Cezary Kępka

Influenza vaccination in secondary prevention from coronary ischaemic events in coronary artery disease: FLUCAD study

AIMS To evaluate the effect of influenza vaccination on the coronary events in patients with confirmed coronary artery disease (CAD). METHODS AND RESULTS Randomized, double-blind, placebo controlled study. We included 658 optimally treated CAD patients; 477 men, mean age 59.9+/-10.3 years. Three hundred and twenty-five patients received the influenza vaccine, and 333 patients placebo. Median follow-up was 298 (interquartile range 263-317) days. Primary endpoint was the cardiovascular death. Its estimated 12-month cumulative event rate was 0.63% in the vaccine vs. 0.76% in controls (HR 1.06 95% CI: 0.15-7.56, P = 0.95). There were two secondary composite endpoints: (i) the MACE (cardiovascular death, myocardial infarction, coronary revascularization) tended to occur less frequently in the vaccine group vs. placebo with the event rate 3.00 and 5.87%, respectively (HR 0.54;95% CI: 0.24-1.21, P = 0.13). (ii) Coronary ischaemic event (MACE or hospitalization for myocardial ischaemia) estimated 12-month event rate was significantly lower in the vaccine group 6.02 vs. 9.97% in controls (HR 0.54; 95% CI: 0.29-0.99, P = 0.047). CONCLUSION In optimally treated CAD patients influenza vaccination improves the clinical course of CAD and reduces the frequency of coronary ischaemic events. Large-scale studies are warranted to evaluate the effect of influenza vaccination on cardiovascular mortality. (ClinicalTrials.gov: NCT 00371098).

Comparison of different quantification methods of late gadolinium enhancement in patients with hypertrophic cardiomyopathy

AIM There is no consensus regarding the technique of quantification of late gadolinium enhancement (LGE). The aim of the study was to compare different methods of LGE quantification in patients with hypertrophic cardiomyopathy (HCM). METHODS Cardiac magnetic resonance was performed in 33 patients with HCM. First, LGE was quantified by visual assessment by the team of experienced readers and compared with different thresholding techniques: from 1SD to 6SD above mean signal intensity (SI) of remote myocardium, above 50% of maximal SI of the enhanced area (full-width at half maximum, FWHM) and above peak SI of remote myocardium. RESULTS LGE was present in 25 (78%) of patients. The median mass of LGE varied greatly depending on the quantification method used and was highest with the utilization of 1SD threshold [75.5 g, interquartile range (IQR): 63.3-112.3g] and lowest for FWHM method (8.4 g, IQR: 4.3-13.3g). There was no difference in mass of LGE as assessed with 6SD threshold and FWHM when compared to visual assessment (p=0.19 and p=0.1, respectively); all other thresholding techniques provided significant differences in the median LGE size when compared to visual analysis. Results for all thresholds, except FWHM were significantly correlated with visual assessment with the strongest correlation for 6SD (rho=0.956, p<0.0001). CONCLUSIONS LGE quantification with the use of a threshold of 6SD above the mean SI of the remote myocardium provided the best agreement with visual assessment in patients with HCM.

Coronary Computed Tomographic Prediction Rule for Time-Efficient Guidewire Crossing Through Chronic Total Occlusion : Insights From the CT-RECTOR Multicenter Registry (Computed Tomography Registry of Chronic Total Occlusion Revascularization)

OBJECTIVES This study sought to establish a coronary computed tomography angiography prediction rule for grading chronic total occlusion (CTO) difficulty for percutaneous coronary intervention (PCI). BACKGROUND The uncertainty of procedural outcome remains the strongest barrier to PCI in CTO. METHODS Data from 4 centers involving 240 consecutive CTO lesions with pre-procedural coronary computed tomography angiography were analyzed. Successful guidewire (GW) crossing ≤30 min was set as an endpoint to eliminate operator bias. The CT-RECTOR (Computed Tomography Registry of Chronic Total Occlusion Revascularization) score was developed by assigning 1 point for each independent predictor, and then summing all points accrued. Continuous distribution of scores was used to stratify CTO into 4 difficulty groups: easy (score 0); intermediate (score 1); difficult (score 2); and very difficult (score ≥3). Discriminatory performance was tested by 10-fold cross-validation and compared with the angiographic J-CTO (Multicenter CTO Registry of Japan) score. RESULTS Study endpoint was achieved in 55% of cases. Multivariable analysis yielded multiple occlusions, blunt stump, severe calcification, bending, duration of CTO ≥12 months, and previously failed PCI as independent predictors for GW crossing. The probability of successful GW crossing ≤30 min for each group (from easy to very difficult) was 95%, 88%, 57%, and 22%, respectively. Areas under receiver-operator characteristic curves for the CT-RECTOR and J-CTO scores were 0.83 and 0.71, respectively (p < 0.001). Both the original model fit and 10-fold cross-validation correctly classified 77.3% of lesions. CONCLUSIONS The CT-RECTOR score represents a simple and accurate noninvasive tool for predicting time-efficient GW crossing that may aid in grading CTO difficulty before PCI. (Computed Tomography Angiography Prediction Score for Percutaneous Revascularization for Chronic Total Occlusions [CT-RECTOR]; NCT02022878).

Transvenous closure of moderate and large secundum atrial septal defects in adults using the Amplatzer septal occluder

The aim was to determine the feasibility of using the Amplatzer septal occluder for closure of moderate and large secundum atrial septal defects in adults. Fifty patients aged 16–76 years (mean ± SD, 40 ± 15.5), underwent successful device implantation. Flow ratios of 1.4–8.5 (mean ± SD, 2.6 ± 1.6) were calculated. The defects were: centrally placed (n = 31), antero‐superior with partial or total deficiency of aortic rim (n = 19), multiple (n = 3) and with aneurysmal septum (n = 23). They measured 4–25 mm (median 14) on echocardiography and balloon sized 7–31 mm (median 19.5). Devices of 7–34 mm (median 20) were implanted. Patient follow up for 1 month (50/50 patients), 3 months (40/50) and 12 months (13/50), achieved respective rates of 90%, 92% and 98% of complete occlusion. In one patient a transient atrioventricular block (2:1) developed, and one had a transient STT elevation. One female had an episode of 30 min loss of vision over the lateral aspect of the left eye 3 months after implantation. In conclusion, transvenous occlusion of secundum atrial septal defects with the Amplatzer septal occluder in adults is safe, and can be performed without significant complications. Large defects, defects with a very deficient or absent aortic rim, defects with an aneurysmal septum as well as some multiple defects can be closed with an almost 100% early complete occlusion rate. This makes the procedure an alternative to surgery for selected adult patients. Cathet Cardiovasc Intervent 2001;52:188–193.

Comparison of Usefulness of Percutaneous Coronary Intervention Guided by Angiography plus Computed Tomography Versus Angiography Alone Using Intravascular Ultrasound End Points

The aim of our study was to assess the impact of coronary computed tomographic angiographic (CTCA) guidance on outcomes of percutaneous coronary intervention (PCI). The study was a randomized single-center trial. Consecutive eligible patients with CTCA-detected significant coronary lesions who were scheduled for PCI were randomized to an angiographically guided versus an angiographically plus computed tomographically guided (ACTG) group. In the ACTG group the operator preliminarily planned PCI based on computed tomographic angiogram. The coprimary end points were minimal stent area and minimal reference lumen area assessed in all patients with intravascular ultrasound performed after achieving optimal angiographic results. Seventy-one patients (50 men, mean age 65 ± 8 years) were randomized. After invasive angiography, PCI of 32 lesions (30 patients) in the ACTG and in 32 lesions (30 patients) in the angiographically guided group was performed. A stented segment length was longer and nominal stent diameter tended to be larger in the ACTG group (23.8 ± 6.7 vs 19.5 ± 6.5 mm, p = 0.01; 3.27 ± 0.44 vs 3.09 ± 0.41 mm(2), p = 0.110). Minimal stent area tended to be larger (6.62 ± 2.01 vs 5.80 ± 2.02 mm(2), p = 0.100) and the smallest peri-stent reference lumen area was significantly larger in the ACTG group (6.76 ± 3.01 vs 5.0 ± 1.62 mm(2), p = 0.006) with a smaller plaque burden (50 ± 16% vs 58 ± 13%, p = 0.025). In conclusion, CTCA analysis before PCI significantly influences treatment strategy and results in better lesion coverage as defined by intravascular criteria.

Coronary Computed Tomographic Angiography for Prediction of Procedural and Intermediate Outcome of Bypass Grafting to Left Anterior Descending Artery Occlusion With Failed Visualization on Conventional Angiography

Conventional coronary angiography (CCA) has considerable limitations regarding visualization of distal vessel segments in chronic total occlusion. We assessed the ability of coronary computed tomographic angiography (CCTA) to predict the success of coronary artery bypass grafting (CABG) to the chronically occluded left anterior descending coronary artery (LAD) incompletely visualized on CCA. Thirty symptomatic patients rejected for CABG on the basis of the CCA findings underwent preoperative CCTA before intended transmyocardial laser revascularization. The LAD was explored operatively in all patients, and CABG to the LAD was attempted if the distal vessel was suitable for anastomosis. The procedural outcome of CABG and the 6-month patency of the left internal mammary artery graft at follow-up CCTA were defined as the primary and secondary end point, respectively. The primary and secondary end points were achieved in 80% and 77% of patients, respectively. We found a significant correlation between the intraoperative and computed tomographic measurement of distal LAD diameter (R = 0.428, p = 0.037). On multivariate analysis, the maximum diameter of the distal LAD by CCTA (odds ratio 8.16, p = 0.043) was the only independent correlate of procedural success of CABG. A cutoff value of 1.5 mm for the mean distal LAD diameter predicted left internal mammary artery graft patency with 100% specificity and 83% sensitivity. Successful CABG resulted in significant improvements in angina class and left ventricular function in LAD segments at 6 months of follow-up. In conclusion, CCTA predicted both the procedural and the intermediate outcome of CABG to chronic LAD occlusion with failed visualization on CCA.

Influence of left ventricular hypertrophy on infarct size and left ventricular ejection fraction in ST-elevation myocardial infarction

BACKGROUND Left ventricular hypertrophy (LVH) predisposes to larger infarct size, which may be underestimated by the left ventricular ejection fraction (LVEF) due to supranormal systolic performance often present in patients with LVH. The aim of the study was to compare infarct size and LVEF in patients with ST-segment elevation myocardial infarction (STEMI) and increased left ventricular mass on cardiac magnetic resonance (CMR). METHODS The study included unselected group of 52 patients (61±11 years, 69% male) with first STEMI who had CMR after median 5 days from the onset of the event. Left ventricular hypertrophy (LVH) was defined as left ventricular mass index exceeding 95th percentile of references values for age and gender. Infarct size was assessed with means of late gadolinium enhancement (LGE). RESULTS LVH was found in 16 patients (31%). In comparison to the rest of the group, patients with LVH had higher absolute and relative infarct mass (p=0.002 and p=0.02, respectively). LVH was related to higher prevalence of microvascular obstruction and myocardial haemorrhage and higher number of LV segments with transmural necrosis (p=0.02, p=0.01 and p=0.01, respectively). Despite marked difference in the infarct size between both studied subgroups there was no difference in LVEF and mean number of dysfunctional LV segments. CONCLUSIONS Patients with LVH undergoing STEMI have larger infarct size underestimated by the LV systolic performance in comparison to patients without LVH.

Clustering of admission hyperglycemia, impaired renal function and anemia and its impact on in-hospital outcomes in patients with ST-elevation myocardial infarction.

OBJECTIVE To examine the incidence and inter-relationships between admission hyperglycemia, anemia and impaired renal function and its impact on clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated with primary PCI. METHODS The study group comprised 1880 patients with STEMI treated with primary PCI, enrolled in a prospective registry. RESULTS The primary endpoint of in-hospital death occurred in 88 (4.7%) patients. Hyperglycemia (glucose >11.1mmol/L) was present in 352(18.7%), anemia (hematocrit <36% women, <39% men) in 396(21.1%), and increased serum creatinine (> or =1.2mg/dL women, > or =1.3mg/dL men) in 423(22.5%) patients. 1026(54.6%) subjects had none of the triad risk factors. Two overlapping conditions were observed in 207(11%) and 3 in 40(2.1%) patients. Compared to the expected distribution, an increased prevalence was observed in patients with zero, two or three risk factors, and decreased prevalence was present in patients with one risk factor (p<0.001). In multivariable model including important baseline risk factors and the whole triad risk factors, hyperglycemia, anemia, and increased serum creatinine were independently associated with the primary outcome (hazard ratio (HR); 95% confidence interval (CI): 2.67; 1.56-4.55, and 2.03; 1.19-3.46, and 1.72;1.01-2.93, respectively). Adjusted HR (95% CI) for the incidence of the primary outcome associated with 1, 2 and 3 examined risk factors as compared to 0 of the risk factors was 2.7(1.4-5.4), 5.4(2.6-8.3) and 8.3(3.0-23.2), respectively. CONCLUSIONS Hyperglycemia, anemia, and impaired renal function are independently of each other related to in-hospital death in patients with STEMI treated with primary PCI. The triad risk factors cluster and accumulation of these risk factors is related to stepwise, additive increase of risk of in-hospital mortality.

Computed tomography angiography for prediction of atrial fibrillation after coronary artery bypass grafting: Proof of concept

BACKGROUND Postoperative atrial fibrillation (AF) is a serious complication of coronary artery bypass grafting (CABG). There are scant data on the application of coronary computed tomography angiography (CCTA) for prediction of postoperative AF. METHODS A total of 102 patients (77 male, mean age: 64±10 years) with pre-procedural CCTA undergoing isolated CABG were enrolled. Clinical risk factors were collected. Qualitative and quantitative CCTA analysis of the atria, pulmonary veins (PV), and epicardial adipose tissue (EAT) along the left atrium (LA) was performed to determine the predictors for postoperative AF. The primary endpoint was defined as any in-hospital AF requiring treatment. RESULTS Postoperative AF occurred in 24% of patients. Patients with AF had higher body mass index (29.7±4.8kg/m(2) vs 27.3±3.9kg/m(2), p=0.013), larger right atrial area (25.4±5.3cm(2) vs 22.3±6.4cm(2), p=0.035), LA systolic volume (114.7±32.8ml vs 96.8±30.4ml, p=0.015), LA EAT volume (5.6±3ml vs 4±2.5ml, p=0.009), and right superior PV ostium area (3.8±1.3cm(2) vs 3±1cm(2), p=0.021) compared to non-AF patients. By multivariable analysis, only LA EAT volume [odds ratio (OR): 1.21, 95% confidence interval (CI): 1.01-1.44, p=0.036] and right superior PV ostium area (OR: 1.63, 95% CI: 1.06-2.50, p=0.026) were independent predictors of AF. The optimal cut-offs for LA EAT volume and right superior PV ostium were >3.4ml and >4.1cm(2), respectively (max. sensitivity: 83%, max. specificity: 86%). CONCLUSIONS Increased LA EAT and right superior PV ostial size are independently associated with AF after CABG. CCTA might be used as a noninvasive prediction tool for AF in patients undergoing CABG.

Advanced computed tomographic anatomical and morphometric plaque analysis for prediction of fractional flow reserve in intermediate coronary lesions

OBJECTIVE To determine the application of advanced coronary computed tomography angiography (CCTA) plaque analysis for predicting invasive fractional flow reserve (FFR) in intermediate coronary lesions. METHODS Sixty-one patients with 71 single intermediate coronary lesions (≥ 50-80% stenosis) on CCTA prospectively underwent coronary angiography and FFR. Advanced anatomical and morphometric plaque analysis was performed based on CCTA data set to determine optimal criteria for significant flow impairment. A significant stenosis was defined as FFR ≤ 0.80. RESULTS FFR averaged 0.85 ± 0.09, and 19 lesions (27%) were functionally significant. FFR correlated with minimum lumen area (MLA) (r=0.456, p<0.001), minimum lumen diameter (MLD) (r=0.326, p=0.006), reference lumen diameter (RLD) (r=0.245, p=0.039), plaque burden (r=-0.313, p=0.008), lumen area stenosis (r=-0.305, p=0.01), lesion length (r=-0.692, p<0.001), and plaque volume (r=-0.668, p<0.001). There was no relationship between FFR and CCTA morphometric plaque parameters. By multivariate analysis the independent predictors of FFR were lesion length (beta=-0.581, p<0.001), MLA (beta=0.360, p=0.041), and RLD (beta=-0.255, p=0.036). The optimal cutoffs for lesion length, MLA, MLD, RLD, and lumen area stenosis were >18.5mm, ≤ 3.0mm(2), ≤ 2.1mm, ≤ 3.2mm, and >69%, respectively (max. sensitivity: 100% for MLA, max. specificity: 79% for lumen area stenosis). CONCLUSIONS CCTA predictors for FFR support the mathematical relationship between stenosis pressure drop and coronary flow. CCTA could prove to be a useful rule-out test for significant hemodynamic effects of intermediate coronary stenoses.