. Technical success was 97.1%. There were 19 periprocedural major adverse events (4.1%) including three deaths (0.6%), nine tamponades (1.9%), four major bleedings (0.8%) and two device embolisations (0.4%). Among patients successfully implanted having a complete follow-up (672 patient-years, median follow-up 370 days), the actual annual stroke rate was 1.2%, lower than the expected stroke risk of 4% (70% reduction). The observed bleeding rate was 2%, while the calculated risk was 3.7% (46% reduction). Kaplan-Meier analysis showed a similar overall survival (93±2% and 87±3% versus 91±3% and 87±4%; p=0.35) and event-free survival (92±2% and 84±3% versus 88±3% and 80±5%; p=0.17) at one and two years, for the ACP/Amulet versus the WATCHMAN groups of patients, respectively. CONCLUSIONS The data from the Belgian left atrial appendage occlusion registry suggest that the procedure is effective and relatively safe in a real-world setting, using either the WATCHMAN or the ACP/Amulet device.

Dopamine‐induced changes in renal blood flow in normals and in patients with renal dysfunction

Background: Despite their controversial effect, “renal” doses of dopamine (3–5 μg · kg−1 · min−1) are often used in intensive care units to preserve renal function and to improve final outcome. Aim: To assess the effects of different doses of dopamine on renal blood flow in patients with normal renal function and in patients with renal dysfunction. Methods and Results: In 17 patients with normal renal function and in 12 patients with moderate renal dysfunction, mean arterial pressure (MAP), heart rate (HR), and average peak renal flow velocities (FlowWire APV) were continuously recorded at baseline and during IV administration of increasing dopamine doses (3, 5, 10, 20, and 30 μg · kg−1 · min−1). MAP and HR did not change during infusion of 3–5 μg · kg−1 · min−1 but increased to the same extent in both groups during infusion of >10 μg · kg−1 · min−1. Baseline APV was similar in both groups. Infusion of 3–5 μg · kg−1 · min−1 induced a significant change in APV only in patients with normal renal function. In patients with renal dysfunction, APV increased only during infusion of >10 μg · kg−1 · min−1 in parallel with MAP and HR. Conclusion: “Renal” doses of dopamine increase renal blood flow in normals but not in patients with moderate renal dysfunction.

Hemodynamic Effect of Myocardial Bridging

Myocardial bridging with systolic milking is a frequent finding during coronary angiography.1 Classically, it is considered a benign congenital anomaly because myocardial perfusion occurs in diastole. Milking is limited to systole and should therefore not impair myocardial perfusion. However, this physiology-based evidence is contradicted by numerous cases of coronary thrombus formation and myocardial infarction, in individuals with pathological findings none other than a myocardial bridging. Pressure-derived fractional flow reserve (FFR) measurement during maximum myocardial hyperemia is an established technique to assess the hemodynamic significance of moderate stenoses in atherosclerotic coronary artery disease.2 Few data are available concerning its use in myocardial bridging,3,4 where the evaluation of the hemodynamic significance of frequently encountered mild and moderate cases of myocardial bridging may be a diagnostic dilemma for the clinician. In particular, outcome data to guide therapy based on FFR …

Evaluation of patient and staff exposure with state of the art X-ray technology in cardiac catheterization: A randomized controlled trial

INTRODUCTION Cardiac catheterization procedures result in high patient radiation exposure and corresponding staff doses are reported to be among the highest for medical staff. The purpose of current randomized controlled study was to quantify the potential radiation dose reduction for both patient and staff, enabled by recent X-ray technology. This technology is equipped with advanced image processing algorithms, real-time dose monitoring, and an acquisition chain optimized for cardiac catheterization applications. METHODS A total of 122 adult patients were randomly assigned to one of two cath labs, either the reference X-ray modality (Allura Xper FD10, Philips Healthcare, the Netherlands) or the new X-ray system (AlluraClarity FD20/10 Philips Healthcare, the Netherlands). Exposure parameters and staff dosimeter readings were recorded for each exposure. Technical measurements were performed to define the radiation scatter behavior. RESULTS With the newer equipment, patient radiation dose is reduced (as total dose-area product) by 67% based on geometric means with 95%CI of 53%, 77% for diagnostic and interventional procedures. The C-arm and leg dosimeter readings were both reduced with 65% (P < 0.001), while for the collar and chest dosimeter readings no statistically significant reduction was noticed. CONCLUSION The new x-ray and image processing technology, significantly reduces patient dose in coronary angiographies, and PCIs by 67%. In general, scatter dose was also reduced, yet for some dosimeters the reduction was limited and not statistically significant. This study clearly indicates that the scatter behavior is highly dependent on C-arm rotation, operator movement and height, dosimeter position, beam filtration, clinical procedure type and system geometry.

The spectrum of spontaneous coronary artery dissection: illustrated review of the literature

Abstract Spontaneous coronary artery dissection or SCAD is a rare and challenging disease that is increasingly diagnosed. It is characterized by a non-traumatic, non-iatrogenic separation of the coronary artery wall and occurs predominantly in young and middle-aged women without traditional cardiovascular risk factors. SCAD is often associated with predisposing conditions such as the peripartum period, systemic inflammatory disease and heritable connective tissue disease. More recently, independent investigators have demonstrated an important association with fibromuscular dysplasia. Extreme emotional or physical stress as well as intense hormonal therapy or drug abuse have been pointed out as precipitating factors. The diagnosis of SCAD can be challenging and starts with clinical suspicion. Advanced imaging techniques such as intravascular ultrasound and optical coherence tomography are useful for the differentiation from atherosclerotic disease and are increasingly used for this indication. The proposed treatment in the acute setting is based on findings from single-centre retrospective series: in stable patients with a TIMI-flow ≥2 a conservative management is proposed because of the high risk of procedural failure and complications as well as a high probability of spontaneous healing. Long-term treatment is comparable to that in non-SCAD acute coronary syndromes (ACS) but dual antiplatelet therapy should only be started in case of stenting and should be kept as short as possible in patients with vascular Ehlers–Danlos syndrome. Prognosis seems to be better compared to non-SCAD ACS but there is a reasonable risk of recurrence. In this review, we discuss the current knowledge of SCAD and provide a clinical pathway for the diagnosis, management and work-up of SCAD patients.

Assessing the landscape of percutaneous coronary chronic total occlusion treatment in Belgium and Luxembourg: the Belgian Working Group on Chronic Total Occlusions (BWGCTO) registry

Abstract Background: Important developments in materials, devices, and techniques have improved outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), and resulted in a growing interest in CTO-PCI. The Belgian Working Group on Chronic Total Occlusions (BWGCTO) working group aims to assess the evolution within the CTO-PCI landscape over the next years. Methods: From May 2016 onwards, patients undergoing CTO-PCI were included in the BWGCTO registry by 15 centres in Belgium and Luxemburg. Baseline, angiographic, and procedural data were collected. Here, we report on the one-year in-hospital outcomes. Results: Over the course of one year, 411 procedures in 388 patients were included with a mean age of 64 ± 11 years. The majority were male (81%). Relatively complex CTOs were treated (Japanese CTO score =2.2 ± 1.2) with a high procedure success rate (82%). Patient- and lesion-wise success rates were 83 and 85%, respectively. Major adverse in-hospital events were acceptably low (3.4%). Antegrade wire escalation technique was applied most frequently (82%). On the other hand, antegrade dissection and re-entry and retrograde strategies were more frequently applied in higher volume centres and successful for lesions with higher complexity. Conclusion: Satisfactory procedural outcomes and a low rate of adverse events were obtained in a complex CTO population, treated by operators with variable experience levels. Antegrade wire escalation was the preferred strategy, regardless of operator volume.