Journal of the American College of Cardiology, Jul 1, 2014
To enhance value, an e-consult program in cardiology needs to provide both high-quality provider ... more To enhance value, an e-consult program in cardiology needs to provide both high-quality provider and patient satisfaction. In a preliminary pilot study, we have shown that offering an e-consult option in cardiology does not appear to increase overall total referral volume, with referring providers requesting e-consults in lieu of traditional visits. Furthermore, e-consults appear to be associated with high rates of satisfaction among both providers and patients. These preliminary findings from a single center should be interpreted with caution. A more definitive study would involve multiple sites; track visit volumes, total costs, and patient outcomes over a longer time period; and assess patient and physician experience and satisfaction in greater detail. This design would allow comparison of the saved cost of an avoided visit against the cost of any potential increase in testing.
Background: Ostial atherosclerotic lesions are distinct from other lesion sites in terms of outco... more Background: Ostial atherosclerotic lesions are distinct from other lesion sites in terms of outcomes following percutaneous interventions. Despite aggressive lesion modification strategies, long-term outcome is hampered by restenosis. Various stent designs have failed to show significant improvement in target lesion revascularization (TLR) rates. The present study evaluates the clinical outcomes following sirolimus-eluting stent implantation for ostial lesions. Materials and methods: The sirolimus-eluting stent (SES) was the device of choice at our institute for all coronary interventions from April 2002 to March 2003. This study population is comprised of 50 patients who received drug-eluting stents for atherosclerotic ostial lesions during this period. Sixty-eight percent of the patients were male and 24 patients (48%) had a history of previous revascularization. Indication for intervention were as follows: acute myocardial infarction, 7 patients (14%), stable angina, 23 patients (46%), unstable angina, 20 patients (40%). Angioplasty and stent implantations were done according to the standard protocol. All patients were prospectively followed up for major adverse cardiac events. The event-free survival was 90% at one year. There were 5 (10%) target vessel revascularization, 3 (6%) myocardial infarctions and 1 (2%) death during a mean follow-up of 414.5 +/- 54.5 days. TLR was required in 4 (8%) patients. Conclusions: SES implantation is feasible in ostial locations and is associated with low subsequent revascularization.
Physiological lesion assessment in the form of Fractional Flow Reserve (FFR) is now well establis... more Physiological lesion assessment in the form of Fractional Flow Reserve (FFR) is now well established for the purpose of guiding multi-vessel revascularization. Chronic total coronary occlusions are frequently associated with multi-vessel disease and the collateral dependent myocardium distal to the occlusion is often supplied by a collateral supply from another epicardial coronary artery. The haemodynamic effect of collateral donation upon collateral donor vessel flow may have important implications for the vessel's FFR; rendering it unreliable at predicting ischaemia should the CTO be revascularized. As a consequence, in the setting of multi-vessel disease, optimal revascularization strategy might be altered. There is a paucity of work in the medical literature directly examining this phenomenon. We endeavoured to review the existing literature related to it, to summarise from current knowledge of coronary physiology what is known about the potential effects of CTO revascularization on both collateral flow and collateral donor vessel physiology, and to highlight where further studies might inform practice.
Recurrent angina after percutaneous or surgical coronary procedures may occur as a consequence of... more Recurrent angina after percutaneous or surgical coronary procedures may occur as a consequence of several potential causes, such as bypass graft failure, restenosis, or atherosclerotic disease progression. Repeat invasive procedures are frequently performed for patients with recurrent symptoms. Nevertheless, non-invasive pharmacological treatment to decrease disease progression or reduce anginal symptoms are an integral part of the management of the patients. New metabolic modulators such as trimetazidine may constitute important therapeutic agents in the symptomatic control of patients with recurrent angina after invasive revascularization.
Background-The factors associated with the occurrence of restenosis after sirolimus-eluting stent... more Background-The factors associated with the occurrence of restenosis after sirolimus-eluting stent (SES) implantation in complex cases are currently unknown. Methods and Results-A cohort of consecutive complex patients treated with SES implantation was selected according to the following criteria: (1) treatment of acute myocardial infarction, (2) treatment of in-stent restenosis, (3) 2.25-mm diameter SES, (4) left main coronary stenting, (5) chronic total occlusion, (6) stented segment Ͼ36 mm, and (7) bifurcation stenting. The present study population was composed of 238 patients (441 lesions) for whom 6-month angiographic follow-up data were obtained (70% of eligible patients). Significant clinical, angiographic, and procedural predictors of post-SES restenosis were evaluated. Binary in-segment restenosis was diagnosed in 7.9% of lesions (6.3% in-stent, 0.9% at the proximal edge, 0.7% at the distal edge). The following characteristics were identified as independent multivariate predictors: treatment of in-stent restenosis (OR 4.16, 95% CI 1.63 to 11.01; PϽ0.01), ostial location (OR 4.84, 95% CI 1.81 to 12.07; PϽ0.01), diabetes (OR 2.63, 95% CI 1.14 to 6.31; Pϭ0.02), total stented length (per 10-mm increase; OR 1.42, 95% CI 1.21 to 1.68; PϽ0.01), reference diameter (per 1.0-mm increase; OR 0.46, 95% CI 0.24 to 0.87; Pϭ0.03), and left anterior descending artery (OR 0.30, 95% CI 0.10 to 0.69; PϽ0.01). Conclusions-Angiographic restenosis after SES implantation in complex patients is an infrequent event, occurring mainly in association with lesion-based characteristics and diabetes mellitus. (Circulation. 2004;109:1366-1370.
Chronic total occlusions (CTOs) are commonly found on diagnostic angiography, and there is some e... more Chronic total occlusions (CTOs) are commonly found on diagnostic angiography, and there is some evidence from one study that successful percutaneous revascularization leads to an improvement in long-term survival rates. However, this study included patients treated for unstable angina with short-duration occlusion, and stent implantation was utilized in only 7%. We re-evaluated the longterm outcomes of a large consecutive series of patients with a CTO of .1-month duration treated at our centre, with stent implantation utilized in the majority. Methods and results All patients treated with percutaneous coronary intervention (PCI) between 1992 and 2002 were retrospectively identified from a dedicated database. A total of 874 consecutive patients were treated for 885 CTO lesions. Mean follow-up time was 4.47 + 2.69 years (median 4.10 years). Patients were evaluated for the occurrence of major adverse cardiac events (MACE) comprising death, acute myocardial infarction, and need for repeat revascularization with either coronary artery bypass surgery or PCI. Successful revascularization was achieved in 576 lesions (65.1%), in which stent implantation was used in 81.0%. At 30 days, the overall MACE rate was significantly lower in those patients with a successful recanalization (5.5 vs. 14.8%, P , 0.00001). At 5 years, survival was significantly higher in those patients with a successful revascularization (93.5 vs. 88.0%, P ¼ 0.02). In addition, there was a significantly higher survival free of MACE (63.7 vs. 41.7%, P , 0.0001), with the majority of events reflecting the need for repeat intervention. Independent predictors for survival were successful revascularization, lower age, and the absence of diabetes mellitus and multivessel disease. Conclusion Successful percutaneous revascularization of a CTO leads to a significantly improved survival rate and a reduction in major adverse events at 5 years. Most events relate to the need for repeat reintervention, and the introduction of drug-eluting stents, with low-restenosis rates, encourages the development of technologies to improve recanalization success rates. However, failed recanalization may be associated acutely with an adverse event, and new technologies must focus on a safe approach to successful recanalization.
Study Question: To compare coronary stent implantation and bypass surgery for multivessel coronar... more Study Question: To compare coronary stent implantation and bypass surgery for multivessel coronary disease in patients with renal insufficiency. Methods: The Arterial Revascularization Therapies Study (ARTS) trial was a randomized analysis comparing CABG and coronary stenting for the treatment of patients with multivessel coronary artery disease. In the ARTS trial, 142 moderate renal-insufficient patients (Ccr Ͻ 60 mL/min) with multivessel coronary disease were randomly assigned either to stent implantation (nϭ69) or CABG (nϭ73). The primary end point was defined as the absence of any of the following major adverse cardiac and cerebrovascular events (MACCE) within 5 years after randomization: death cerebrovascular accident (CVA), documented nonfatal MI adjudicated by either new abnormal Q wave or predefined enzymatic changes, or repeat revascularization by coronary stenting or CABG. Results: At 5 years, there was no significant difference between the two groups in terms of mortality (14.5% in the stent group vs. 12.3% in the CABG group; pϭ0.81), or combined end point of death, CVA, or MI (30.4% in the stent group vs. 23.3% in the CABG group; pϭ0.35). Among patients who survived without CVA or MI, 18.8% in the stent group underwent a second revascularization procedure when compared with 8.2% in the surgery group (pϭ0.08). The event-free survival at 5 years was 50.7% in the stent group and 68.5% in the surgery group (pϭ0.04). Conclusions: The researchers concluded that at 5 years, the differences in mortality and combined incidence of death, CVA, and MI between coronary stenting and surgery did not reach statistically significant level in patients with renal insufficiency. Perspective: In this 142-patient prospective cohort with moderate renal-insufficiency (Ccr Ͻ60 mL/min), the difference in 5-year mortality and combined incidence of death, CVA, and MI between coronary stent and surgery did not reach a statistically significant level, although the actual event rates in the stent group were higher than in the CABG group. The occurrence of MACCE in the stent group was statistically higher than in the CABG group, mainly due to the higher incidence of repeat revascularization in the stent group. However, the difference of MACCE rate between the stent and the CABG in the Ccr Ͻ60 mL/min group was similar as compared to the Ccr Ն60 mL/min group. It remains to be seen whether drug-eluting stents will consistently reduce restenosis rates in patients with renal insufficiency. Debabrata Mukherjee
Chronic total occlusion of the left main coronary artery (LMCA) is rare. Recently, percutaneous c... more Chronic total occlusion of the left main coronary artery (LMCA) is rare. Recently, percutaneous coronary intervention has been increasingly applied to unprotected LMCA lesions. We describe a patient with chronic total occlusion of the LMCA who was successfully treated with bifurcation stenting with sirolimus-eluting stents.
International Journal of Cardiovascular Interventions, Jun 1, 2005
To assess the safety and efficacy of the implantation of Paclitaxel Eluting Stents (PES) for de n... more To assess the safety and efficacy of the implantation of Paclitaxel Eluting Stents (PES) for de novo, non-flow limiting lesions. We assessed the 12-month occurrence of major adverse cardiac events (MACE) in 21 patients (4% of the total population treated in a 'real world' registry) with 22 non-significant coronary narrowings treated with PES. The following criteria had to be met: (1) the lesion was de novo; (2) the location was non-ostial, and not a bifurcation lesion; (3) the diameter stenosis by quantitative coronary angiography (QCA) was <50%; (4) there was no visible thrombus and (5) the lesion was not located in an angiographically diffusely diseased segment. Procedural success rate was 100% without any periprocedural myocardial infarction. After a mean follow-up of 407.33+/-53 (range: 344-498) days the overall MACE-free survival was 95.2%. Freedom from target revascularization was 95.2%. The result of this non-randomized observational study suggests that the implantation of PES for de novo, non-significant lesions appears most probably safe and effective.
; for the ISCHEMIA Research Group IMPORTANCE While many features of stable ischemic heart disease... more ; for the ISCHEMIA Research Group IMPORTANCE While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. OBJECTIVE To describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. INTERVENTIONS CCTA and angina assessment. MAIN OUTCOMES AND MEASURES Sex differences in stress test, CCTA findings, and symptom severity. RESULTS Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA) (352 of 1022 [34.4%] vs 378 of 3353 [11.3%]). Of individuals who were randomized, women had more angina at baseline than men (median [interquartile range] Seattle Angina Questionnaire Angina Frequency score: 80 [70-100] vs 90 [70-100]). Women had less severe ischemia on stress imaging (383 of 919 [41.7%] vs 1363 of 2972 [45.9%] with severe ischemia; 386 of 919 [42.0%] vs 1215 of 2972 [40.9%] with moderate ischemia; and 150 of 919 [16.3%] vs 394 of 2972 [13.3%] with mild or no ischemia). Ischemia was similar by sex on exercise tolerance testing. Women had less extensive CAD on CCTA (205 of 568 women [36%] vs 1142 of 2418 men [47%] with 3-vessel disease; 184 of 568 women [32%] vs 754 of 2418 men [31%] with 2-vessel disease; and 178 of 568 women [31%] vs 519 of 2418 men [22%] with 1-vessel disease). Female sex was independently associated with greater angina frequency (odds ratio, 1.41; 95% CI, 1.13-1.76). CONCLUSIONS AND RELEVANCE Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease.
IntroductionNo-reflow (NR) phenomenon is characterised by the failure of myocardial reperfusion d... more IntroductionNo-reflow (NR) phenomenon is characterised by the failure of myocardial reperfusion despite the absence of mechanical coronary obstruction. NR negatively affects patient outcomes, emphasising the importance of prediction and management. The objective was to evaluate the incidence and independent predictors of NR in patients presenting with ST-elevation myocardial infarction (STEMI).MethodsThis was a single-centre prospective case–control study. Cases were subjects who suffered NR, and the control comparators were those who did not. Clinical outcomes were documented. Salient variables relating to the patients and their presentation, history and angiographical findings were compared using one-way analysis of variance or χ2 test. Multiple regression determined the independent predictors, and a risk score was established based on the β coefficient.ResultsOf 173 consecutive patients, 24 (13.9%) suffered from NR, with 46% occurring post stent implantation. Patients with NR had...
Journal of the American College of Cardiology, 2020
Background: Sex differences in ischemia, coronary anatomy and symptoms have not been investigated... more Background: Sex differences in ischemia, coronary anatomy and symptoms have not been investigated among patients who have moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary CT angiography (CCTA) was required to have obstructive CAD to undergo randomization. We describe sex differences in stress testing and CCTA findings as well as symptoms in the ISCHEMIA trial. Methods: ISCHEMIA enrolled patients based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most participants. Stress tests and CCTAs were reviewed at core laboratories. Those with no obstructive coronary artery disease (CAD) or with left main CAD >50% were excluded. Angina was assessed using the Seattle Angina Questionnaire (SAQ). Results: Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA), 34% versus 11%, p<0.001, resulting in more women excluded after enrollment. Randomized women (n=1168) had more angina at baseline than randomized men (n=4011), despite less extensive CAD on CCTA and less severe ischemia in women vs. men with stress imaging (Figure). Conclusion: Women randomized in the ISCHEMIA trial had more frequent angina despite less extensive CAD and less ischemia than men. Our findings likely reflect inherent sex differences in the complex relationships between angina, atherosclerosis and ischemia that may have implications for testing and treatment of patients with suspected ischemic heart disease.
scores have a comparable safety profile, they identify a significantly lower proportion of patien... more scores have a comparable safety profile, they identify a significantly lower proportion of patients as low risk.
1, 5, and 10, and after 40 weeks adjusted for the gestational age in preterm LBW infants. Blood p... more 1, 5, and 10, and after 40 weeks adjusted for the gestational age in preterm LBW infants. Blood pressure was measured at each visit using Welch Allyn VSMTM 300 monitor. Results At birth, the NBW infants had significantly lower BCD (difference À9.3 cap/area, 95% CI: À1.5 to À17.1, p=0.021) and MCD (difference À12.6 cap/area, 95% CI: À1.5 to À21.7, p=0.025) compared to the LBW infants. LBW oxygen group had a significantly lower SBP (mean difference À9.5 mmHg, 95% CI: À1 to À19, p=0.047), DBP (difference À13 mmHg, 95% CI: À4 to À22, p=0.009). At 40 weeks old, the LBW oxygen group showed a significant reduction in BCD (difference À19.3 cap/area, 95% CI: À9 to À30, p=0.003) and MCD (difference À22 cap/area, 95% CI: À8 to À36 p=0.007). Similarly the LBW non-oxygen group had a significant reduction in BCD (difference À29 cap/area, 95% CI À17 to À41 p<0.0001) and MCD (mean difference À29 cap/area, 95% CI, À16 to À41 p<0.001). Both LBW groups showed a significant rise in BP. The rise in SBP (mean difference 24 mmHg, 95% CI: 14-34, p<0.0001) and DBP (mean difference 14 mmHg, 95% CI: 7-22, p<0.001) was more pronounced in LBW oxygen group compared to the LBW control group (difference 14 mmHg, 95% CI: 0.5-27, p=0.043 and difference 9 mmHg, 0.3-19, p=0.056 respectively) Conclusions We confirm that LBW infants have higher capillary density at birth but develop significant capillary rarefaction and increase in their blood pressure at 40 weeks compared to NBW infants. Oxygen therapy in the neonatal period in LBW infants was associated with higher blood pressure levels but we could not detect any effect on capillary rarefaction. Further studies are needed to investigate the humoral factors that trigger the changes of microcirculation in LBW infants during the neonatal period which may be of importance in preventing hypertension in later life.
Journal of the American College of Cardiology, 2017
2. Hirsch A, Windhausen F, Tijssen JG, et al. Diverging associations of an intended early invasiv... more 2. Hirsch A, Windhausen F, Tijssen JG, et al. Diverging associations of an intended early invasive strategy compared with actual revascularization, and outcome in patients with non-ST-segment elevation acute coronary syndrome: the problem of treatment selection bias. Eur Heart J 2009;30:645-54. 3. Damman P, Wallentin L, Fox KA, et al. Long-term cardiovascular mortality after procedure-related or spontaneous myocardial infarction in patients with non-ST-segment elevation acute coronary syndrome: a collaborative analysis of individual patient data from the FRISC II, ICTUS, and RITA-3 trials (FIR).
Cardiogoniometry (CGM) is a method of 3-dimensional electrocardiographic assessment which has pri... more Cardiogoniometry (CGM) is a method of 3-dimensional electrocardiographic assessment which has primarily been investigated to evaluate its role in diagnosing patients with suspected coronary artery disease (CAD). Previous work has suggested it has considerable diagnostic ability at identifying patients with both stable CAD and those with acute coronary syndrome (ACS). However, previous studies which investigated the diagnostic performance of CGM in stable CAD did not use robust measures to accurately identify patients with physiologically significant coronary ischaemia. Furthermore, although the ability of CGM to identify specific lesions in stable CAD has been evaluated, to the best of our knowledge no research has been performed to assess the ability of CGM to detect the site of the culprit lesion in patients with non-ST elevation myocardial infarction. The first two studies of this thesis aim to address these two questions about the role of CGM in patients with CAD. Cardiac resynchronisation therapy (CRT) is a treatment used in patients with heart failure and left bundle branch block which attempts to restore synchronous contraction of the ventricles by pacing both the left and right ventricle together. Unfortunately, 25% of patients do not gain a clinical benefit from CRT, such patients are classed as 'nonresponders'. Many methods have been proposed to optimise CRT for 'non-responders', however, no specific optimisation method has yet been identified which significantly improves the long term benefit of CRT in non-responders. The detailed spatial and temporal information on cardiac electrical activity that CGM provides suggests that CGM may have a role in the optimisation of CRT. The aim of the third study in this thesis is to evaluate whether CGM can detect changes to CRT pacing settings, in view of developing a method of CRT optimisation using CGM.
Journal of the American College of Cardiology, Jul 1, 2014
To enhance value, an e-consult program in cardiology needs to provide both high-quality provider ... more To enhance value, an e-consult program in cardiology needs to provide both high-quality provider and patient satisfaction. In a preliminary pilot study, we have shown that offering an e-consult option in cardiology does not appear to increase overall total referral volume, with referring providers requesting e-consults in lieu of traditional visits. Furthermore, e-consults appear to be associated with high rates of satisfaction among both providers and patients. These preliminary findings from a single center should be interpreted with caution. A more definitive study would involve multiple sites; track visit volumes, total costs, and patient outcomes over a longer time period; and assess patient and physician experience and satisfaction in greater detail. This design would allow comparison of the saved cost of an avoided visit against the cost of any potential increase in testing.
Background: Ostial atherosclerotic lesions are distinct from other lesion sites in terms of outco... more Background: Ostial atherosclerotic lesions are distinct from other lesion sites in terms of outcomes following percutaneous interventions. Despite aggressive lesion modification strategies, long-term outcome is hampered by restenosis. Various stent designs have failed to show significant improvement in target lesion revascularization (TLR) rates. The present study evaluates the clinical outcomes following sirolimus-eluting stent implantation for ostial lesions. Materials and methods: The sirolimus-eluting stent (SES) was the device of choice at our institute for all coronary interventions from April 2002 to March 2003. This study population is comprised of 50 patients who received drug-eluting stents for atherosclerotic ostial lesions during this period. Sixty-eight percent of the patients were male and 24 patients (48%) had a history of previous revascularization. Indication for intervention were as follows: acute myocardial infarction, 7 patients (14%), stable angina, 23 patients (46%), unstable angina, 20 patients (40%). Angioplasty and stent implantations were done according to the standard protocol. All patients were prospectively followed up for major adverse cardiac events. The event-free survival was 90% at one year. There were 5 (10%) target vessel revascularization, 3 (6%) myocardial infarctions and 1 (2%) death during a mean follow-up of 414.5 +/- 54.5 days. TLR was required in 4 (8%) patients. Conclusions: SES implantation is feasible in ostial locations and is associated with low subsequent revascularization.
Physiological lesion assessment in the form of Fractional Flow Reserve (FFR) is now well establis... more Physiological lesion assessment in the form of Fractional Flow Reserve (FFR) is now well established for the purpose of guiding multi-vessel revascularization. Chronic total coronary occlusions are frequently associated with multi-vessel disease and the collateral dependent myocardium distal to the occlusion is often supplied by a collateral supply from another epicardial coronary artery. The haemodynamic effect of collateral donation upon collateral donor vessel flow may have important implications for the vessel's FFR; rendering it unreliable at predicting ischaemia should the CTO be revascularized. As a consequence, in the setting of multi-vessel disease, optimal revascularization strategy might be altered. There is a paucity of work in the medical literature directly examining this phenomenon. We endeavoured to review the existing literature related to it, to summarise from current knowledge of coronary physiology what is known about the potential effects of CTO revascularization on both collateral flow and collateral donor vessel physiology, and to highlight where further studies might inform practice.
Recurrent angina after percutaneous or surgical coronary procedures may occur as a consequence of... more Recurrent angina after percutaneous or surgical coronary procedures may occur as a consequence of several potential causes, such as bypass graft failure, restenosis, or atherosclerotic disease progression. Repeat invasive procedures are frequently performed for patients with recurrent symptoms. Nevertheless, non-invasive pharmacological treatment to decrease disease progression or reduce anginal symptoms are an integral part of the management of the patients. New metabolic modulators such as trimetazidine may constitute important therapeutic agents in the symptomatic control of patients with recurrent angina after invasive revascularization.
Background-The factors associated with the occurrence of restenosis after sirolimus-eluting stent... more Background-The factors associated with the occurrence of restenosis after sirolimus-eluting stent (SES) implantation in complex cases are currently unknown. Methods and Results-A cohort of consecutive complex patients treated with SES implantation was selected according to the following criteria: (1) treatment of acute myocardial infarction, (2) treatment of in-stent restenosis, (3) 2.25-mm diameter SES, (4) left main coronary stenting, (5) chronic total occlusion, (6) stented segment Ͼ36 mm, and (7) bifurcation stenting. The present study population was composed of 238 patients (441 lesions) for whom 6-month angiographic follow-up data were obtained (70% of eligible patients). Significant clinical, angiographic, and procedural predictors of post-SES restenosis were evaluated. Binary in-segment restenosis was diagnosed in 7.9% of lesions (6.3% in-stent, 0.9% at the proximal edge, 0.7% at the distal edge). The following characteristics were identified as independent multivariate predictors: treatment of in-stent restenosis (OR 4.16, 95% CI 1.63 to 11.01; PϽ0.01), ostial location (OR 4.84, 95% CI 1.81 to 12.07; PϽ0.01), diabetes (OR 2.63, 95% CI 1.14 to 6.31; Pϭ0.02), total stented length (per 10-mm increase; OR 1.42, 95% CI 1.21 to 1.68; PϽ0.01), reference diameter (per 1.0-mm increase; OR 0.46, 95% CI 0.24 to 0.87; Pϭ0.03), and left anterior descending artery (OR 0.30, 95% CI 0.10 to 0.69; PϽ0.01). Conclusions-Angiographic restenosis after SES implantation in complex patients is an infrequent event, occurring mainly in association with lesion-based characteristics and diabetes mellitus. (Circulation. 2004;109:1366-1370.
Chronic total occlusions (CTOs) are commonly found on diagnostic angiography, and there is some e... more Chronic total occlusions (CTOs) are commonly found on diagnostic angiography, and there is some evidence from one study that successful percutaneous revascularization leads to an improvement in long-term survival rates. However, this study included patients treated for unstable angina with short-duration occlusion, and stent implantation was utilized in only 7%. We re-evaluated the longterm outcomes of a large consecutive series of patients with a CTO of .1-month duration treated at our centre, with stent implantation utilized in the majority. Methods and results All patients treated with percutaneous coronary intervention (PCI) between 1992 and 2002 were retrospectively identified from a dedicated database. A total of 874 consecutive patients were treated for 885 CTO lesions. Mean follow-up time was 4.47 + 2.69 years (median 4.10 years). Patients were evaluated for the occurrence of major adverse cardiac events (MACE) comprising death, acute myocardial infarction, and need for repeat revascularization with either coronary artery bypass surgery or PCI. Successful revascularization was achieved in 576 lesions (65.1%), in which stent implantation was used in 81.0%. At 30 days, the overall MACE rate was significantly lower in those patients with a successful recanalization (5.5 vs. 14.8%, P , 0.00001). At 5 years, survival was significantly higher in those patients with a successful revascularization (93.5 vs. 88.0%, P ¼ 0.02). In addition, there was a significantly higher survival free of MACE (63.7 vs. 41.7%, P , 0.0001), with the majority of events reflecting the need for repeat intervention. Independent predictors for survival were successful revascularization, lower age, and the absence of diabetes mellitus and multivessel disease. Conclusion Successful percutaneous revascularization of a CTO leads to a significantly improved survival rate and a reduction in major adverse events at 5 years. Most events relate to the need for repeat reintervention, and the introduction of drug-eluting stents, with low-restenosis rates, encourages the development of technologies to improve recanalization success rates. However, failed recanalization may be associated acutely with an adverse event, and new technologies must focus on a safe approach to successful recanalization.
Study Question: To compare coronary stent implantation and bypass surgery for multivessel coronar... more Study Question: To compare coronary stent implantation and bypass surgery for multivessel coronary disease in patients with renal insufficiency. Methods: The Arterial Revascularization Therapies Study (ARTS) trial was a randomized analysis comparing CABG and coronary stenting for the treatment of patients with multivessel coronary artery disease. In the ARTS trial, 142 moderate renal-insufficient patients (Ccr Ͻ 60 mL/min) with multivessel coronary disease were randomly assigned either to stent implantation (nϭ69) or CABG (nϭ73). The primary end point was defined as the absence of any of the following major adverse cardiac and cerebrovascular events (MACCE) within 5 years after randomization: death cerebrovascular accident (CVA), documented nonfatal MI adjudicated by either new abnormal Q wave or predefined enzymatic changes, or repeat revascularization by coronary stenting or CABG. Results: At 5 years, there was no significant difference between the two groups in terms of mortality (14.5% in the stent group vs. 12.3% in the CABG group; pϭ0.81), or combined end point of death, CVA, or MI (30.4% in the stent group vs. 23.3% in the CABG group; pϭ0.35). Among patients who survived without CVA or MI, 18.8% in the stent group underwent a second revascularization procedure when compared with 8.2% in the surgery group (pϭ0.08). The event-free survival at 5 years was 50.7% in the stent group and 68.5% in the surgery group (pϭ0.04). Conclusions: The researchers concluded that at 5 years, the differences in mortality and combined incidence of death, CVA, and MI between coronary stenting and surgery did not reach statistically significant level in patients with renal insufficiency. Perspective: In this 142-patient prospective cohort with moderate renal-insufficiency (Ccr Ͻ60 mL/min), the difference in 5-year mortality and combined incidence of death, CVA, and MI between coronary stent and surgery did not reach a statistically significant level, although the actual event rates in the stent group were higher than in the CABG group. The occurrence of MACCE in the stent group was statistically higher than in the CABG group, mainly due to the higher incidence of repeat revascularization in the stent group. However, the difference of MACCE rate between the stent and the CABG in the Ccr Ͻ60 mL/min group was similar as compared to the Ccr Ն60 mL/min group. It remains to be seen whether drug-eluting stents will consistently reduce restenosis rates in patients with renal insufficiency. Debabrata Mukherjee
Chronic total occlusion of the left main coronary artery (LMCA) is rare. Recently, percutaneous c... more Chronic total occlusion of the left main coronary artery (LMCA) is rare. Recently, percutaneous coronary intervention has been increasingly applied to unprotected LMCA lesions. We describe a patient with chronic total occlusion of the LMCA who was successfully treated with bifurcation stenting with sirolimus-eluting stents.
International Journal of Cardiovascular Interventions, Jun 1, 2005
To assess the safety and efficacy of the implantation of Paclitaxel Eluting Stents (PES) for de n... more To assess the safety and efficacy of the implantation of Paclitaxel Eluting Stents (PES) for de novo, non-flow limiting lesions. We assessed the 12-month occurrence of major adverse cardiac events (MACE) in 21 patients (4% of the total population treated in a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;real world&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; registry) with 22 non-significant coronary narrowings treated with PES. The following criteria had to be met: (1) the lesion was de novo; (2) the location was non-ostial, and not a bifurcation lesion; (3) the diameter stenosis by quantitative coronary angiography (QCA) was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50%; (4) there was no visible thrombus and (5) the lesion was not located in an angiographically diffusely diseased segment. Procedural success rate was 100% without any periprocedural myocardial infarction. After a mean follow-up of 407.33+/-53 (range: 344-498) days the overall MACE-free survival was 95.2%. Freedom from target revascularization was 95.2%. The result of this non-randomized observational study suggests that the implantation of PES for de novo, non-significant lesions appears most probably safe and effective.
; for the ISCHEMIA Research Group IMPORTANCE While many features of stable ischemic heart disease... more ; for the ISCHEMIA Research Group IMPORTANCE While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. OBJECTIVE To describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. INTERVENTIONS CCTA and angina assessment. MAIN OUTCOMES AND MEASURES Sex differences in stress test, CCTA findings, and symptom severity. RESULTS Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA) (352 of 1022 [34.4%] vs 378 of 3353 [11.3%]). Of individuals who were randomized, women had more angina at baseline than men (median [interquartile range] Seattle Angina Questionnaire Angina Frequency score: 80 [70-100] vs 90 [70-100]). Women had less severe ischemia on stress imaging (383 of 919 [41.7%] vs 1363 of 2972 [45.9%] with severe ischemia; 386 of 919 [42.0%] vs 1215 of 2972 [40.9%] with moderate ischemia; and 150 of 919 [16.3%] vs 394 of 2972 [13.3%] with mild or no ischemia). Ischemia was similar by sex on exercise tolerance testing. Women had less extensive CAD on CCTA (205 of 568 women [36%] vs 1142 of 2418 men [47%] with 3-vessel disease; 184 of 568 women [32%] vs 754 of 2418 men [31%] with 2-vessel disease; and 178 of 568 women [31%] vs 519 of 2418 men [22%] with 1-vessel disease). Female sex was independently associated with greater angina frequency (odds ratio, 1.41; 95% CI, 1.13-1.76). CONCLUSIONS AND RELEVANCE Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease.
IntroductionNo-reflow (NR) phenomenon is characterised by the failure of myocardial reperfusion d... more IntroductionNo-reflow (NR) phenomenon is characterised by the failure of myocardial reperfusion despite the absence of mechanical coronary obstruction. NR negatively affects patient outcomes, emphasising the importance of prediction and management. The objective was to evaluate the incidence and independent predictors of NR in patients presenting with ST-elevation myocardial infarction (STEMI).MethodsThis was a single-centre prospective case–control study. Cases were subjects who suffered NR, and the control comparators were those who did not. Clinical outcomes were documented. Salient variables relating to the patients and their presentation, history and angiographical findings were compared using one-way analysis of variance or χ2 test. Multiple regression determined the independent predictors, and a risk score was established based on the β coefficient.ResultsOf 173 consecutive patients, 24 (13.9%) suffered from NR, with 46% occurring post stent implantation. Patients with NR had...
Journal of the American College of Cardiology, 2020
Background: Sex differences in ischemia, coronary anatomy and symptoms have not been investigated... more Background: Sex differences in ischemia, coronary anatomy and symptoms have not been investigated among patients who have moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary CT angiography (CCTA) was required to have obstructive CAD to undergo randomization. We describe sex differences in stress testing and CCTA findings as well as symptoms in the ISCHEMIA trial. Methods: ISCHEMIA enrolled patients based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most participants. Stress tests and CCTAs were reviewed at core laboratories. Those with no obstructive coronary artery disease (CAD) or with left main CAD >50% were excluded. Angina was assessed using the Seattle Angina Questionnaire (SAQ). Results: Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA), 34% versus 11%, p<0.001, resulting in more women excluded after enrollment. Randomized women (n=1168) had more angina at baseline than randomized men (n=4011), despite less extensive CAD on CCTA and less severe ischemia in women vs. men with stress imaging (Figure). Conclusion: Women randomized in the ISCHEMIA trial had more frequent angina despite less extensive CAD and less ischemia than men. Our findings likely reflect inherent sex differences in the complex relationships between angina, atherosclerosis and ischemia that may have implications for testing and treatment of patients with suspected ischemic heart disease.
scores have a comparable safety profile, they identify a significantly lower proportion of patien... more scores have a comparable safety profile, they identify a significantly lower proportion of patients as low risk.
1, 5, and 10, and after 40 weeks adjusted for the gestational age in preterm LBW infants. Blood p... more 1, 5, and 10, and after 40 weeks adjusted for the gestational age in preterm LBW infants. Blood pressure was measured at each visit using Welch Allyn VSMTM 300 monitor. Results At birth, the NBW infants had significantly lower BCD (difference À9.3 cap/area, 95% CI: À1.5 to À17.1, p=0.021) and MCD (difference À12.6 cap/area, 95% CI: À1.5 to À21.7, p=0.025) compared to the LBW infants. LBW oxygen group had a significantly lower SBP (mean difference À9.5 mmHg, 95% CI: À1 to À19, p=0.047), DBP (difference À13 mmHg, 95% CI: À4 to À22, p=0.009). At 40 weeks old, the LBW oxygen group showed a significant reduction in BCD (difference À19.3 cap/area, 95% CI: À9 to À30, p=0.003) and MCD (difference À22 cap/area, 95% CI: À8 to À36 p=0.007). Similarly the LBW non-oxygen group had a significant reduction in BCD (difference À29 cap/area, 95% CI À17 to À41 p<0.0001) and MCD (mean difference À29 cap/area, 95% CI, À16 to À41 p<0.001). Both LBW groups showed a significant rise in BP. The rise in SBP (mean difference 24 mmHg, 95% CI: 14-34, p<0.0001) and DBP (mean difference 14 mmHg, 95% CI: 7-22, p<0.001) was more pronounced in LBW oxygen group compared to the LBW control group (difference 14 mmHg, 95% CI: 0.5-27, p=0.043 and difference 9 mmHg, 0.3-19, p=0.056 respectively) Conclusions We confirm that LBW infants have higher capillary density at birth but develop significant capillary rarefaction and increase in their blood pressure at 40 weeks compared to NBW infants. Oxygen therapy in the neonatal period in LBW infants was associated with higher blood pressure levels but we could not detect any effect on capillary rarefaction. Further studies are needed to investigate the humoral factors that trigger the changes of microcirculation in LBW infants during the neonatal period which may be of importance in preventing hypertension in later life.
Journal of the American College of Cardiology, 2017
2. Hirsch A, Windhausen F, Tijssen JG, et al. Diverging associations of an intended early invasiv... more 2. Hirsch A, Windhausen F, Tijssen JG, et al. Diverging associations of an intended early invasive strategy compared with actual revascularization, and outcome in patients with non-ST-segment elevation acute coronary syndrome: the problem of treatment selection bias. Eur Heart J 2009;30:645-54. 3. Damman P, Wallentin L, Fox KA, et al. Long-term cardiovascular mortality after procedure-related or spontaneous myocardial infarction in patients with non-ST-segment elevation acute coronary syndrome: a collaborative analysis of individual patient data from the FRISC II, ICTUS, and RITA-3 trials (FIR).
Cardiogoniometry (CGM) is a method of 3-dimensional electrocardiographic assessment which has pri... more Cardiogoniometry (CGM) is a method of 3-dimensional electrocardiographic assessment which has primarily been investigated to evaluate its role in diagnosing patients with suspected coronary artery disease (CAD). Previous work has suggested it has considerable diagnostic ability at identifying patients with both stable CAD and those with acute coronary syndrome (ACS). However, previous studies which investigated the diagnostic performance of CGM in stable CAD did not use robust measures to accurately identify patients with physiologically significant coronary ischaemia. Furthermore, although the ability of CGM to identify specific lesions in stable CAD has been evaluated, to the best of our knowledge no research has been performed to assess the ability of CGM to detect the site of the culprit lesion in patients with non-ST elevation myocardial infarction. The first two studies of this thesis aim to address these two questions about the role of CGM in patients with CAD. Cardiac resynchronisation therapy (CRT) is a treatment used in patients with heart failure and left bundle branch block which attempts to restore synchronous contraction of the ventricles by pacing both the left and right ventricle together. Unfortunately, 25% of patients do not gain a clinical benefit from CRT, such patients are classed as 'nonresponders'. Many methods have been proposed to optimise CRT for 'non-responders', however, no specific optimisation method has yet been identified which significantly improves the long term benefit of CRT in non-responders. The detailed spatial and temporal information on cardiac electrical activity that CGM provides suggests that CGM may have a role in the optimisation of CRT. The aim of the third study in this thesis is to evaluate whether CGM can detect changes to CRT pacing settings, in view of developing a method of CRT optimisation using CGM.
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Papers by Angela Hoye