Sinan Dagdelen

Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention and Long-term Mortality and Morbidity in Multivessel Disease Meta-analysis of Randomized Clinical Trials of the Arterial Grafting and Stenting Era

IMPORTANCE Recent trials of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for multivessel disease were not designed to detect a difference in mortality and therefore were underpowered for this outcome. Consequently, the comparative effects of these 2 revascularization methods on long-term mortality are still unclear. In the absence of solid evidence for mortality difference, PCI is oftentimes preferred over CABG in these patients, given its less invasive nature. OBJECTIVES To determine the comparative effects of CABG vs PCI on long-term mortality and morbidity by performing a meta-analysis of all randomized clinical trials of the current era that compared the 2 treatment techniques in patients with multivessel disease. DATA SOURCES A systematic literature search was conducted for all randomized clinical trials directly comparing CABG with PCI. STUDY SELECTION To reflect current practice, we included randomized trials with 1 or more arterial grafts used in at least 90%, and 1 or more stents used in at least 70% of the cases that reported outcomes in patients with multivessel disease. DATA EXTRACTION Numbers of events at the longest possible follow-up and sample sizes were extracted. DATA SYNTHESIS A total of 6 randomized trials enrolling a total of 6055 patients were included, with a weighted average follow-up of 4.1 years. There was a significant reduction in total mortality with CABG compared with PCI (I2 = 0%; risk ratio [RR], 0.73 [95% CI, 0.62-0.86]) (P < .001). There were also significant reductions in myocardial infarction (I2 = 8.02%; RR, 0.58 [95% CI, 0.48-0.72]) (P < .001) and repeat revascularization (I2 = 75.6%; RR, 0.29 [95% CI, 0.21-0.41]) (P < .001) with CABG. There was a trend toward excess strokes with CABG (I2 = 24.9%; RR, 1.36 [95% CI, 0.99-1.86]), but this was not statistically significant (P = .06). For reduction in total mortality, there was no heterogeneity between trials that were limited to and not limited to patients with diabetes or whether stents were drug eluting or not. Owing to lack of individual patient-level data, additional subgroup analyses could not be performed. CONCLUSIONS AND RELEVANCE In patients with multivessel coronary disease, compared with PCI, CABG leads to an unequivocal reduction in long-term mortality and myocardial infarctions and to reductions in repeat revascularizations, regardless of whether patients are diabetic or not. These findings have implications for management of such patients.

Fast track recovery of high risk coronary bypass surgery patients

OBJECTIVE Fast track recovery protocols on younger, low risk patients result in shorter hospital stays and decreased costs. However, data is lacking on the impact of these protocols on high risk patients based on an objective scoring system. METHODS In this study, a high risk cohort of patients (EuroSCORE >or=6, n=158) was compared with a low risk cohort of patients (EuroSCORE <6, n=1004) to define the safety and efficacy of fast track recovery among high risk patients. A standard perioperative data is collected prospectively for every patient. RESULTS Time to extubation was longer in the high risk group (299+/-253 vs. 232+/-256min; P=0.003), but intensive care unit (ICU) stay (25.6+/-28.7 vs. 21.5+/-9.4h; P=ns), and postoperative length of stay (5.8+/-2.4 vs. 5.6+/-2.7 days; P=ns) was similar when compared with the low risk group. Of the high risk patients 81% were extubated within 6h, 87% were discharged from the intensive care unit within 24h, and 67% were discharged from the hospital within 5 days. Multiple regression analysis showed that any red blood cell transfusion (P=0.02), and cross clamp time >60min (P=0.03) were the predictors of delayed extubation (>or=6h) in the high risk group. The predictors of extended ICU stay were any red blood cell transfusion (P=0.0001), and peripheral vascular disease (P=0.05). Any red blood cell transfusion was the only predictor for mortality (P=0.02) and readmission to the hospital within the first 30 days (P=0.02) in this cohort of patients. CONCLUSIONS This study confirms the safety and efficacy of fast track recovery protocol among high risk patients undergoing coronary artery bypass surgery. All patients are basically suitable for fast track recovery and the preoperative risk factors are poor predictors of prolonged ventilation, increased ICU and hospital stay. Red blood cell transfusion is associated with delayed extubation and discharge from the ICU, and increased mortality and hospital readmission rate.

A randomized study comparing the effectiveness of right and left radial approach for coronary angiography

Our aim was to compare the effectiveness between right radial approach (RRA) and left radial approach (LRA) by means of a randomized study in a large unselected patient population undergoing diagnostic coronary angiography.

The long-term incidence and predictors of radial artery occlusion following a transradial coronary procedure.

BACKGROUND Radial artery occlusion (RAO) is an infrequent complication of transradial coronary procedures (TRA). To our knowledge, there is no satisfactory data regarding the late term incidence and predictors of RAO in the literature. Our aim was to establish the long-term incidence of radial artery occlusion and investigate its predictors. METHODS This was a single center prospective study. A total number of 409 consecutive patients undergoing their first TRA were recruited. Clinical and procedural data were all recorded. Doppler ultrasound examination was performed at 6-15 months following the intervention. RESULTS RAO was detected in 67 patients and 342 patients maintained radial artery patency. The overall RAO incidence was 16.4% at late term. Patients with RAO were younger than the patients with patent radial arteries (55.9 ± 9.7 vs. 59.1 ± 9.4 years, p = 0.014). The incidence of RAO in hypertensive patients (9.8%) was lower (p < 0.001) than the observed incidence (23%) in non-hypertensive patients. RAO group had higher rate (28%, p = 0.027) of post--procedural access site pain. Regression analysis revealed that hypertension was negative while post-procedural access site pain was positive independent predictors for RAO. In addition, the relative risk for RAO also increased significantly (p < 0.001) when the ratio of sheath/artery diameter (S/A) was > 1. CONCLUSIONS The present study reveals that the long-term incidence of RAO is 16.4%. Hypertension, post-procedural access site pain and S/A ratio > 1 are independent predictors of RAO at late term.

Comparison of Effects of Low- versus High-Dose Heparin on Access-Site Complications during Transradial Coronary Angiography: A Double-Blind Randomized Study

Objectives: Although heparin is highly effective in reducing the rate of radial artery occlusion after transradial catheterization, the optimal heparin dose is still controversial. The aim of this study was to evaluate the efficacy and safety of two different heparin doses during transradial coronary angiography. Methods: 490 consecutive patients undergoing transradial coronary angiography were prospectively enrolled into this double-blind randomized trial. A total of 202 patients enrolled in the low-dose (LD; 2,500 U of heparin) group and 202 patients enrolled in the high-dose (HD; 5,000 U of heparin) group were included in the final analysis. The primary endpoint of the study was radial artery occlusion. Bleeding and hematomas were the secondary outcome measures. Results: At day 7, radial artery occlusion occurred in 5.9% of the patients in the LD group and in 5.4% of the patients in the HD group (p = 0.83). Bleeding during deflation of the transradial band occurred in 6.4% of the patients in the LD group and in 18.3% of the patients in the HD group; the difference was statistically significant (p < 0.001). Higher-dose heparin was found to be an independent predictor of bleeding (p = 0.007). Conclusion: A lower dose of heparin (i.e. 2,500 U) decreases bleeding during transradial band deflation without an increase in radial artery occlusion.

Incidence and Predictors of Radial Artery Spasm at the Beginning of a Transradial Coronary Procedure

OBJECTIVES Our aim was to establish the frequency of radial artery spasm (RAS) and its predictors at the beginning of a transradial approach (TRA). METHODS This was a single-center prospective study. A total of 1,722 consecutive patients undergoing their first transradial coronary procedure were recruited. After radial artery puncture, a hydrophilic sheath was used to complete arterial puncture, then 500 μg glycerol trinitrate and 2.5 mg verapamil were injected into radial artery along the sheath. After retrograde radial arteriography spasm was defined angiographically as a stenosis greater than 25%. Patient demographics, procedural data such as total procedural duration, the number of catheters and guidewires used, the amount of contrast media usage, dose area product (DAP) and fluoroscopy time, and vascular complications were recorded. RESULTS The overall spasm incidence was 10.3%. The procedural success rate was lower in patients with spasm than in patients without spasm (80% vs. 95.7%, P < 0.001). The patients with spasm were older (mean age 63.9 ± 9.4 years vs. 60.0 ± 11.2 years, P < 0.001) and more commonly female (51.3% vs. 34.4%, P < 0.001). Spasm was more common in hypertensive patients (66% vs. 56%, P < 0.009). Surprisingly, smoking was less common in patients with spasm (17% vs. 29%, P < 0.001). Multiple logistic regression analysis showed that female gender (OR = 1,524, 95% CI: 1.033-2.248, P = 0.034) was the only independent predictor of RAS at the beginning of the procedure. CONCLUSIONS The incidence of RAS was 10,3%, and female gender was the sole independent predictor of RAS at the very beginning of the procedure in patients undergoing a TRA.

Association between serum vitamin D levels and subclinical coronary atherosclerosis and plaque burden/composition in young adult population

Evidence suggests that low 25-OH vitamin D 25(OH)D concentrations may increase the risk of several cardiovascular diseases such as hypertension, peripheral vascular disease, diabetes mellitus, obesity, myocardial infarction, heart failure and cardiovascular mortality. Recent studies suggested a possible relationship between vitamin D deficiency and increased carotid intima-media wall thickness and vascular calcification. We hypothesized that low 25(OH)D may be associated with coronary atherosclerosis and coronary plaque burden and composition, and investigated the relationship between serum vitamin D levels and coronary atherosclerosis, plaque burden or structure, in young adult patients by using dual-source 128x2 slice coronary computed tomography angiography (CCTA). We included 98 patients with coronary atherosclerosis and 110, age and gender matched, subjects with normal findings on CCTA examinations. Patients with subclinical atherosclerosis had significantly higher serum total cholesterol, triglycerides, hs-CRP, uric acid, HbA1c and creatinine levels and lower serum 25(OH)D levels in comparison with controls. There was no significant correlation between 25(OH)D and plaque morphology. There was also a positive relationship between 25(OH)D and plaque burden of coronary atherosclerosis. In multivariate analysis, coronary atherosclerosis was associated high hs-CRP (adjusted OR: 2.832), uric acid (adjusted OR: 3.671) and low 25(OH)D (adjusted OR: 0.689). Low levels of 25(OH)D were associated with coronary atherosclerosis and plaque burden, but there was no significant correlation between 25(OH)D and plaque morphology.

Quantitation of Papillary Muscle Function with Tissue and Strain Doppler Echocardiography Measures Papillary Muscle Contractile Functions

It is well known that papillary muscle dysfunction may cause mitral regurgitation, however, there is not a standard technique to measure the papillary muscle function. The aim of this study is to investigate papillary muscle function by using tissue and strain rate Doppler echocardiography. Method: A study group (SG) of 42 patients (12 females, 30 males, mean age: 53.8 ± 10.9 years) with coronary artery disease who have segmental left ventricular dysfunction and mitral regurgitation, and as a control group (CG) 20 patients (6 females, 14 males, mean age 52.5 ± 10.2 years) who have no coronary artery disease and mitral regurgitation were studied. A subgroup 20 patients (7 females, 13 males, mean age 42.5 ± 7.5 years) who have rheumatic mitral regurgitation was included to the study. The patients who have left ventricular and mitral annular dilatation were not included into the study. Longitudinal wall motion of mid‐inferior segment (one point) and posterior papillary muscle (two point) of the left ventricle was assessed by tissue and strain rate Doppler echocardiography from the apical two‐chamber view. Systolic tissue velocity (Sm), strain rate (SR), and strain (S) were measured from the two points in all patients. Results: Comparing the one point values Sm, SR, and S were found less in SG than CG (respectively 4.2 ± 1.4 vs 11.3 ± 1.9 cm/sec, −1.0 ± 0.4 vs −1.7 ± 0.3 s−1, −13.5 ± 5.0 vs −18.1 ± 3.9%; P < 0.001 for all). Comparing the two point values Sm, SR and S were found less in SG than CG (respectively 2.8 ± 1.2 vs 3.7 ± 2.0 cm/sec, −0.8 ± 0.4 vs −1.6 ± 0.3 s−1, −9.7 ± 4.6 vs −15.8 ± 3.7%; P < 0.001 for all). Systolic mitral annulus, left ventricular systolic and diastolic dimensions were similar in two groups. Comparing the CG and subgroup, there were no significant differences with respect to Sm, SR, and S measured from the two points. Conclusions: Papillary muscle function may be assessed quantitatively by using tissue and strain rate Doppler echocardiography. Tissue velocity, strain rate, and strain values were found decreased in dysfunctional papillary muscle. (ECHOCARDIOGRAPHY, Volume 20, February 2003)

Arterial Anatomic Variations and Its Influence on Transradial Coronary Procedural Outcome

OBJECTIVES Our aim was to establish the frequency of arterial anatomic variations and its relation to coronary procedural outcome in patients undergoing a first transradial coronary procedure. METHODS This was a single center prospective study. A total of 1,446 consecutive patients undergoing their first transradial coronary procedure were recruited. Retrograde radial arteriography was performed to define radial artery anatomy. If the operator encountered serious problems during crossing the subclavian-aortic truncus, retrograde subclavian arteriography was also performed. Patient demographics; procedural data such as: total procedural duration, the number of catheters and guidewires used, the amount of contrast media usage, dose area product (DAP), and fluoroscopy time; and vascular complications were recorded. RESULTS Anatomic variations were noted in 270 patients (18.6%), and these patients were significantly older (mean age 64.4 ± 10.4 vs. 59.2 ± 10.8 years, P < 0.001) and more commonly female (46% vs. 33%, P < 0.001) with significantly higher procedural failure rates (8.8% vs. 5.6%, P = 0.006). In addition, procedural duration (P < 0.001) and fluoroscopy time (P < 0.001) were statistically longer in patients with anatomic variations. Anatomic variations also had an adverse impact on the amount of contrast agent usage (63.9 ± 28.3 mL vs. 59.1 ± 25.3 mL, P = 0.006) and minor vascular complication rate (P = 0.007). CONCLUSIONS This study indicates that anatomic variation of the arterial path has an adverse impact on transradial coronary procedural outcome.

Right ventricular endomyocardial fibrosis mimicking Ebstein anomaly in a patient with Behçet’s disease: case report and review of the literature

Behçet’s disease is a multisystemic, chronic inflammatory disorder with diffuse clinical manifestations including the cardiovascular system. Endomyocardial fibrosis is a rarely seen complication of Behçet’s disease leading to progressive heart failure. We report a case of right ventricular endomyocardial fibrosis mimicking Ebstein anomaly in a 26-year-old male Turkish patient with Behçet’s disease, who had heart failure symptoms. In addition, the previously reported cases of endomyocardial fibrosis complicating Behçet’s disease are reviewed in this article.