Klaus Reynen

Coronary arteriography in elderly patients: risk, therapeutic consequences and long-term follow-up

Objective Elderly people comprise the fastest-growing segment of the German population. This study evaluated the benefit of coronary arteriography in the management of selected old-age patients suffering from symptomatic coronary heart disease.Method From 1982 to 1992, with annually increasing frequency, coronary arteriography was performed in 398 patients with suspected or proven coronary artery disease who were 75 years of age or older.Results Compared with 300 consecutive patients younger than 75 years, patients older than 75 years presented significantly more often with unstable angina, history of myocardial infarction, and multivessel disease; mean ejection fraction was significantly lower and risk of cardiac catheterization significantly higher. In more than half the older patients, balloon angioplasty (n = 130) or bypass surgery (n = 73) were judged to be indicated. Long-term prognosis was significantly worse with medical therapy: the 5-year survival rate was 58% for those receiving medical therapy, whereas it was 73% for those undergoing angioplasty, and 67% for those undergoing surgery. Multivanate analysis revealed history of diabetes and left ventricular ejection fraction as the most powerful predictors of death. Prognosis was significantly improved by surgery compared with medicine in patients with extensive coronary artery disease and impaired left ventricular function. More revasculanzed patients were free of angina at follow-up after a mean of 35 months, whereas intensity of antianginal medication was lower only in the surgically treated patients.Conclusions In about half the selected aged patients, coronary angioplasty or bypass surgery was deemed feasible. Long-term prognosis, however, was primarily determined by left ventricular ejection fraction and history of diabetes. Compared with medical therapy, bypass surgery improved prognosis in patients with extensive coronary artery disease and impaired ventricular function. Interventions were effective in alleviating anginal complaints and reducing the need for antianginal drugs.

Evaluation of left ventricular inflow and volume by MR

Considerable progress has been achieved during the past few years in the evaluation of intracardial blood flow by MR. Similar to ultrasound Doppler, it is possible now to registrate parameters of left ventricular diastolic filling as E/A ratio, velocity time integral of A- to E-wave (A(area)/E(area)), or isovolumetric relaxation time index. A total of 24 patients (7 women, 17 men, aged 24-69 yr) were examined, 5 of whom suffered from a hypertensive heart disease, 5 from a coronary heart disease, and 7 from mitral valve stenosis of various degree; 7 showed normal findings. E/A-ratio, A(area)/E(area), as well as isovolumetric relaxation time (IVRT) were evaluated by two different examiners on the same day by MR and ultrasound-Doppler, showing correlation factors of .89 for E/A ratio, .67 for A(area)/E(area), and .76 for IVRT in comparing both techniques. Additionally, to test the potential for making left ventricular function diagnoses from MR, time-volume curves for normal cases and patients with hypertrophic and dilated cardiomyopathy were elaborated by a computer-assisted 3D imaging technique. This technique showed good concordance with the results from cardiac catheterization or radionuclide ventriculography.

Percutaneous transluminal coronary angioplasty in patients with severely depressed left ventricular function.

Among nearly 2,000 consecutive percutaneous transluminal coronary angioplasty (PTCA) patients, 42 patients (36 male, 6 female; mean age 60 +/- 11 years) with mainly unstable angina had ejection fractions of < or = 35% (mean 30 +/- 5%). All patients had previous myocardial infarctions; 31 (= 74%) had multivessel disease. Successful procedure was achieved in 35 of the 42 (= 83%) patients, 31 of 35 (= 89%) stenoses could be successfully dilated and 9 of 15 (= 60%) occlusions reopened. In-hospital mortality was 2.4%. Follow-up angiography in 22 of the 35 patients who had been successfully treated showed significant improvement of ejection fraction from 29 +/- 5 to 36 +/- 7%. At clinical follow-up 19 +/- 14 months (2-53 months) after the procedure, nearly all surviving patients were in anginal class I or II, 5 had died from cardiac and 1 from noncardiac causes. Thus, PTCA in patients with severely depressed left ventricular function shows acceptable acute results; attenuation of ventricular dysfunction and continued symptomatic improvement can be achieved. However, late outcome is significantly worse than in patients with normal ventricular function.

Phase-mapping technique for the evaluation of aortic valve stenosis by MR

New MR-techniques for quantitative blood flow registration such as phase-mapping (a two-dimensional space-resolved technique with a time-averaged measurement of blood flow) or RACE (real-time acquisition and evaluation of blood flow in one-dimensional space projection) are available for the diagnosis of valvular heart disease. Initial results of grading aortic valve stenosis by these methods are shown in comparison to continuous wave Ultrasound-Doppler. Two groups of 15 patients were examined by RACE or phase-mapping, 12 respectively 8 of whom suffered from an aortic valve stenosis. The shape of blood flow profiles as well as grading of aortic valve stenosis show high concordance when comparing the results of MR and Doppler technique. Good reliability and practicability of the demonstrated MR-method are shown. With respect to the results of RACE and phase-mapping the development of an alternative and competing MR-method for the evaluation of valvular heart disease and shunt diagnostics seems possible.

Intracoronary radiotherapy with a 188Rhenium liquid-filled angioplasty balloon system in in-stent restenosis: a single-center, prospective, randomized, placebo-controlled, double-blind evaluation.

BackgroundIn cases of in-stent restenosis, intracoronary radiotherapy with &bgr;-emitters and &ggr;-emitters has been shown to reduce the risk of repeat restenosis. The present randomised, placebo-controlled study addresses the question of whether intracoronary radiotherapy applied by the easy-to-handle 188Rhenium liquid-filled angioplasty balloon system is also able to reduce the angiographic re-restenosis rate in stents. Methods and resultsAt our center, from May 2000 to December 2003, 165 patients (mean age 64±10, median 65 years; 127 men, 38 women) with symptomatic in-stent restenosis underwent either intracoronary brachytherapy or sham procedure. Index clinical and angiographic parameters were largely comparable in both groups. Radiation therapy was performed with a standard percutaneous transluminal coronary angioplasty (PTCA) balloon catheter inflated with liquid 188Rhenium in the redilated in-stent restenosis for 240–890, mean 384±125 s with low pressure (3 atm) in order to reach 30 Gy at 0.5 mm depth of the vessel wall. In 82 patients, intracoronary radiotherapy was carried out without complications, but one of the 83 patients who underwent sham procedure suffered small myocardial infarction. During follow-up, stent thrombosis with subsequent non-Q-wave myocardial infarction occurred in one patient in each group (6 days and 8 months after the procedure, respectively). At 6 months after the index procedure, repeat angiography was performed in 156 of the 164 patients with successful procedure (rate 95%): restenosis (stenosis >50% in diameter) or reocclusion was observed in only 19 of 78 (=24%) patients of the radiation but in 31 of 78 (=40%) patients of the sham procedure group (P=0.04). Event-free survival (free of death, myocardial infarction, target vessel revascularization) at 1 year was 87% for patients being radiated and 74% for patients having undergone sham procedure (P=0.05). ConclusionsIntracoronary radiation therapy with the liquid-filled &bgr;-emitting 188Rhenium balloon is not only easy to perform, safe, and comparably inexpensive but also an effective option to prevent repeat restenosis and the need for target vessel revascularization in cases of in-stent restenosis.

Comparative morphometric and immunohistological assessment of the development of restenosis after arterial injury and a cholesterol-rich diet in apolipoprotein E -/-mice and C57BL/6 control mice

ObjectiveAnimal models of restenosis have been a cornerstone of testing potential therapies and have improved the understanding of the underlying mechanisms. The aim of this study was to provide an in-depth comparison of the progression of restenotic lesion formation after arterial injury in apolipoprotein E −/− and C57BL/6 control mice. MethodsIn this study, we investigated the difference in lesion formation of apolipoprotein E −/− and C57BL/6 controls on a high-cholesterol, high-fat diet after arterial injury. One week prior to arterial injury of the left femoral artery, mice were started on a high-cholesterol, high-fat diet. Diets were continued after arterial injury until euthanization. At five consecutive time points (2, 5, 10, 15, and 21 days), the intimal hyperplasia in the injured arteries was analyzed. ResultsIn the C57BL/6 control mice, a continuously increasing lesion formation, consisting primarily of &agr;-smooth muscle actin-positive cells, was observed. Lesion formation in apolipoprotein E −/− mice was significantly more pronounced, resulting in complete occlusion of the arteries in four out of five vessels after 21 days. Lesions in apolipoprotein E −/− mice consisted predominantly of lipid-loaded foam cells and &agr;-smooth muscle actin-positive cells. Further histological evaluation demonstrated cholesterol crystals in the lesions and neovascularizsation in cases of occlusion. ConclusionsThus, apoE −/− mice on a high-cholesterol, high-fat diet provide a more valid model for the characterization of the development of restenotic lesions after mechanical irritation such as angioplasty than C57BL/6 mice.

Surgical removal of a lipoma of the heart

In a 29-year-old woman echocardiography revealed a tumour originating from the anterior wall of the right ventricle. Noninvasive findings aroused suspicion of a lipoma. The tumour was removed under cardiopulmonary bypass, the resulting defect in the right ventricular wall being covered with a Goretex patch. Histological examination classified the tumour as a rhabdomyolipoma.

Natural course of angiographic parameters after myocardial infarction: an evaluation in the prethrombolytic and pre-angiotensin converting enzyme inhibition era.

BACKGROUND After myocardial infarction, left ventricular dilation is a frequent cause of cardiac insufficiency, which is associated with high morbidity and mortality. In this angiographic study, the natural course of postinfarction ventricular dilation could be followed up because patients undergoing revascularization procedures were excluded and only some few patients received angiotensin-converting enzyme inhibitors. METHODS AND RESULTS Of 85 patients suffering from angina after myocardial infarction, 59 could be examined twice by angiocardiography in a mean interval of 52 +/- 14 months; 37 of the 59 patients had sustained posterior myocardial infarction, 20 had anterior myocardial infarction, and 2 had both. During follow-up, end-diastolic volume index increased from 100 +/- 27 mL/m2 to 110 +/- 34 mL/m2; in 26 of the 59 patients the increase was greater than 15 mL/m2. Irrespective of the time since infarction, patients with an end-diastolic volume index greater than 100 mL/m2 and an ejection fraction less than 50% at the time of first angiography were at high risk of progressive ventricular dilation and further deterioration of left ventricular function (for both, P = .003). This process was independent of extent of coronary artery involvement and coronary disease progression. Multivariate analysis identified ejection fraction at the time of index angiography as the strongest predictor of further left ventricular dilation (P = .0004). CONCLUSIONS Continuing left ventricular dilation occurs in less than half the patients who had myocardial infarction. Left ventricular ejection fraction is the most sensitive parameter to predict the risk of ventricular dilation after infarction.

Quantification of aortic valvular insufficiency by MRI

Flow-encoded MRI sequences nowadays allow a quantitative evaluation of blood flow in any slice position. For the first time there is the possibility of determining quantitatively the volumes of both left ventricular ejection and regurgitation over the aortic valve in a non-invasive ways, thus obtaining the regurgitation fraction as a reliable measure for the evaluation of aortic valvular insufficiencies. The quantitative assessment of aortic valvular insufficiencies was carried out by MRI and compared with the diagnosis by means of Doppler ultrasound and in some cases by cardiac catheter also. The new MRI method is characterized by a good correlation with the clinical grading of aortic valvular insufficiencies. It should be possible to develop a new non-invasive standard for quantifying aortic valvular insufficiencies.