Simon Redwood

Clinical outcomes in unselected patients treated with the PROMUS Element platinum-chromium, everolimus-eluting stent: Final five-year results from the PE PROVE Study

The goal of this analysis was to evaluate the final 5‐year safety and effectiveness of the PROMUS Element platinum‐chromium everolimus‐eluting stent in unselected patients treated in routine clinical practice.

Pre‐dilatation of severely stenotic aortic valves using angioplasty balloons prior to balloon aortic valvuloplasty

We present a technique that facilitates balloon aortic valvuloplasty in severely stenosed aortic valves through which valvuloplasty balloons are unable to pass using commonly available angioplasty balloons.

133 Coronary wave intensity: a novel invasive tool for predicting myocardial viability following acute coronary syndromes

Introduction Wave intensity analysis (WIA) uses simultaneous changes in intracoronary pressure and flow to characterise energy transfer within the coronary circulation. In normal hearts, flow is predominantly driven by a microcirculatory-derived, diastolic phase, backward expansion wave (BEW) and aortic-derived, systolic phase, forward compression wave (FCW) (Abstract 133 figure 1A). Regional changes in contraction and microvascular function following acute coronary syndromes (ACS) may affect these waves, but the utility of WIA in this setting remains unknown.Abstract 133 Figure 1 (A) Typical Coronary Wave Intensity Profile. (B) Quantitative LGE Mass and Regional Wall Motion Assessment

099 Dynamic three-dimensional whole heart magnetic resonance myocardial perfusion imaging: validation against the Duke Jeopardy Score to assess myocardium at risk

Background Three-dimensional (3D) myocardial perfusion cardiovascular magnetic resonance (CMR) permits whole heart coverage and can establish an estimation of myocardium at risk and ischaemic burden. For invasive estimation of ischaemic burden, semi-quantitative angiographic scores including the Duke Jeopardy Score have clinical legitimacy as the magnitude of myocardium at risk due to severe coronary stenosis is associated with an adverse prognosis. The Duke Jeopardy score combines assessment of stenosis severity and location. Objectives To determine the association between myocardium at risk defined by the Duke Jeopardy Score and 3D CMR perfusion imaging. Methods 53 patients referred for angiography underwent rest and adenosine stress 3D myocardial perfusion CMR at 3Tesla (3D turbo gradient echo, flip angle 15, TR 2.0 ms/TE 1.0 ms, 12 slices of 5 mm thickness, in-plane resolution 2.3×2.3 mm2, 10-fold k-space and time k-t broad linear speed up technique acceleration with k-t principal component analysis). Volume of myocardial hypoperfusion was calculated by a blinded observer using with GTVolume software (GyroTools, Switzerland) with quantitative methods based upon adjusting the signal intensity threshold >2 SDs below the signal of remote myocardium. Volume of hypoperfusion was calculated by summation of the contiguous slices. Jeopardy score was calculated from the coronary angiograms to quantify the myocardium at risk. The coronary tree was divided into six segments of nearly equal myocardial perfusion (eg, left anterior descending artery, major diagonal branch, circumflex artery, major obtuse marginal branch artery, right coronary artery, and posterior descending artery). A score of 2 for each significant lesion was given. Vessels were analysed by a cardiologist blinded to CMR and clinical details and assigned a score ranging from 0 (no Jeopardy) to 12 (maximum Jeopardy). Results 53 patients were scanned with 159 coronary vessels anaylsed. The mean percentage volume of hypoperfusion on 3D-CMR was 9.9% (±10.9). The mean Jeopardy Score was 4.0 (±3.9). The mean percentage volume of hypoperfusion for Jeopardy scores of 0, 6, 12 were 0, 13.1% and 36.7% respectively. Pearsons correlation coefficient showed a strong correlation (r=0.82, 95% CI 0.70 to 0.89) between the Jeopardy Score and volume of hypoperfusion on CMR (p<0.0001) (Abstract 099 figure 1).Abstract 099 Figure 1 Strong correlation between invasive measures of disease severity and ischaemic burden (r=0.82). The dotted line represents the 10% threshold for which revascularisation may confer prognostic benefit over medical therapy alone. Conclusion There is a strong correlation between myocardium at risk by invasive indices and volume of inducible ischaemia by dynamic 3D CMR whole heart perfusion imaging. 3D CMR perfusion imaging offers a non-invasive alternative method of detecting ischaemic burden and myocardium at risk for the purpose of serial studies, guiding revascularisation and risk stratification.

022 Dynamic three-dimensional whole heart magnetic resonance myocardial perfusion imaging: validation against pressure wire derived fractional flow reserve for the detection of flow-limiting coronary heart disease

Background Three-dimensional (3D) myocardial perfusion cardiovascular magnetic resonance (CMR) has recently been proposed to overcome the limited spatial coverage of conventional perfusion CMR methods. The method has shown good diagnostic accuracy for the detection of coronary artery disease determined by quantitative coronary angiography. However the relationship between the severity of a coronary stenosis on quantitative coronary angiography and its functional significance is variable. Pressure wire-derived fractional flow reserve (FFR) <0.75 correlates closely with objective evidence of reversible ischaemia and it has been demonstrated that ischaemia-guided PCI confers a prognostic benefit. Objectives To determine the diagnostic accuracy of whole heart 3D myocardial perfusion CMR against invasively determined FFR. Methods 55 patients referred for angiography underwent rest and adenosine stress 3D myocardial perfusion CMR at 3Tesla (3D turbo gradient echo, flip angle 15, TR 2.0 ms/TE 1.0 ms, 12 slices of 5 mm thickness, in-plane resolution 2.3×2.3 mm2, 10-fold k-space and time k-t broad linear speed up technique acceleration with k-t principal component analysis). Perfusion was scored visually as on a coronary territory basis on a score from 0 to 3. Ischaemic burden was calculated by quantitative segmentation of the volume of hypoenhancement. The FFR was measured in vessels with >50% severity stenosis. Fractional flow reserve <0.75 was considered haemodynamically significant. Results Two patients were excluded (one due to claustrophobia, the other had poor image quality). From the remaining 53 patients and 159 coronary vessels, 64 underwent pressure wire assessment and 39 had an FFR<0.75. Sensitivity, specificity and diagnostic accuracy of CMR analysis per patient was 90%, 91% and 91%, respectively for the detection of significant coronary artery disease. By coronary territory the values were 79%, 92% and 88%. Conclusion 3D CMR stress perfusion can detect functionally significant coronary artery disease with excellent sensitivity, specificity and predictive values when compared with FFR. 3D CMR perfusion imaging may offer an alternative method of detecting ischaemia for the purpose of guiding revascularisation and risk stratification.Abstract 022 Figure 1 3D CMR perfusion of a patient with a proximal LAD lesion with positive fractional flow reserve (FFR=0.61). Note the subendocardial perfusion defect from the base towards the apex.

025 Feasibility of combined cardiovascular MRI and percutaneous coronary intervention in a hybrid laboratory

Background The relationship between anatomy and associated pathophysiology in coronary artery disease (CAD) is complex and incompletely understood yet is important for patient management. This information cannot be comprehensively provided by a single investigative modality. A hybrid x-ray and MRI (XMR) laboratory can potentially overcome this limitation. However, the feasibility of combined invasive and non-invasive studies and percutaneous coronary intervention (PCI) in an XMR laboratory is unknown. Methods 10 patients with angina scheduled for coronary angiography or PCI underwent combined procedures an XMR laboratory. 3T Cardiovascular Magnetic Resonance (CMR) exams included serial high-resolution perfusion, functional and scar imaging. Invasive procedures included diagnostic coronary angiography, PCI and fractional flow reserve (FFR) measurements pre and post PCI. Results Four females and 6 males with mean age 73 (range 51–86) were included. All procedures were completed and well tolerated without complication. Mean study duration was 117 min (range 36–208). The procedures and outcomes are summarised in Abstract 025 table 1. Eight patients underwent both CMR and invasive studies. Six patients had single vessel PCI. FFR and stress perfusion imaging were both performed in 14 coronary territories (4 post PCI). Management was guided by functional information in eight patients. An example case is shown in Abstract 025 figure 1. End-diastolic (B) and end-systolic (C) frames from the short axis cine demonstrate an anterior/anteroseptal wall motion abnormality. Stress perfusion imaging pre PCI demonstrated a severe perfusion defect in the LAD territory from base to apex (E–G; blue arrows) and a defect in the RCA territory (E; green arrows). There were corresponding severe lesions in the proximal LAD with an FFR of 0.45 (D) and RCA (A). Following PCI to the LAD FFR increased to 0.98 and stress perfusion was significantly improved (I–K). The RCA territory defect remained (I; green arrows) but there was also persistent hypoperfusion in the mid anterior slice (J; blue arrow) and apical lateral wall (K; blue arrow) despite the absence of scar on late gadolinium enhancement imaging (L–N).Abstract 025 Table 1 Patient number Age Sex Coronary disease CMR stress perfusion FFR pre PCI FFR post PCI Outcome 1 65 F Minor N/A N/A Medical 2 77 M LADCx NegativeNegative N/A Medical 3 71 M RCA N/A PCI RCA 4 76 F LAD Positive 0.68 PCI LAD 5 79 M LAD Positive 0.38 0.92 PCI LAD 6 79 F LADCx NegativeNegative 0.730.90 0.83 PCI LAD 7 86 F LAD Scar N/A Medical 8 61 M CxRCA PositiveNegative 0.550.29 0.95 PCI Cx 9 75 M LADCxRCA NegativeNegativeNegative 0.830.91 Medical 10 51 M LADCxRCA PositiveNegativePositive 0.450.96 0.98 PCI LAD Cx, circumflex artery; LAD, left anterior descending artery; RCA, right coronary artery.Abstract 025 Figure 1 Conclusions Combined CMR and interventional coronary procedures are feasible and well tolerated in an XMR laboratory. This set-up has exciting research and clinical applications which should improve knowledge and management of coronary artery disease.

26 The effects of pre-existing significant coronary artery disease upon outcome after transcatheter aortic valve implantation using the Edwards bioprosthesis

Introduction Patients undergoing surgical aortic valve replacement (sAVR) routinely undergo simultaneous coronary artery bypass grafting (CABG) for significant coronary artery disease (CAD) due to adverse prognostic impact. While manufacturers advise percutaneous intervention (PCI) of significant CAD prior to transcatheter aortic valve implantation (TAVI) there is considerable variation among operators. Methods We performed a retrospective analysis of 168 patients who underwent TAVI using the Edwards bioprosthesis from March 2008 to October 2010 at St. Thomas Hospital, London. They were divided into two groups according to the results of the pre-TAVI coronary angiogram: (Group 1) patients with ≥1 coronary stenosis of ≥70% severity and those without (Group 2). The end-point was all-cause mortality. Results In total, 70 patients (41.7%) had significant CAD prior to TAVI, with 10 (6.0%) undergoing PCI prior to their procedure. There were no significant differences in either the baseline characteristics or access approach between the two groups (Abstract 26 tables 1 and 2). At a mean follow-up of 335±277 days (mean±SD), the overall mortality was 22.6%; Group 1 mortality was 30% and in group 2 was 17.3% (p=0.124) (see Abstract 26 figure 1) There was no difference seen in the length of stay in the intensive care unit (2.7±6.2 vs 4.1±14.9 days, p=0.462) nor in the number of days to discharge (12.6±10.1 vs 12.8±13, p=0.928). Among those patients who underwent PCI in Group 1, 8 had single vessel intervention and 2 had PCI to 2 vessels. The target vessels were left main stem (LMS) (n=2), proximal left anterior descending artery (LAD) (n=5), circumflex (n=1), right coronary artery (RCA) (n=2), saphenous vein graft (SVG) to LAD (n=1) and SVG to circumflex (n=1). Mortality in this sub-group was not significantly different from the CAD patients who did not receive PCI (50% vs 26.7%, p=0.272).Abstract 26 Table 1 Group 1 Significant CAD (n=70) Group 2 No significant CAD (n=98) p Value Age (years±SD) 83.7±7.5 81.7±8.5 0.112 Diabetes Mellitus 16 (22.9) 27 (27.6%) 0.492 Cerebrovascular disease 11 (15.7%) 17 (17.3%) 0.780 Peripheral vascular disease 15 (21.4%) 12 (12.2%) 0.110 Glomerular filtration rate 48.4±27.9 46.8±23.1 0.685 Logistic Euroscore (%±SD) 23.5±12.9 21.5±16.2 0.399 LV ejection fraction (%±SD) 48.8±11.3 47.9±12.4 0.658 Aortic valve area (cm2±SD) 0.63±0.20 0.67±0.22 0.219 Previous CABG 18 (25.7%) 27 (27.6%) 0.791 Previous PCI 16 (22.9%) 12 (12.2%) 0.070Abstract 26 Table 2 Group 1 Significant CAD (n=70) Group 2 No significant CAD (n=98) p value Transfemoral 44 (44.9%) 29 (41.4%) 0.778 Transapical 47 (48.0%) 37 (52.9%) Transaortic 7 (7.1%) 4 (5.7%)Abstract 26 Figure 1 Conclusion The presence of significant CAD had no significant impact upon the all-cause mortality of patients after TAVI in our study. As yet, the impact of PCI to significant CAD upon outcome after TAVI is not known and will be assessed in a prospective, randomised controlled trial currently underway.

33 Completeness of revascularisation predicts mortality following percutaneous coronary intervention: utility of the BCIS-1 Jeopardy Score

Introduction Many coronary-scoring systems are complicated to use on a day-to-day basis, have varying degrees of reproducibility and exclude important subsets of patients such as those with previous coronary artery bypass grafts (CABG) or left main stem (LMS) disease (Abstract 33 table 1). The recently described BCIS-1 Myocardial Jeopardy score (BCIS-1 JS), a modification of the Duke Jeopardy score to include LMS and CABG, is simple to use and overcomes many of these limitations. We assessed the prognostic relevance of the BCIS-1 JS in patients undergoing percutaneous coronary intervention (PCI).Abstract 33 Table 1 Left Main Stem Disease classified Patients with CABG classified Ease of use Relevance to contemporary PCI Prognostic validation Duke Jeopardy Score (Original) x x √ x √ Syntax Score √ x x √ √ BCIS-1 JS √ √ √ √ x Methods Consecutive patients undergoing PCI between 2005 and 2009 a single cardiac centre were screened. Patients were eligible if they had undergone assessment of left ventricular function before PCI and the sample was enriched for coronary artery bypass graft (CABG) cases by using the following weighting—1 CABG: 3 non-CABG. Clinicians (who were blinded to clinical or outcome data) scored diagnostic and procedural coronary angiograms. The BCIS—1 JS was recorded before and after PCI (range: 0 to 12) and a Revascularisation Index (RI) calculated as RI=(JSPRE—JSPOST)/JSPRE. RI=1.0 indicates full revascularisation and 0 indicates no revascularisation. The primary end-point was all-cause mortality. Mortality data was captured by tracking the database of the UK Office of National statistics. Predictors of outcome were assessed by univariate and multivariate analyses. Results 660 patients were included (68±9 years). 44% presented as acute coronary syndromes with 41% having left ventricular dysfunction. Over a follow-up period of 2.6±1.1 years there were 42 deaths. All-cause mortality was inversely related to baseline BCIS-1 JS (HR 2.20 (1.34 to 3.62), p=0.002) and to post-PCI BCIS-1 JS (HR 3.98 (2.33 to 6.78), p=0.0001). Increasing degrees of revascularisation were associated with improved survival (Abstract 33 figure 1); a revascularisation index of ≥ 0.67 was associated with a survival advantage compared to a RI ≤0.66 (HR 0.39 (0.24 to 0.54), p=0.0001) (Abstract 33 table 2). A multiple regression model, incorporating age, acuity of presentation, LV function and renal failure, demonstrated that RI=0.67–1 continued to be an independent predictor of survival (HR 0.51 95% CI 0.35 to 0.81, p=0.004) (Abstract 33 figure 1).Abstract 33 Figure 1 Cumulative survival according to Revascularisation Index (RI).Abstract 33 Table 2 Variables Univariate analysis HR (95% CI) p value Multivariate analysis HR (95% CI) p value Revascularisation Index (0.67–1) 0.36 (0.24 to 0.54) 0.0001 0.51 (0.33 to 0.81) 0.004 BCIS-1 JS pre PCI 1.26 (1.14 to 1.39) 0.0001 1.14 (0.65 to 2.02) 0.65 BCIS-1 JS post PCI 1.35 (1.23 to 1.48) 0.0001 1.78 (0.93 to 3.39) 0.08 LV impairment 3.76 (2.53 to 5.58) 0.0001 1.97 (1.21 to 3.20) 0.007 Age 1.04 (1.01 to 1.08) 0.01 1.04 (1.00 to 1.08) 0.05 Renal dysfunction 5.82 (2.77 to 12.24) 0.0001 3.74 (1.60 to 7.37) 0.002 Acute coronary syndrome 2.31 (1.24 to 4.30) 0.008 1.30 (0.63 to 2.66) 0.47 Cardiogenic shock 14.56 (6.45 to 32.88) 0.0001 2.83 (0.69 to 11.54) 0.15 Previous CABG 3.35 (1.80 to 6.25) 0.0001 1.83 (0.88 to 3.82) 0.10 Conclusion The BCIS-1 Jeopardy Score predicts mortality following PCI. Furthermore, it can be used to assess the degree of revascularisation, with more complete revascularisation (RI≥0.67) conferring a survival advantage in the medium term.

41 Reduced arterial wave reflection and enhanced LV relaxation contribute to warm-up angina

Background The mechanisms of the clinically observed phenomenon of reduced angina on second exertion, or warm-up angina, are poorly understood. This study compared changes in central haemodynamics, peripheral wave reflection and patterns of coronary blood flow during serial exercise that may contribute. Methods and Results 16 patients (15 male, 61±4.3 yrs) with a positive exercise stress test and exertional angina completed the protocol. During cardiac catheterisation via radial access they performed 2 consecutive exertions (Ex1, Ex2) using a supine cycle ergometer. Throughout exertions, distal coronary pressure (Pd) and flow velocity (V) were recorded in the culprit vessel using a dual sensor coronary guide wire while aortic pressure was recorded using a second wire. Time to 1 mm ST depression was longer in Ex2 (p=0.003) and rate pressure product (RPP) was higher (p=0.025) confirming warm-up. A 33% decline in aortic wave reflection (p<0.0001) in Ex2 (see Abstract 41 figure 1A) coincided with a reduction in both tension time index and diastolic time index (p<0.0001). However, the latter was offset by reduced microvascular resistance (Pd/V), p=0.0002, and enhanced left ventricular relaxation during Ex2 as suggested by a larger backward-travelling suction wave (p=0.01) on wave intensity analysis (WIA) of the intra-coronary signals. See Abstract 41 figure 1B. The energy of the forward compression wave and overall coronary blood flow, as measured by the velocity time integral, did not change.Abstract 41 Figure 1 (A) shows aortic pressure traces taken at peak exertion with a reduction in pressure augmentation during Ex2; (B) shows WIA with an increase in the backward expansion, or “sucking” wave originating from the microvasculature. Conclusions In patients with warm-up angina, exercise induces changes in the aortic pressure waveform, microvascular function and LV relaxation. These combine to reduce afterload without compromising myocardial diastolic blood flow thereby likely enabling improved performance on second exercise.