Jennifer A. Rossington

Collateral Donor Artery Physiology and the Influence of a Chronic Total Occlusion on Fractional Flow Reserve

Background—The presence of a concomitant chronic total coronary occlusion (CTO) and a large collateral contribution might alter the fractional flow reserve (FFR) of an interrogated vessel, rendering the FFR unreliable at predicting ischemia should the CTO vessel be revascularized and potentially affecting the decision on optimal revascularization strategy. We tested the hypothesis that donor vessel FFR would significantly change after percutaneous coronary intervention of a concomitant CTO. Methods and Results—In consecutive patients undergoing percutaneous coronary intervention of a CTO, coronary pressure and flow velocity were measured at baseline and hyperemia in proximal and distal segments of both nontarget vessels, before and after percutaneous coronary intervention. Hemodynamics including FFR, absolute coronary flow, and the coronary flow velocity–pressure gradient relation were calculated. After successful percutaneous coronary intervention in 34 of 46 patients, FFR in the predominant donor vessel increased from 0.782 to 0.810 (difference, 0.028 [0.012 to 0.044]; P=0.001). Mean decrease in baseline donor vessel absolute flow adjusted for rate pressure product: 177.5 to 139.9 mL/min (difference −37.6 [−62.6 to −12.6]; P=0.005), mean decrease in hyperemic flow: 306.5 to 272.9 mL/min (difference, −33.5 [−58.7 to −8.3]; P=0.011). Change in predominant donor vessel FFR correlated with angiographic (%) diameter stenosis severity (r=0.44; P=0.009) and was strongly related to stenosis severity measured by the coronary flow velocity–pressure gradient relation (r=0.69; P<0.001). Conclusions—Recanalization of a CTO results in a modest increase in the FFR of the predominant collateral donor vessel associated with a reduction in coronary flow. A larger increase in FFR is associated with greater coronary stenosis severity.

A Tear in the Heart: Myocardial Laceration Following Left Ventriculogram With a Dedicated Radial Catheter

CASE PRESENTATION A71-year-old woman attended for elective coronary angiography for investigation of angina. The procedural access point was the right radial artery, and therefore the dedicated radial 5F Optitorque Tiger (Terumo, Somerset, NJ) catheter was used. Initial pressure waveform revealed the catheter to be within the left ventricular (LV) cavity. Opportunity to acquire left ventriculogram was taken at this stage; with 25 mL of contrast agent delivered by pump at the rate of 8 mL/ second at 600 Psi. Instantaneous contrast extravasation was noted with staining of the anterolateral LV wall (Figure; Video, Supplementary Digital Content 1 demonstrates contrast extravasation and staining). She experienced mild chest discomfort and transient bundle branch block, without evidence of hemodynamic compromise. Subsequent coronary angiogram with the same catheter demonstrated an atherosclerotic stenosis in the mid left anterior descending artery at the level of second diagonal, with normal flow in all coronary arteries and no evidence of extrinsic compression. Presence of contrast staining in the myocardium was present throughout the angiography. She was monitored overnight and was discharged following reassuring electrocardiography and echocardiography results. She subsequently returned for successful percutaneous coronary intervention to her left anterior descending artery, a few weeks later. The radial Optitorque Tiger catheter has been designed to minimize catheter exchange with ability to FIGURE.

Microvascular dysfunction in the immediate aftermath of chronic total coronary occlusion recanalization

The aim of this study was to compare microvascular resistance under both baseline and hyperemic conditions immediately after percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) with an unobstructed reference vessel in the same patient

Is there Sex-related Outcome Difference according to oral P2Y12 inhibitors in Patients with Acute Coronary Syndromes? A Systematic Review and Meta-Analysis of 107,126 Patients

BACKGROUND AND OBJECTIVES The majority of patients included in trials of anti-platelet therapy are male. This systematic review and meta-analysis aimed to determine whether, in addition to aspirin, P2Y12 blockade is beneficial in both women and men with acute coronary syndromes. METHODS Electronic databases were searched and nine eligible randomised controlled studies were identified that had sex-specific clinical outcomes (n=107,126 patients). Risk Ratios (RR) and 95% Confidence Intervals (CI) were calculated for a composite of cardiovascular death, myocardial infarction or stroke (MACE), and a safety endpoint of major bleeding for each sex. Indirect comparison analysis was performed to statistically compare ticagrelor against prasugrel. RESULTS Compared to aspirin alone, clopidogrel reduced MACE in men (RR, 0.79; 95% CI, 0.68 to 0.92; p=0.003), but was not statistically significant in women (RR, 0.88; 95% CI, 0.75 to 1.02, p=0.08). Clopidogrel therapy significantly increased bleeding in women but not men. Compared to clopidogrel, prasugrel was beneficial in men (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02) but not statistically significant in women (RR, 0.94; 95% CI, 0.83 to 1.06; p=0.30); ticagrelor reduced MACE in both men (RR, 0.85; 95% CI, 0.77 to 0.94; p=0.001) and women (RR, 0.84; 95% CI, 0.73 to 0.97; p=0.02). Indirect comparison demonstrated no significant difference between ticagrelor and prasugrel in either sex. Compared to clopidogrel, ticagrelor and prasugrel increased bleeding risk in both women and men. CONCLUSION In summary, in comparison to monotherapy with aspirin, P2Y12 inhibitors reduce MACE in women and men. Ticagrelor was shown to be superior to clopidogrel in both sexes. Prasugrel showed a statistically significant benefit only in men; however indirect comparison did not demonstrate superiority of ticagrelor over prasugrel in women.

60 Cardiogoniometry vs the 12-lead electrocardiogram at identifying the culprit lesion in patients with with non-st segment elevation myocardial infarction: the cognition study

Introduction Cardiogoniometry (CGM) is a method of 3-dimensional electrocardiographic assessment which provides detailed spatial and temporal information about cardiac electrical activity. The 12-lead electrocardiogram (ECG) is instrumental at localising ischaemia in patients with ST-elevation myocardial infarction, however ECG changes in non-ST elevation myocardial infarction (NSTEMI) are often non-specific for an ischaemic territory. The aim our our study was to evaluate the ability of CGM to identify the culprit lesion in patients with NSTEMI Methods At a tertiary cardiology centre, patients with a diagnosis of NSTEMI were consecutively recruited in a prospective, double blind, observational study. CGM and 12-lead ECG recordings were performed prior to coronary angiography and were interpreted by independent investigators, with the location of the culprit lesion indicated by each recording recorded. Based on coronary angiography, the site of the culprit lesion was then determined by the operating interventionist. Measures of diagnostic performance were than calculated for CGM and the 12-lead ECG for each lesion site: left anterior descending (LAD), left circumflex (LCx) and right coronary (RCA). Kappa statistic for agreement was calculated between CGM, 12-lead ECG and coronary angiography. Results Thirty patients (aged 67.5±10.8; 76.9% male) were recruited. Markers of diagnostic performance are shown in the table. Both CGM and the 12-lead ECG were able to provide ischaemia localising information in 57.7% of participants. Conclusion Although CGM is superior to the 12-lead ECG at accurately locating the culprit lesion site in patients with NSTEMI, it is only able to provide ischaemia localising information in a similar number of patients as the 12-lead ECG.Abstract 60 Table 1

TCT-220 Is Inhibition of Platelet Aggregation by Endogenous Endothelial Platelet Antagonists Enhanced by Oral Ticagrelor Mediated P2Y12 Blockade in Patients With Coronary Artery Disease?

P2Y12 receptor antagonists inhibit ADP-induced platelet aggregation and have an important role in the managment of acute coronary syndromes. Nitric oxide and prostacyclin (PGI2) are endogenous endothelial inhibitors of platelet activation. This study evaluated the interaction between P2Y12

95 A Systematic Review of The Clinical Applications of Cardiogoniometry in Cardiovascular Disease

Introduction Cardiogoniometry (CGM) is a novel method of 3-D electrocardiographic (ECG) assessment, which has previously been shown to have significant diagnostic accuracy at identifying patients with stable coronary artery disease (CAD) and acute coronary syndromes (ACS). However, there is considerable variation of reported diagnostic accuracy of CGM depending on the gold standard test used to compare it to. The aim of our review is to identify what is diagnostic accuracy of CGM at identifying stable CAD and ACS, and identify other novel clinical applications of the technology. Methods Using a pre-defined search strategy, electronic databases (MEDLINE and Embase) were searched for papers published between 1946–June 2015 and reference lists were pursued. For inclusion, papers had to be original research articles that investigated the clinical application of CGM. Sixteen publications were identified from our search; seven investigated the diagnostic accuracy of CGM to identify stable CAD; one investigated the diagnostic accuracy of CGM to identify ACS; one investigated CGM as a screening tool for cardiac allograft vasculopathy in heart transplant patients and seven investigated specific CGM parameters without commenting on diagnostic accuracy. If data was available and suitable for collation, it was pooled to calculate a comprehensive overview on markers of diagnostic accuracy, which included sensitivity and specificity. Results When looking at studies investigating the diagnostic accuracy of CGM to identify stable CAD the figures of diagnostic accuracy varied: Sensitivity (64–89%) and specificity (64%–82%), however CGM consistently outperformed 12-lead ECG in terms of sensitivity (29–76%) and was comparable in terms of specificity (18–95%). The collated data pooled for our analysis included 772 patients, of which 473 had stable CAD. Our analysis showed CGM has a sensitivity of 70% and specificity of 82% at identifying stable CAD, being significantly more accurate than 12-lead ECG. The one study identified investigating the diagnostic accuracy of CGM to identify ACS included patients with non-ST segment elevation ACS and used multiple comparators including 12-lead ECG. It showed that the sensitivity and specificity of CGM to identify non-ST segment elevation ACS was 69% and 54% respectively, having significantly higher sensitivity than 12-lead ECG. The diagnostic accuracy reported for CGM to detect cardiac allograft vasculopathy was 100% and 88% respectively for sensitivity and specificity. Conclusion CGM has superior diagnostic accuracy to 12-lead ECG at identifying patients with stable CAD and is significantly more sensitive than 12-lead ECG at identifying patients with non-ST segment elevation ACS. It may have an important role in screening patients with stable CAD and those with acute chest pain.

Biomarkers of coronary endothelial health: correlation with invasive measures of collateral function, flow and resistance in chronically occluded coronary arteries and the effect of recanalization.

ObjectivesIn the presence of a chronically occluded coronary artery, the collateral circulation matures by a process of arteriogenesis; however, there is considerable variation between individuals in the functional capacity of that collateral network. This could be explained by differences in endothelial health and function. We aimed to examine the relationship between the functional extent of collateralization and levels of biomarkers that have been shown to relate to endothelial health. MethodsWe measured four potential biomarkers of endothelial health in 34 patients with mature collateral networks who underwent a successful percutaneous coronary intervention (PCI) for a chronic total coronary occlusion (CTO) before PCI and 6–8 weeks after PCI, and examined the relationship of biomarker levels with physiological measures of collateralization. ResultsWe did not find a significant change in the systemic levels of sICAM-1, sE-selectin, microparticles or tissue factor 6–8 weeks after PCI. We did find an association between estimated retrograde collateral flow before CTO recanalization and lower levels of sICAM-1 (r=0.39, P=0.026), sE-selectin (r=0.48, P=0.005) and microparticles (r=0.38, P=0.03). ConclusionRecanalization of a CTO and resultant regression of a mature collateral circulation do not alter systemic levels of sICAM-1, sE-selectin, microparticles or tissue factor. The identified relationship of retrograde collateral flow with sICAM-1, sE-selectin and microparticles is likely to represent an association with an ability to develop collaterals rather than their presence and extent.

Response to Letter Regarding Article, “Collateral Donor Artery Physiology and the Influence of a Chronic Total Occlusion on Fractional Flow Reserve”

We appreciate the interest and comments from Dr Saito1 on our article.2 It is gratifying that some of the findings of their in vitro work have been borne out by our results. Many of their comments have already been addressed in the article.2 We agree that the mass of collateral dependent myocardium and extent of collateralization are likely to be important factors in the extent of change in donor vessel fractional flow reserve (FFR) …