Background Coronar y arter y disease (CAD) frequently coexists with severe aortic valve stenosis ... more Background Coronar y arter y disease (CAD) frequently coexists with severe aortic valve stenosis (AS) in patients planned for transcatheter aortic valve implantation (TAVI). How to manage CAD in this patient population is still an unresolved question. In particular, it is still not known whether fractional flow reserve (FFR) guided revascularization with percutaneous coronar y inter vention (PCI) is superior to medical treatment for CAD in terms of clinical outcomes. Study design The third Nordic Aortic Valve Intervention (NOTION-3) Trial is an open-label investigator-initiated, multicenter multinational trial planned to randomize 452 patients with severe AS and significant CAD to either FFR-guided PCI or medical treatment, in addition to TAVI. Patients are eligible for the study in the presence of at least 1 significant PCI-eligible coronary stenosis. A significant stenosis is defined as either FFR ≤0.80 and/or diameter stenosis > 90%. The primary end point is a composite of first occurring all-cause mortality, myocardial infarction, or urgent revascularization (PCI or coronar y arter y bypass graft performed during unplanned hospital admission) until the last included patient have been followed for 1 year after the TAVI. Summary NOTION-3 is a multicenter, multinational randomized trial aiming at comparing FFR-guided revascularization vs medical treatment of CAD in patients with severe AS planned for TAVI.
Nitric oxide (NO), formed by endothelial constitutive nitric oxide synthase (eNOS) maintains endo... more Nitric oxide (NO), formed by endothelial constitutive nitric oxide synthase (eNOS) maintains endothelium-dependent vasodilatation and also mediates antithrombotic actions. The eNOS gene harbours a common polymorphism in intron 4 (4a/b), and some clinical studies have suggested an association of the rare a-allele with coronary artery disease (CAD) and myocardial infarction (MI). However, contradictory results have also been reported. We studied associations of eNOS polymorphism with CAD and MI in two prospective autopsy series comprising altogether 700 Caucasian Finnish men, who died suddenly. In ANCOVA, no significant differences in areas of atherosclerotic lesions and coronary stenosis percentages were found between men carrying the a-allele (ba+aa) compared with those homozygous for the b-allele. Subjects with the a-allele had significantly lower risk of MI (odds ratio 0.44, 95% confidence interval 0.25-0.77, P=0.004) compared with those carrying the bb genotype. Men with the a-allele also tended to have coronary thrombosis less often (odds ratio 0.43, 95% confidence interval 0.18-1.01, P=0.055). The eNOS gene 4a/b polymorphism was not associated with the extent of coronary atherosclerosis, but the a-allele of the variant seems to protect to some degree against the development of MI.
In vivo morphologic comparison of Saphenous vein grafts and native coronary arteries following no... more In vivo morphologic comparison of Saphenous vein grafts and native coronary arteries following non-ST elevation myocardial infarction. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Carrev(2018),
Background and Aims: according to the heterogeneous results of previous studies, the prevalence o... more Background and Aims: according to the heterogeneous results of previous studies, the prevalence of abdominal aortic aneurysm seems high among men with coronary artery disease. the associating risk factors for abdominal aortic aneurysm in this population require clarification. our objective was to assess the prevalence of non-diagnosed abdominal aortic aneurysms in men with angiographically verified coronary artery disease and to document the associated co-morbidities and risk factors. Material and Methods: altogether, 407 men with coronary artery disease were screened after invasive coronary angiography in two series at independent centers. risk factor data were recorded and analyzed. Results and Conclusion: the mean age of the study cohort was 70.0 years (standard deviation: 11.0). the prevalence of previously undiagnosed abdominal aortic aneurysms in the whole screened population of 407 men was 6.1% (n = 25/407). in a multivariate analysis of the whole study population, the only significant risk factors for abdominal aortic aneurysm were age (odds ratio: 1.04, 95% confidence interval: 1.00-1.09) and history of smoking (odds ratio: 3.13, 95% confidence interval: 1.26-7.80). non-smokers with abdominal aortic aneurysm were significantly older than smokers (mean age: 80.7 (standard deviation: 8.0) vs 68.0 (standard deviation: 11.1), p = 0.003), and age was a significant risk factor only among non-smokers (p = 0.011; p = 0.018 for interaction). among smokers, the prevalence of abdominal aortic aneurysm was 8.8%, and 72% (n = 18/25) of all diagnosed abdominal aortic aneurysm patients were smokers. Prevalence of undiagnosed abdominal
Journal of the American College of Cardiology, Oct 1, 2015
frequently presented with ST-elevation myocardial infarction (STEMI; 45.7%, 40.0%, 22.9%, p¼0.030... more frequently presented with ST-elevation myocardial infarction (STEMI; 45.7%, 40.0%, 22.9%, p¼0.030) and with TIMI flow <3 (32.9%, 20.0%, 17.1%, p¼0.042). According to the ratio of upstream and downstream RG, 69.5% of lesions were classified as upstreamdominant lesions and 30.5%, as downstream-dominant lesions. Among the 66 upstream-dominant lesions, 65 cases (98.5%) had upstream rupture and the RG ratio (RGupstream/RGdownstream) was an independent predictor for upstream rupture (OR 1.481, 95% CI 1.035-2.120, p¼0.032). Upstream-dominant lesions more frequently presented with STEMI than downstream-dominant lesions (48.5% vs. 24.1%, p¼0.026). In the idealized model and CFD analysis, axial plaque stress in the upstream segment was higher than in the downstream segment (10,968 dyne/cm2 vs. 5,651 dyne/ cm 2) in upstream-dominant lesions. The inverse was also true for downstream-dominant lesions (7,667 dyne/cm2 vs. 12,312 dyne/ cm 2). CONCLUSIONS Both clinical presentation and degree of flow limitation were associated with the location of plaque rupture. Longitudinal lesion asymmetry assessed by RG, which can affect regional distribution of hemodynamic stress, was associated with the location of rupture as well as clinical presentation.
Introduction: The role of endothelial shear stress (ESS) in the natural history of plaque growth ... more Introduction: The role of endothelial shear stress (ESS) in the natural history of plaque growth and TCFA formation/destabilization has been studied, but the role in plaque erosion is unknown. High ESS gradient (ESSG) has been hypothesized to promote plaque erosion, but no studies have included matched “control” stable plaques with the same minimal luminal area (MLA) and reference luminal area (RLA) but no adverse coronary event. Hypothesis: To compare ESS and ESSG between coronary plaques that developed erosion and similar morphology plaques that remain stable. Methods: We studied a subset of patients from both TOTAL and COMPLETE trials who underwent angiography and OCT evaluation: 27 patients (27 arteries: 18 LAD, 3 LCX, 6 RCA). Plaques were divided into Plaque Erosion (n=16) from TOTAL study with OCT features of plaque erosion and Control (n=11) plaques (non-culprit lesions from COMPLETE) with matched MLA and RLA and no OCT evidence of plaque disruption. Orthogonal angiographic v...
Pulmonary arteriovenous malformations are rare, mostly asymptomatic vascular anomalies. These mal... more Pulmonary arteriovenous malformations are rare, mostly asymptomatic vascular anomalies. These malformations cause direct right to left shunting of unoxygenated blood, resulting chronically in cyanosis, dyspnea, and exercise intolerance. The serious complications reported earlier have mainly been neurologic, for example, cerebrovascular accidents and brain abscesses and are most likely caused by paradoxical embolism. Detection of pulmonary arteriovenous malformations is challenging, and the emergency department personnel play an essential role. Once suspected, the diagnosis can be made promptly using standard imaging techniques and appropriate treatment may prevent serious complications. In this report, we describe a case of a 41-year-old man with acute anterior myocardial infarction, unexpectedly caused by emboli from pulmonary arteriovenous malformations. This rare etiology of acute myocardial infarction should be taken into consideration especially in cases with atypical presentation.
Journal of the American College of Cardiology, Oct 1, 2015
BACKGROUND Several clinical trials have indicated the advantage of everolimus-eluting cobalt chro... more BACKGROUND Several clinical trials have indicated the advantage of everolimus-eluting cobalt chromium stents (EES) for the treatment of stable coronary artery disease (CAD), proposing its safety profile so as to shorten the duration of dual anti-platelet (DAPT) up to three months. However, the early vascular reactions during this period and underlying mechanisms remains unclear.
Background Analysis of intracoronary thrombus type by optical coherence tomography (OCT) imaging ... more Background Analysis of intracoronary thrombus type by optical coherence tomography (OCT) imaging is highly subjective. We aimed to compare a newly developed image analysis method to subjective visual classification of thrombus type identified by OCT. Methods Thirty patients with acute ST elevation myocardial infarction were included. Thrombus type visually classified by two independent readers was compared with analysis using QCU-CMS software. Results Repeatability of the computer-based measurements was good. By using a ROC, area under curve values for discrimination of white and red thrombi were 0.92 (95% confidence intervals (CI) 0.83-1.00) for median attenuation, 0.96 (95% CI 0.89-1.00) for mean backscatter and 0.96 (95% CI 0.89-1.00) for mean grayscale intensity. Median attenuation of 0.57 mm-1 (sensitivity 100%, specificity 71%), mean backscatter of 5.35 (sensitivity 92%, specificity 94%) and mean grayscale intensity of 120.1 (sensitivity 85%, specificity 100%) were identified as the best cutoff values to differentiate between red and white thrombi. Conclusions Attenuation, backscatter and grayscale intensity of thrombi in OCT images differentiated red and white thrombi with high sensitivity and specificity. Measurement of these continuous parameters can be used as a less user-dependent method to characterize in vivo thrombi. The clinical significance of these findings needs to be tested in further studies.
Background Percutaneous coronary intervention in complex bifurcation lesions is prone to suboptim... more Background Percutaneous coronary intervention in complex bifurcation lesions is prone to suboptimal implantation results and is associated with increased risk of subsequent clinical events. Angiographic ambiguity is high during bifurcation stenting, but it is unknown if procedural guidance by intravascular optical coherence tomography (OCT) improves clinical outcome. Methods and design OCTOBER is a randomized, investigator-initiated, multicenter trial aimed to show superiority of OCT-guided stent implantation compared to standard angiographic-guided implantation in bifurcation lesions. The primary outcome measure is a 2-year composite end point of cardiac death, target lesion myocardial infarction, and ischemia-driven target lesion revascularization. The calculated sample size is 1,200 patients in total, and allocation is 1:1. Eligible patients have stable or unstable angina pectoris or stabilized non-ST elevation myocardial infarction, and a coronary bifurcation lesion with significant main vessel stenosis and more than 50 % stenosis in a side branch with a reference diameter ≥2.5mm. Treatment is performed by the provisional side branch stenting technique or 2-stent techniques, and the systematic OCT guiding protocol is aimed to evaluate (1) plaque preparation, (2) lesion length, (3) segmental reference sizes, (4) lesion coverage, (5) stent expansion, (6) malapposition, (7) wire positions, and (8) ostial results. Implications A positive outcome of the OCTOBER trial may establish OCT as a routine tool for optimization of complex percutaneous coronary intervention, whereas a negative result would indicate that OCT remains a tool for ad hoc evaluation in selected cases.
coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main... more coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial.
European Heart Journal - Quality of Care and Clinical Outcomes, 2016
The aim of this study was to investigate the incidence of permanent working disability (PWD) in y... more The aim of this study was to investigate the incidence of permanent working disability (PWD) in young patients after percutaneous or surgical coronary revascularization. Methods and results The study included 1035 consecutive patients ≤50 years old who underwent coronary revascularization [910 and 125 patients in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups, respectively] between 2002 and 2012 at 4 Finnish hospitals. The median follow-up time was 41 months. The overall incidence of PWD was higher after CABG compared to PCI (at 5 years, 34.8 vs. 14.7%, P , 0.001). Freedom from PWD in the general population aged 45 was 97.2% at 4 years follow-up. Median time to grant disability pension was 11.6 months after CABG and 24.4 months after PCI (P ¼ 0.018). Reasons for PWD were classified as cardiac (35.3 vs. 36.9%), psychiatric (14.7 vs. 14.6%), and musculoskeletal (14.7 vs. 15.5%) in patients undergoing CABG vs. PCI. Overall freedom from PWD was higher in patients without major adverse cardiac and cerebrovascular event (MACCE) (at 5 years, 85.6 vs. 71.9%, P , 0.001). Nevertheless, rate of PWD was high also in patients without MACCE and patients with preserved ejection fraction during follow-up. Conclusions Although coronary revascularization confers good overall survival in young patients, PWD is common especially after CABG and mostly for cardiac reasons even without occurrence of MACCE. Supportive measures to preserve occupational health are warranted concomitantly with coronary revascularization at all levels of health care.
Aims: Our aim was to compare stenosis severity and plaque content between STEMI culprit lesions w... more Aims: Our aim was to compare stenosis severity and plaque content between STEMI culprit lesions with intact fibrous cap (IFC) and those with plaque rupture (PR) in a prospective study. Methods and results: We evaluated 93 patients undergoing OCT and thrombectomy as part of a prospective substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial. Culprit lesion morphology was assessable by OCT in 70/93 (75.3%). IFC was found in 31 (44.3%), PR in 34 (48.6%) and calcified nodule in five (7.1%) patients. Following thrombectomy, OCT demonstrated similar lumen area stenosis in IFC (79.3%) and PR (79.6%) (p=0.88). Lumen area stenosis <50% was observed in none of the patients with PR and in one patient with IFC. IFC had fewer quadrants with lipid plaque as compared to PR (28.16±15.02 vs. 39.12±14.23, p=0.004). However, in both lesion types, lipid was the predominant plaque type (83.9 vs. 63.7% of diseased quadrants). Conclusions: In a prospective study of STEMI patients treated with thrombectomy, mild residual stenoses were uncommon in IFC lesions. Although lipid content was lower than in PR lesions, lipid composed the majority of the diseased segments in IFC.
Incomplete strut coverage has been documented an important histopathologic morphometric predictor... more Incomplete strut coverage has been documented an important histopathologic morphometric predictor for later thrombotic events. This study sought to investigate whether optical coherence tomography (OCT)-guided percutaneous coronary intervention with Nobori biolimus-eluting stent implantation in patients with non-ST-segment-elevation myocardial infarction would provide improved strut coverage at 6 months in comparison with angiographic guidance only. One hundred patients were randomized 1:1 to either OCT-guided or angio-guided Nobori biolimus-eluting stent implantation. Postprocedure OCT was performed in all patients. In the OCT-guided group, prespecified criteria indicating additional intervention were related to (1) stent underexpansion, (2) strut malapposition, (3) edge dissection(s), and (4) residual stenosis at the distal or proximal reference segment(s). A final OCT was performed in case of reintervention. Six-month OCT follow-up was available in 85 patients. Twenty-three (46%)...
Scandinavian Journal of Work, Environment & Health, 2015
Long-term working capacity in young coronary artery disease patients under 50 years of age has no... more Long-term working capacity in young coronary artery disease patients under 50 years of age has not been previously published. This is a socioeconomically important population with potentially decades of working life ahead.
Manual thrombectomy has been proposed as a strategy to reduce thrombus burden during primary perc... more Manual thrombectomy has been proposed as a strategy to reduce thrombus burden during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, the effectiveness of manual thrombectomy in reducing thrombus burden is uncertain. In this substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial, we compared the thrombus burden at the culprit lesion using optical coherence tomography (OCT) in patients treated with thrombectomy vs. PCI-alone. The TOTAL trial (N = 10 732) was an international, multicentre, randomized trial of thrombectomy (using the Export catheter, Medtronic Cardiovascular, Santa Rosa, CA, USA) in STEMI patients treated with primary PCI. The OCT substudy prospectively enrolled 214 patients from 13 sites in 5 countries. Optical coherence tomography was performed immediately after thrombectomy or PCI-alone and then repeated after stent deployment. Thrombus quantification was performed by an independent c...
Data on the outcome of young patients after coronary artery bypass grafting (CABG) and percutaneo... more Data on the outcome of young patients after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are scarce. Data on 2209 consecutive patients≤50 years old who underwent CABG or PCI were retrospectively collected from 15 European institutions. PCI and CABG had similar 30-day mortality (0.8% vs. 1.4%, p=0.27), late survival (at 5 years, 97.8% vs. 94.9%, p=0.082) and freedom from stroke (at 5 years, 98.0% and 98.0%, p=0.731). PCI was associated with significantly lower freedom from major adverse cardiac and cerebrovascular events (MACCE) (at 5 years, 73.9% vs. 85.0%, p<0.0001), repeat revascularization (at 5 years, 77.6% vs. 92.5%, p<0.0001) and myocardial infarction (at 5 years 89.9% vs. 96.6%, p<0.0001) compared with CABG. These findings were confirmed in propensity score adjusted and matching analyses. Freedom from MACCE after PCI was particularly low among diabetics (at 5 years, 58.0% vs. 75.9%, p<0.0001) and in patients with multivessel disease (at 5 years, 63.6% vs. 85.1%, p<0.0001). PCI in patients with ST elevation myocardial infarction was associated with significantly better 5 years survival (97.5% vs. 88.8%, p=0.001), which was driven by its lower 30-day mortality (1.5% vs. 6.0%, p=0.017). In conclusion, patients ≤ 50 years old have an excellent immediate outcome after either PCI or CABG with similar long-term survival when used according to the current clinical practice. PCI was associated with significantly lower freedom from myocardial infarction and repeat revascularization.
Background Coronar y arter y disease (CAD) frequently coexists with severe aortic valve stenosis ... more Background Coronar y arter y disease (CAD) frequently coexists with severe aortic valve stenosis (AS) in patients planned for transcatheter aortic valve implantation (TAVI). How to manage CAD in this patient population is still an unresolved question. In particular, it is still not known whether fractional flow reserve (FFR) guided revascularization with percutaneous coronar y inter vention (PCI) is superior to medical treatment for CAD in terms of clinical outcomes. Study design The third Nordic Aortic Valve Intervention (NOTION-3) Trial is an open-label investigator-initiated, multicenter multinational trial planned to randomize 452 patients with severe AS and significant CAD to either FFR-guided PCI or medical treatment, in addition to TAVI. Patients are eligible for the study in the presence of at least 1 significant PCI-eligible coronary stenosis. A significant stenosis is defined as either FFR ≤0.80 and/or diameter stenosis > 90%. The primary end point is a composite of first occurring all-cause mortality, myocardial infarction, or urgent revascularization (PCI or coronar y arter y bypass graft performed during unplanned hospital admission) until the last included patient have been followed for 1 year after the TAVI. Summary NOTION-3 is a multicenter, multinational randomized trial aiming at comparing FFR-guided revascularization vs medical treatment of CAD in patients with severe AS planned for TAVI.
Nitric oxide (NO), formed by endothelial constitutive nitric oxide synthase (eNOS) maintains endo... more Nitric oxide (NO), formed by endothelial constitutive nitric oxide synthase (eNOS) maintains endothelium-dependent vasodilatation and also mediates antithrombotic actions. The eNOS gene harbours a common polymorphism in intron 4 (4a/b), and some clinical studies have suggested an association of the rare a-allele with coronary artery disease (CAD) and myocardial infarction (MI). However, contradictory results have also been reported. We studied associations of eNOS polymorphism with CAD and MI in two prospective autopsy series comprising altogether 700 Caucasian Finnish men, who died suddenly. In ANCOVA, no significant differences in areas of atherosclerotic lesions and coronary stenosis percentages were found between men carrying the a-allele (ba+aa) compared with those homozygous for the b-allele. Subjects with the a-allele had significantly lower risk of MI (odds ratio 0.44, 95% confidence interval 0.25-0.77, P=0.004) compared with those carrying the bb genotype. Men with the a-allele also tended to have coronary thrombosis less often (odds ratio 0.43, 95% confidence interval 0.18-1.01, P=0.055). The eNOS gene 4a/b polymorphism was not associated with the extent of coronary atherosclerosis, but the a-allele of the variant seems to protect to some degree against the development of MI.
In vivo morphologic comparison of Saphenous vein grafts and native coronary arteries following no... more In vivo morphologic comparison of Saphenous vein grafts and native coronary arteries following non-ST elevation myocardial infarction. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Carrev(2018),
Background and Aims: according to the heterogeneous results of previous studies, the prevalence o... more Background and Aims: according to the heterogeneous results of previous studies, the prevalence of abdominal aortic aneurysm seems high among men with coronary artery disease. the associating risk factors for abdominal aortic aneurysm in this population require clarification. our objective was to assess the prevalence of non-diagnosed abdominal aortic aneurysms in men with angiographically verified coronary artery disease and to document the associated co-morbidities and risk factors. Material and Methods: altogether, 407 men with coronary artery disease were screened after invasive coronary angiography in two series at independent centers. risk factor data were recorded and analyzed. Results and Conclusion: the mean age of the study cohort was 70.0 years (standard deviation: 11.0). the prevalence of previously undiagnosed abdominal aortic aneurysms in the whole screened population of 407 men was 6.1% (n = 25/407). in a multivariate analysis of the whole study population, the only significant risk factors for abdominal aortic aneurysm were age (odds ratio: 1.04, 95% confidence interval: 1.00-1.09) and history of smoking (odds ratio: 3.13, 95% confidence interval: 1.26-7.80). non-smokers with abdominal aortic aneurysm were significantly older than smokers (mean age: 80.7 (standard deviation: 8.0) vs 68.0 (standard deviation: 11.1), p = 0.003), and age was a significant risk factor only among non-smokers (p = 0.011; p = 0.018 for interaction). among smokers, the prevalence of abdominal aortic aneurysm was 8.8%, and 72% (n = 18/25) of all diagnosed abdominal aortic aneurysm patients were smokers. Prevalence of undiagnosed abdominal
Journal of the American College of Cardiology, Oct 1, 2015
frequently presented with ST-elevation myocardial infarction (STEMI; 45.7%, 40.0%, 22.9%, p¼0.030... more frequently presented with ST-elevation myocardial infarction (STEMI; 45.7%, 40.0%, 22.9%, p¼0.030) and with TIMI flow <3 (32.9%, 20.0%, 17.1%, p¼0.042). According to the ratio of upstream and downstream RG, 69.5% of lesions were classified as upstreamdominant lesions and 30.5%, as downstream-dominant lesions. Among the 66 upstream-dominant lesions, 65 cases (98.5%) had upstream rupture and the RG ratio (RGupstream/RGdownstream) was an independent predictor for upstream rupture (OR 1.481, 95% CI 1.035-2.120, p¼0.032). Upstream-dominant lesions more frequently presented with STEMI than downstream-dominant lesions (48.5% vs. 24.1%, p¼0.026). In the idealized model and CFD analysis, axial plaque stress in the upstream segment was higher than in the downstream segment (10,968 dyne/cm2 vs. 5,651 dyne/ cm 2) in upstream-dominant lesions. The inverse was also true for downstream-dominant lesions (7,667 dyne/cm2 vs. 12,312 dyne/ cm 2). CONCLUSIONS Both clinical presentation and degree of flow limitation were associated with the location of plaque rupture. Longitudinal lesion asymmetry assessed by RG, which can affect regional distribution of hemodynamic stress, was associated with the location of rupture as well as clinical presentation.
Introduction: The role of endothelial shear stress (ESS) in the natural history of plaque growth ... more Introduction: The role of endothelial shear stress (ESS) in the natural history of plaque growth and TCFA formation/destabilization has been studied, but the role in plaque erosion is unknown. High ESS gradient (ESSG) has been hypothesized to promote plaque erosion, but no studies have included matched “control” stable plaques with the same minimal luminal area (MLA) and reference luminal area (RLA) but no adverse coronary event. Hypothesis: To compare ESS and ESSG between coronary plaques that developed erosion and similar morphology plaques that remain stable. Methods: We studied a subset of patients from both TOTAL and COMPLETE trials who underwent angiography and OCT evaluation: 27 patients (27 arteries: 18 LAD, 3 LCX, 6 RCA). Plaques were divided into Plaque Erosion (n=16) from TOTAL study with OCT features of plaque erosion and Control (n=11) plaques (non-culprit lesions from COMPLETE) with matched MLA and RLA and no OCT evidence of plaque disruption. Orthogonal angiographic v...
Pulmonary arteriovenous malformations are rare, mostly asymptomatic vascular anomalies. These mal... more Pulmonary arteriovenous malformations are rare, mostly asymptomatic vascular anomalies. These malformations cause direct right to left shunting of unoxygenated blood, resulting chronically in cyanosis, dyspnea, and exercise intolerance. The serious complications reported earlier have mainly been neurologic, for example, cerebrovascular accidents and brain abscesses and are most likely caused by paradoxical embolism. Detection of pulmonary arteriovenous malformations is challenging, and the emergency department personnel play an essential role. Once suspected, the diagnosis can be made promptly using standard imaging techniques and appropriate treatment may prevent serious complications. In this report, we describe a case of a 41-year-old man with acute anterior myocardial infarction, unexpectedly caused by emboli from pulmonary arteriovenous malformations. This rare etiology of acute myocardial infarction should be taken into consideration especially in cases with atypical presentation.
Journal of the American College of Cardiology, Oct 1, 2015
BACKGROUND Several clinical trials have indicated the advantage of everolimus-eluting cobalt chro... more BACKGROUND Several clinical trials have indicated the advantage of everolimus-eluting cobalt chromium stents (EES) for the treatment of stable coronary artery disease (CAD), proposing its safety profile so as to shorten the duration of dual anti-platelet (DAPT) up to three months. However, the early vascular reactions during this period and underlying mechanisms remains unclear.
Background Analysis of intracoronary thrombus type by optical coherence tomography (OCT) imaging ... more Background Analysis of intracoronary thrombus type by optical coherence tomography (OCT) imaging is highly subjective. We aimed to compare a newly developed image analysis method to subjective visual classification of thrombus type identified by OCT. Methods Thirty patients with acute ST elevation myocardial infarction were included. Thrombus type visually classified by two independent readers was compared with analysis using QCU-CMS software. Results Repeatability of the computer-based measurements was good. By using a ROC, area under curve values for discrimination of white and red thrombi were 0.92 (95% confidence intervals (CI) 0.83-1.00) for median attenuation, 0.96 (95% CI 0.89-1.00) for mean backscatter and 0.96 (95% CI 0.89-1.00) for mean grayscale intensity. Median attenuation of 0.57 mm-1 (sensitivity 100%, specificity 71%), mean backscatter of 5.35 (sensitivity 92%, specificity 94%) and mean grayscale intensity of 120.1 (sensitivity 85%, specificity 100%) were identified as the best cutoff values to differentiate between red and white thrombi. Conclusions Attenuation, backscatter and grayscale intensity of thrombi in OCT images differentiated red and white thrombi with high sensitivity and specificity. Measurement of these continuous parameters can be used as a less user-dependent method to characterize in vivo thrombi. The clinical significance of these findings needs to be tested in further studies.
Background Percutaneous coronary intervention in complex bifurcation lesions is prone to suboptim... more Background Percutaneous coronary intervention in complex bifurcation lesions is prone to suboptimal implantation results and is associated with increased risk of subsequent clinical events. Angiographic ambiguity is high during bifurcation stenting, but it is unknown if procedural guidance by intravascular optical coherence tomography (OCT) improves clinical outcome. Methods and design OCTOBER is a randomized, investigator-initiated, multicenter trial aimed to show superiority of OCT-guided stent implantation compared to standard angiographic-guided implantation in bifurcation lesions. The primary outcome measure is a 2-year composite end point of cardiac death, target lesion myocardial infarction, and ischemia-driven target lesion revascularization. The calculated sample size is 1,200 patients in total, and allocation is 1:1. Eligible patients have stable or unstable angina pectoris or stabilized non-ST elevation myocardial infarction, and a coronary bifurcation lesion with significant main vessel stenosis and more than 50 % stenosis in a side branch with a reference diameter ≥2.5mm. Treatment is performed by the provisional side branch stenting technique or 2-stent techniques, and the systematic OCT guiding protocol is aimed to evaluate (1) plaque preparation, (2) lesion length, (3) segmental reference sizes, (4) lesion coverage, (5) stent expansion, (6) malapposition, (7) wire positions, and (8) ostial results. Implications A positive outcome of the OCTOBER trial may establish OCT as a routine tool for optimization of complex percutaneous coronary intervention, whereas a negative result would indicate that OCT remains a tool for ad hoc evaluation in selected cases.
coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main... more coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial.
European Heart Journal - Quality of Care and Clinical Outcomes, 2016
The aim of this study was to investigate the incidence of permanent working disability (PWD) in y... more The aim of this study was to investigate the incidence of permanent working disability (PWD) in young patients after percutaneous or surgical coronary revascularization. Methods and results The study included 1035 consecutive patients ≤50 years old who underwent coronary revascularization [910 and 125 patients in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups, respectively] between 2002 and 2012 at 4 Finnish hospitals. The median follow-up time was 41 months. The overall incidence of PWD was higher after CABG compared to PCI (at 5 years, 34.8 vs. 14.7%, P , 0.001). Freedom from PWD in the general population aged 45 was 97.2% at 4 years follow-up. Median time to grant disability pension was 11.6 months after CABG and 24.4 months after PCI (P ¼ 0.018). Reasons for PWD were classified as cardiac (35.3 vs. 36.9%), psychiatric (14.7 vs. 14.6%), and musculoskeletal (14.7 vs. 15.5%) in patients undergoing CABG vs. PCI. Overall freedom from PWD was higher in patients without major adverse cardiac and cerebrovascular event (MACCE) (at 5 years, 85.6 vs. 71.9%, P , 0.001). Nevertheless, rate of PWD was high also in patients without MACCE and patients with preserved ejection fraction during follow-up. Conclusions Although coronary revascularization confers good overall survival in young patients, PWD is common especially after CABG and mostly for cardiac reasons even without occurrence of MACCE. Supportive measures to preserve occupational health are warranted concomitantly with coronary revascularization at all levels of health care.
Aims: Our aim was to compare stenosis severity and plaque content between STEMI culprit lesions w... more Aims: Our aim was to compare stenosis severity and plaque content between STEMI culprit lesions with intact fibrous cap (IFC) and those with plaque rupture (PR) in a prospective study. Methods and results: We evaluated 93 patients undergoing OCT and thrombectomy as part of a prospective substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial. Culprit lesion morphology was assessable by OCT in 70/93 (75.3%). IFC was found in 31 (44.3%), PR in 34 (48.6%) and calcified nodule in five (7.1%) patients. Following thrombectomy, OCT demonstrated similar lumen area stenosis in IFC (79.3%) and PR (79.6%) (p=0.88). Lumen area stenosis <50% was observed in none of the patients with PR and in one patient with IFC. IFC had fewer quadrants with lipid plaque as compared to PR (28.16±15.02 vs. 39.12±14.23, p=0.004). However, in both lesion types, lipid was the predominant plaque type (83.9 vs. 63.7% of diseased quadrants). Conclusions: In a prospective study of STEMI patients treated with thrombectomy, mild residual stenoses were uncommon in IFC lesions. Although lipid content was lower than in PR lesions, lipid composed the majority of the diseased segments in IFC.
Incomplete strut coverage has been documented an important histopathologic morphometric predictor... more Incomplete strut coverage has been documented an important histopathologic morphometric predictor for later thrombotic events. This study sought to investigate whether optical coherence tomography (OCT)-guided percutaneous coronary intervention with Nobori biolimus-eluting stent implantation in patients with non-ST-segment-elevation myocardial infarction would provide improved strut coverage at 6 months in comparison with angiographic guidance only. One hundred patients were randomized 1:1 to either OCT-guided or angio-guided Nobori biolimus-eluting stent implantation. Postprocedure OCT was performed in all patients. In the OCT-guided group, prespecified criteria indicating additional intervention were related to (1) stent underexpansion, (2) strut malapposition, (3) edge dissection(s), and (4) residual stenosis at the distal or proximal reference segment(s). A final OCT was performed in case of reintervention. Six-month OCT follow-up was available in 85 patients. Twenty-three (46%)...
Scandinavian Journal of Work, Environment & Health, 2015
Long-term working capacity in young coronary artery disease patients under 50 years of age has no... more Long-term working capacity in young coronary artery disease patients under 50 years of age has not been previously published. This is a socioeconomically important population with potentially decades of working life ahead.
Manual thrombectomy has been proposed as a strategy to reduce thrombus burden during primary perc... more Manual thrombectomy has been proposed as a strategy to reduce thrombus burden during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, the effectiveness of manual thrombectomy in reducing thrombus burden is uncertain. In this substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial, we compared the thrombus burden at the culprit lesion using optical coherence tomography (OCT) in patients treated with thrombectomy vs. PCI-alone. The TOTAL trial (N = 10 732) was an international, multicentre, randomized trial of thrombectomy (using the Export catheter, Medtronic Cardiovascular, Santa Rosa, CA, USA) in STEMI patients treated with primary PCI. The OCT substudy prospectively enrolled 214 patients from 13 sites in 5 countries. Optical coherence tomography was performed immediately after thrombectomy or PCI-alone and then repeated after stent deployment. Thrombus quantification was performed by an independent c...
Data on the outcome of young patients after coronary artery bypass grafting (CABG) and percutaneo... more Data on the outcome of young patients after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are scarce. Data on 2209 consecutive patients≤50 years old who underwent CABG or PCI were retrospectively collected from 15 European institutions. PCI and CABG had similar 30-day mortality (0.8% vs. 1.4%, p=0.27), late survival (at 5 years, 97.8% vs. 94.9%, p=0.082) and freedom from stroke (at 5 years, 98.0% and 98.0%, p=0.731). PCI was associated with significantly lower freedom from major adverse cardiac and cerebrovascular events (MACCE) (at 5 years, 73.9% vs. 85.0%, p<0.0001), repeat revascularization (at 5 years, 77.6% vs. 92.5%, p<0.0001) and myocardial infarction (at 5 years 89.9% vs. 96.6%, p<0.0001) compared with CABG. These findings were confirmed in propensity score adjusted and matching analyses. Freedom from MACCE after PCI was particularly low among diabetics (at 5 years, 58.0% vs. 75.9%, p<0.0001) and in patients with multivessel disease (at 5 years, 63.6% vs. 85.1%, p<0.0001). PCI in patients with ST elevation myocardial infarction was associated with significantly better 5 years survival (97.5% vs. 88.8%, p=0.001), which was driven by its lower 30-day mortality (1.5% vs. 6.0%, p=0.017). In conclusion, patients ≤ 50 years old have an excellent immediate outcome after either PCI or CABG with similar long-term survival when used according to the current clinical practice. PCI was associated with significantly lower freedom from myocardial infarction and repeat revascularization.
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Papers by Olli Kajander