Claude Hanet

Prognostic value of intracoronary flow velocity and diameter stenosis in assessing the short- and long-term outcomes of coronary balloon angioplasty - The DEBATE study (Doppler Endpoints Balloon Angioplasty Trial Europe)

BACKGROUND The aim of this prospective, multicenter study was the identification of Doppler flow velocity measurements predictive of clinical outcome of patients undergoing single-vessel balloon angioplasty with no previous Q-wave myocardial infarction. METHODS AND RESULTS In 297 patients, a Doppler guidewire was used to measure basal and maximal hyperemic flow velocities proximal and distal to the stenosis before and after angioplasty. In 225 patients with an angiographically successful percutaneous transluminal coronary angioplasty (PTCA), postprocedural distal coronary flow reserve (CFR) and percent diameter stenosis (DS%) were correlated with symptoms and/or ischemia at 1 and 6 months, with the need for target lesion revascularization, and with angiographic restenosis (defined as DS > or = 50% at follow-up). Logistic regression and receiver operator characteristic curve analyses were applied to determine the prognostic cutoff value of CFR and DS separately and in combination. Optimal cutoff criteria for predictors of these clinical events were DS, 35%; CFR, 2.5. A distal CFR after angioplasty > 2.5 with a residual DS < or = 35% identified lesions with a low incidence of recurrence of symptoms at 1 month (10% versus 19%, P=.149) and at 6 months (23% versus 47%, P=.005), a low need for reintervention (16% versus 34%, P=.024), and a low restenosis rate (16% versus 41%, P=.002) compared with patients who did not meet these criteria. CONCLUSIONS Measurements of distal CFR after PTCA, in combination with DS%, have a predictive value, albeit modest for the short- and long-term outcomes after PTCA, and thus may be used to identify patients who will or will not benefit from additional therapy such as stent implantation.

Long-term clinical and angiographic follow-up of sequential internal thoracic artery grafting

OBJECTIVE Sequential internal thoracic artery (ITA) grafting allows a more complete arterial revascularization of the myocardium. We wanted to verify whether the excellent clinical and angiographic short term results reported by us before where maintained over 10 years and more. METHODS the first consecutive 500 patients having received at least one sequential ITA graft between October 1985 and August 1991 were reviewed. Age averaged 61 years. Fifty-three patients had a left ventricular ejection fraction less than 40%, 117 were not elective, 35 (7%) were reoperations, 56 (11%) had diabetes. In total 2156 anastomoses were constructed (4.3/patient), among them 1367 arterial anastomoses (2.7/patient) and 1150 sequential ITA anastomoses (2.3/patient). The clinical follow-up was 97.4% complete and averaged 9.6 (range 8.6-13.6) years. One hundred and sixty-one patients consented to a late angiographic restudy after a mean interval of 7.4 (range 1-12.2) years. RESULTS At 5 and 10 years, 89 and 72% of the patients were still alive. At 10 years 82% are still asymptomatic and 71% free of any type of ischaemia. Only four patients (0.8%) needed a repeat surgical revascularization, and 11 (2.3%) a percutaneous coronary angioplasty. At 5 and 10 years, 92.8 and 69% of the patients remained free of any cardiac event. Overall, 95.5% of the arterial anastomoses were patent and 96.1% of the sequential ITA were patent. There was a significant difference between the patency rate of pedicled ITA and free ITA anastomoses: 96.3 vs. 86.5% (P=0.02). There was no difference in patency between left ITA and right ITA anastomoses for the LAD and Cx areas. Sequential ITA anastomoses showed excellent patency rates to all coronary vessels but the very distal circumflex and the distal branches of right coronary artery (85%). There was no significant difference between the patency of the proximal and the distal sequential ITA anastomoses. The sequential anastomoses constructed in the length tend to remain more patent than the diamond-shaped ones: 97.2 vs. 91.5% (P=0.004). CONCLUSIONS Sequential ITA grafting optimizes arterial revascularization. The long-term patency is excellent, is identical to that of single ITA grafting, and appears not much different from postoperative patency. The need for repeat surgical and interventional revascularization has been extremely low: 3.1% over the whole follow-up.

Does angiography six months after coronary intervention influence management and outcome

OBJECTIVES This study was performed to assess whether angiography six months after coronary balloon angioplasty or stent implantation has an influence on clinical management and one-year outcome. BACKGROUND The Benestent II study randomized 827 patients to balloon angioplasty or stent implantation. A subrandomization was undertaken allocating patients to six-month clinical follow-up (CF) or clinical and angiographic follow-up (AF). METHODS Seven hundred and six patients (349 CF and 357 AF) had no intercurrent angiography, so that restenosis and disease progression elsewhere remained unknown until the time of six-month follow-up. These two groups, which were well matched at enrolment, were compared with respect to symptoms, medication and major cardiac events defined as death, myocardial infarction and need for revascularization at six and 12 months. RESULTS At six-month follow-up, 53 (15%) of the CF and 76 (21%) of the AF patients had stable angina (p = 0.041), while 5 (1%) and 4 (1%) had symptoms of unstable angina. At 12-month follow-up, 44 (13%) patients in both groups had stable angina, and only 1 patient in the CF group had unstable angina. Seventy-seven patients (27 CF and 50 AF; p < 0.01) had major cardiac events between 6 and 12 months. Of the 349 patients in the CF group, 21 underwent repeat percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery between 6 and 12 months, compared with 44 of the 357 patients in the AF group (relative risk 2.05 [1.24 to 3.37], p = 0.003). CONCLUSIONS Patients who had AF six months after balloon angioplasty or stent implantation experienced more repeat revascularization procedures than those who had CF. They also had significantly more angina at six-month follow-up but this may be due to bias.

Noninvasive estimation of pulmonary arterial wedge pressure with Doppler transmitral flow velocity pattern in patients with known heart disease.

Pulmonary arterial wedge pressure (PAWP) is an important marker of cardiac function. Regrettably, it requires catheterization, which can occasionally result in serious complications. A noninvasive method of estimating PAWP would thus be helpful. Recent studies have indicated that the Doppler transmitral flow velocity pattern was strongly dependent on preload and could provide an estimate of PAWP. This study was therefore designed to evaluate the relation between doppler transmitral flow velocity indexes and measured PAWP in 91 patients (learning group: 73 men, mean age 57 +/- 13 years) with ischemic heart disease (n = 41), dilated (n = 29) or hypertrophic cardiomyopathy (n = 4), or aortic stenosis (n = 17). Multiple regression analysis was used to derive an equation for estimation of PAWP, which was subsequently tested in a separate group of 33 patients (testing group: 28 men, mean age 58 +/- 12 years) with similar cardiac conditions. PAWP ranged from 4 to 48 mm Hg in the learning group and from 7 to 40 mm Hg in the testing group. In the learning group, PAWP correlated with the E/A ratio (r = 0.95), atrial filling fraction (r = -0.80), peak E velocity (r = 0.79), isovolumic relaxation period (r = -0.75), and deceleration time (r = -0.61). In the learning group, PAWP was best predicted as PAWP = 18.4 + [17.1.In(E/A ratio)]. This equation allowed prediction of PAWP within 3 mm Hg of the measured value in 24 of 33 patients (73%) in the testing group. In 8 additional patients, the equation also accurately predicted the changes in PAWP induced by volume loading or intravenous nitrates (r = 0.98).(ABSTRACT TRUNCATED AT 250 WORDS)

Bilateral Mammary Grafting - Clinical, Functional and Angiographic Assessment in 400 Consecutive Patients

Between October 1985 and September 1991, 400 patients benefited from bilateral internal mammary artery (BIMA) grafting. Of these, 354 (88.5%) were male and the average age was 57.4 years. There were 132 (33%) urgent procedures, 55 in diabetic patients (14%) and 15 in end-stage renal failures (4%). An average of 3.9 distal anastomoses (AN) per patient was undertaken, 2.8 using arterial grafts. Two hundred sixty-nine patients (67.2%) received exclusively arterial grafts. Right internal mammary artery (RIMA) grafts were predominantly directed to the left coronary system (348 AN = 78%) and particularly to the circumflex (CX) area. Postoperative myocardial infarction was diagnosed in 16 patients (4%). Reoperation was required for early myocardial ischemia in 12 patients (3%) and for excessive bleeding in 23 patients (5.8%). Sternal complications occurred in 18 patients (4.1%), 5 in diabetic patients (9%) and 3 in renal patients (20%). The hospital mortality was 2% (8 patients, 3 cardiac causes). Follow-up averages 37.7 months. Late mortality was 3% (12 patients, 4 cardiac causes). Angina recurred in 12 patients (3.1%). The maximal stress test at a mean interval of 9 months was abnormal in 7.4% (21 patients). One hundred eighty-one patients (47%) consented to an angiographic restudy at an average of 13 months postoperatively. Pedicled RIMA patency rates equal those of pedicled LIMA (95.1 vs 96.7, NS) and the grafted vessel does not alter the patency rates of IMA AN. A pedicled IMA graft is preferable to a free IMA graft (96.1 vs 79.6, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of quantitative and qualitative angiographic lesion morphology, and clinical characteristics in predicting major adverse cardiac events during and after native coronary balloon angioplasty

Major, adverse cardiac events (death, myocardial infarction, bypass surgery and reintervention) occur in 4 to 7% of all patients undergoing coronary balloon angioplasty. Prospectively collected clinical data, and angiographic quantitative and qualitative lesion morphologic assessment and procedural factors were examined to determine whether the occurrence of these events could be predicted. Of 1,442 patients undergoing balloon angioplasty for native primary coronary disease in 2 European multicenter trials, 69 had major, adverse cardiac procedural or in-hospital complications after > or = 1 balloon inflation and were randomly matched with patients who completed an uncomplicated in-hospital course after successful angioplasty. No quantitative angiographic variable was associated with major adverse cardiac events in univariate and multivariate analyses. Univariate analysis showed that major adverse cardiac events were associated with the following preprocedural variables: (1) unstable angina (odds ratio [OR] 3.11; p < 0.0001), (2) type C lesion (OR 2.53; p < 0.004), (3) lesion location at a bend > 45 degrees (OR 2.34; p < 0.004), and (4) stenosis located in the middle segment of the artery dilated (OR 1.88; p < 0.03); and with the following postprocedural variable: angiographically visible dissection (OR 5.39; p < 0.0001). Multivariate logistic analysis was performed to identify variables independently correlated with the occurrence of major adverse cardiac events. The preprocedural multivariate model entered unstable angina (OR 3.77; p < 0.0003), lesions located at a bend > 45 degrees (OR 2.87; p < 0.0005), and stenosis located in the middle portion of the artery dilated (OR 1.95; p < 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of balloon size and stenosis morphology on immediate and delayed elastic recoil after percutaneous transluminal coronary angioplasty

After successful coronary angioplasty, the minimal luminal diameter of the dilated coronary artery segment is generally smaller than the diameter of the largest balloon catheter at the maximal inflation pressure. The determinants of this phenomenon were studied in 28 patients. Biplane angiograms were obtained after intracoronary administration of isosorbide dinitrate (1 mg) before, immediately and 24 h after coronary angioplasty. Balloon and coronary luminal diameters were measured by automated contour detection. Immediately after the procedure, the difference between inflated balloon diameter and minimal luminal diameter averaged 0.93 +/- 0.43 mm for the entire group and was greater both in eccentric stenoses (1.13 +/- 0.39 vs. 0.70 +/- 0.36 mm; p less than 0.01) and after angioplasty with an oversized balloon (1.20 +/- 0.37 vs. 0.71 +/- 0.33 mm; p less than 0.005). At 24 h, the balloon - minimal luminal diameter difference was unchanged at the group level (0.86 +/- 0.38 mm, but the minimal luminal diameter increased significantly in the subgroup of coronary segments dilated with an oversized balloon (1.97 +/- 0.37 vs. 1.81 +/- 0.28 mm; p less than 0.05). Thus, the difference between the minimal diameter of a dilated coronary segment immediately after a successful coronary balloon angioplasty procedure and the maximal diameter of the inflated balloon catheter is dependent both on eccentricity of the stenosis and on the balloon/artery diameter ratio. Moreover, the increase in minimal luminal diameter 24 h after angioplasty performed with an oversized balloon suggest that in addition to elastic recoil partly reversible factors related to vessel barotrauma are involved.

The Athlete's Heart - Gender Aspects

Background— Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified. Methods and Results— From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologist’s supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P<0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99). Conclusion— Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.BACKGROUND: Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified. METHODS AND RESULTS: From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologists supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P>0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99). CONCLUSIONS: Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.

Acetylcysteine, coronary procedure and prevention of contrast-induced worsening of renal function: which benefit for which patient?

Objectives — This study was designed to determine whether acetylcysteine could provide a protective effect on renal function in a population of patients with normal renal function or mild to moderate chronic renal failure, usually referred for a coronary procedure. Background — Contrast-induced nephropathy is a well-recognized complication of coronary angiography. Recent studies suggest that saline hydration and acetylcysteine reduce the incidence of contrast-induced worsening of renal function in patients with pre-existing chronic renal failure who are undergoing computed tomography examinations. Methods — One hundred eight patients were blindly and randomly assigned to receive either acetylcysteine or placebo before and after administration of contrast agent in association with a moderate hydration protocol. Serum creatinine and urea nitrogen were measured before and 24 hours after coronary procedure. Results — The mean serum creatinine concentration remained unchanged 24 hours after contrast agent administration in both groups: from 1.04 ± 0.26 to 1.03 ± 0.29 mg/dl in the acetylcysteine group and from 1.16 ± 1.1 to 1.06 ± 0.41 mg/dl in the control group (p = 0.29, for the comparison between two groups, NS). We divided the population into 3 subgroups according to their creatinine clearance: no significant change of serum creatinine concentration was observed in patients with normal renal function nor in patients with pre-existing mild to moderate chronic renal failure in both groups. There was no significant difference for the incidence of contrast-induced nephropathy between both groups (2 of the 53 patients in the acetylcysteine group and 3 of the 51 patients in the placebo group, p = 0.98, NS). Conclusions — Our data do not support the systematic use of acetylcysteine before a coronary procedure in patients with normal renal function or mild to moderate chronic renal failure, to prevent contrast-induced nephropathy.

Angiographic predictors of 6-month patency of bypass grafts implanted to the right coronary artery a prospective randomized comparison of gastroepiploic artery and saphenous vein grafts.

OBJECTIVES The purpose of this study was to define the pre-operative angiographic variables that could influence graft patency and flow pattern. BACKGROUND Saphenous vein grafts (SVG) and pedicled right gastroepiploic artery (RGEA) grafts are routinely used to revascularize the right coronary artery (RCA). Little is known about the predictive value of objective pre-operative angiographic parameters on the 6-month graft patency and on the interest of these parameters to select the optimal graft material in individual cases. METHODS We prospectively enrolled 172 consecutive patient candidates for coronary revascularization. Revascularization of the RCA was randomly performed with SVG in 82 patients or with the RGEA in 90 patients. Both groups were comparable with respect to all pre-operative continuous and discrete variable and risk factors. All patients underwent a systematic angiographic control 6 months after surgery. Pre-operative angiographic parameters included minimal lumen diameter (MLD), percent stenosis and reference diameter of the RCA measured by quantitative angiography (CAAS II system, Pie Medical, Maastricht, the Netherlands), location of the stenosis, run off of the RCA, and regional wall motion of the revascularized territory. RESULTS A significant difference in the distribution of flow patterns was observed between SVG and RGEA. In multivariate analysis, graft-dependent flow pattern was significantly associated with both MLD and percent stenosis of the RCA in the RGEA group but with percent stenosis only in the SVG group. In the RGEA group, the proportion of patent grafts was higher when MLD was below a threshold value lying in the third MLD quartile (0.77 to 1.40 mm). CONCLUSIONS Pre-operative angiography predicts graft patency in RGEA, whereas the flow pattern in SVG is significantly less influenced by quantitative angiographic parameters.