Srinivas Duvvuri

Rotational atherectomy for in-stent restenosis: acute and long-term results of the first 100 cases

OBJECTIVESnThis study evaluated the clinical safety and long-term results of rotational atherectomy (RA) followed by low-pressure balloon dilatation (percutaneous transluminal coronary angioplasty [PTCA]) for the treatment of in-stent restenosis (ISR).nnnBACKGROUNDnIn-stent restenosis is associated with a high incidence of recurrence after interventional treatment. Because ISR is due to neointimal hyperplasia, rotational ablation may be a more effective treatment than PTCA.nnnMETHODSnBetween November 1995 and November 1996, 100 consecutive patients with first-time ISR were treated by RA. Quantitative coronary angiography and intravascular ultrasound (IVUS) were used to analyze the acute procedural results. The incidence of repeat in-stent restenosis and target vessel revascularization (TVR) at follow-up was determined.nnnRESULTSnProcedural success without any major in-hospital complications was achieved in 100% of cases. Slow flow was observed in 3% and creatine kinase-MB enzyme elevation >3x normal occurred in 2%. The mean burr-to-artery ratio was 0.68+/-0.18 and adjuvant balloon dilatation was performed at 4.2+/-2.1 atm. Minimum luminal diameter increased from 0.86+/-0.28 mm to 1.89< or =0.21 mm after RA and to 2.56+/-0.29 mm after adjunct PTCA. Quantitative IVUS analysis showed that 77% of the luminal gain occurred due to rotational ablation of the restenotic tissue and only 23% occurred after adjunct balloon dilation, and further stent expansion did not contribute to the luminal enlarge. ment. At a mean follow-up of 13+/-5 months, repeat in-stent restenosis occurred in 28% of patients with TVR of 26%. Univariate predictors of repeat restenosis were burr-to-artery ratio <0.6, ISR in <90 days of stenting, ostial lesion, stent for a restenotic lesion and diffuse type ISR.nnnCONCLUSIONSnRotational atherectomy is a safe and feasible technique for treatment of ISR and is associated with a relatively low recurrent restenosis in comparison to historical controls of balloon angioplasty.

Creatine kinase-MB enzyme elevation after coronary intervention with different devices

The present study was conducted to evaluate the incidence of CK-MB elevation and to identify the possible mechanisms of CK-MB release after various coronary interventional devices. We prospectively studied 1,675 consecutive patients following various coronary interventions for CK-MB elevation, from January 1997 to February 1998 and followed them for in-hospital events. CK-MB elevation was detected in 313 patients (18.7%); with 1-3 x normal in 12.8%, 3-5 x normal in 3.5%, and >5 x normal in 2.4%. CK-MB elevation was more common after nonballoon devices (19.5% vs. 11.5% after balloon angioplasty; P < 0.01). Among the newer nonballoon devices, rotational atherectomy alone had a lower CK-MB elevation compared to stent-alone group (16.0% vs. 20.5%; P = 0.07). On univariate analysis, due to selective use of abciximab in high-risk coronary interventions, there was higher incidence of CK-MB elevation with abciximab (24.5% vs. 15.0% without abciximab; P < 0.01). Some kind of procedural complication was observed in 49% of the CK-MB elevation group, with side-branch closure being the most frequent (22.7%). In conclusion, CK-MB elevation is common after successful coronary interventions and is higher after nonballoon devices. Cathet. Cardiovasc. Intervent. 48:123-129, 1999.

THE EFFECT OF EARLY POSTINFARCTION REVASCULARIZATION OF ASYMPTOMATIC PATIENTS ON LEFT VENTRICULAR REMODELING

BACKGROUNDnPatients with angina after a Q-wave myocardial infarction benefit from elective revascularization, but it is not known whether asymptomatic patients, including those with a totally occluded infarct-related artery, improve after revascularization.nnnOBJECTIVEnTo determine the effect of early postinfarction revascularization of asymptomatic patients on left ventricular remodeling.nnnMETHODSnWe prospectively studied 31 consecutive asymptomatic patients (aged 57 +/- 2 years, 24 with anterior infarcts) after Q-wave myocardial infarction with > or = 70% stenosis of the infarct-related artery (IRA) who underwent early elective revascularization (days 4-10 after myocardial infarction). Group I consisted in patients with a totally occluded IRA (n = 10), and group II consisted in patients with a patent, though stenosed, IRA (n = 21). Resting echocardiography and low-dose dobutamine echocardiography were performed at baseline (day 3 +/- 1), and rest echocardiography was repeated after an 8-week follow-up. Significant myocardial viability was defined as > or = 2 wall segments improved (in a 16-segment model of left ventricle) versus baseline, and significant functional recovery as > or = 2 segments improved versus baseline on follow-up examination. Left ventricular end-systolic volume indices (ESVI) and end-diastolic volume indices and ejection fractions were measured by using a modified version of Simpsons rule (using apical two-chamber and four-chamber views).nnnRESULTSnThe left ventricular ESVI of patients in group I had decreased by 4.2 +/- 1.9 ml/m2, whereas for patients in group II the left ventricular ESVI had increased by 4.2 +/- 1.7 ml/m2 (P = 0.006). Similarly, the left ventricular end-diastolic volume index had decreased by 0.7 +/- 2.4 ml/m2 versus baseline at follow-up for patients in group I and increased by 7.8 +/- 2.1 ml/m2 for patients in group II (P = 0.02). The left ventricular ejection fraction increased by 7.3 +/- 3% for patients in group I and decreased by 0.4 +/- 2% for patients in group II (P = 0.04).nnnCONCLUSIONnThere is less global left ventricular remodeling, a potentially deleterious process, after elective revascularization early after Q-wave myocardial infarction in asymptomatic patients who had had a totally occluded IRA before revascularization than there is in patients who had already had a patent, though stenosed, IRA before revascularization. These results suggest that restoration of patency of IRA after a Q-wave myocardial infarction is beneficial even for asymptomatic patients.

935-33 Angiographically Complex Lesions are Associated with Increased Levels of Thrombin Generation and Activity Following PTCA

Angiographically complex coronary lesions (irregular borders. overhanging edges. or filling defects) are associated with unstable coronary syndromes and an increased incidence of thrombosis following coronary angioplasty (PTCA). To study the relationship between angiographic lesion morphology and activation of the coagulation cascade. we measured coronary plasma levels of FPA and Fl + 2 in a series of patients undergoing PTCA. Samples were withdrawn through a coronary sampling catheter placed proximal to the lesion prior to PTCA (Pre-PTCA) and placed distal to the lesion 10xa0min after the final balloon inflation (Post-PTCA). Angiographic interpretations of lesion complexity were made without knowledge of the plasma FPA and Fl + 2 levels. Results: Plasma FPA and Fl + 2 levels measured in 50 patients are shown below in median (95% confidence intervals). Twenty-four (48%) of the patients had a complex lesion morphology. Coagulation Marker Lesion Morphology Pre PTCA Post 10xa0Min PTCA FPA Complex 2.1 (1.6–3.5) ‡ 3.3 (2.6–5.8) ‡‡ ng/ml Simple 1.9 (1.3–3.9) 2.1 (1.5–9.8) Flxa0+xa02 Complex 0.65 (0.54–1.04) * 0.76(0.64–1.03) ** nmol/L Simple 0.64 (0.53–0.77) 0.61 (0.48–1.08) pxa0lxa00.02: † vs ‡‡ pxa0lxa00.003: * vs ** Although pre-PTCA FPA and Flxa0+ xa02 values were similar for simple and complex lesions. post-PTCA FPA and Flxa0+xa02 values increased only for complex lesions. Thus. complex lesions are associated with increased thrombin generation and activity. This may playa role in the thrombotic and restenotic complications associated with percutaneous treatment of complex coronary lesions