Papers by William J van Gaal
International Journal of Cardiology, 2009
sentation with an acute coronary syndrome, diabetes mellitus, receipt of drug-eluting stent, and ... more sentation with an acute coronary syndrome, diabetes mellitus, receipt of drug-eluting stent, and stent diameter were not associated with systemic inflammation. Conclusion: Acute systemic inflammation is absent in most patients after contemporary PCI, possibly reflecting technical advances and improved pharmacological management. Lesion length and complexity predicted an inflammatory reaction, suggesting it to be primarily a manifestation of the extent of vascular injury.
The International Journal of Cardiovascular Imaging, 2009
We sought to assess the tolerance and safety of adenosine-stress cardiovascular magnetic resonanc... more We sought to assess the tolerance and safety of adenosine-stress cardiovascular magnetic resonance (CMR) perfusion imaging in patients with coronary artery disease (CAD). We retrospectively examined all adenosine CMR perfusion scans performed in our centre in patients with known or suspected (CAD) and normal volunteers at either 1.5 or 3 T. All subjects were initially screened for contraindications to adenosine. The dose of adenosine infused was 140 lg/kg/min. Significant CAD was defined angiographically as the presence of at least one stenosis of [50% diameter. Data were collected from 351 consecutive subjects (mean age 62 ± 11 years, range 25-85 years-245 men). Of the 351 subjects, 305 had a coronary angiogram, the remaining 46 subjects were normal volunteers studied for research protocols. In total, 233 subjects (76%) were found to have significant CAD of whom 128 had multi-vessel disease. There were no deaths, myocardial infarctions, or episodes of bronchospasm during the CMR study. Transient 2nd (Mobitz II) or 3rd-degree atrioventricular (AV) block occurred in 27 patients (8%). There were no sustained episodes of advanced AV block. Transient chest pain was the most common side effect (199 subjects-57%). The use of intravenous adenosine in CMR perfusion imaging is safe and well-tolerated, even in patients with severe CAD. Where a careful screening policy for contraindications to adenosine is followed, serious adverse events in the CMR scanner are relatively rare and symptoms resolve following termination of the infusion, without the need for aminophylline.
Journal of Cardiovascular Magnetic Resonance, 2008
Principles and Practice, 2011
... William J. van Gaal 1, & Adrian P. Banning 2 1 The Northern Hospital, Epping, VIC, Austra... more ... William J. van Gaal 1, & Adrian P. Banning 2 1 The Northern Hospital, Epping, VIC, Australia 2 John Radcliffe Hospital, Oxford, UK Introduction ... Arshad A. Angiojet rheolytic thrombectomy in patients undergoing primary angioplasty for acute myocardial infarction: The AIMI study. ...
Expert Review of Cardiovascular Therapy, 2014
Current medical research and opinion, Jan 29, 2015
Ticagrelor is recommended in local and international guidelines as first-line therapy in combinat... more Ticagrelor is recommended in local and international guidelines as first-line therapy in combination with aspirin in patients presenting with acute coronary syndromes (ACS). The purpose of this article is to provide practical guidance regarding the use of ticagrelor in this setting. Ticagrelor, a direct-acting, reversible P2Y12 receptor antagonist, has a faster onset, and a more potent and predictable antiplatelet effect compared with clopidogrel. The authors recommend considering the use of ticagrelor in moderate-to-high risk ACS patients treated with an invasive approach and those managed non-invasively who have elevated troponin levels. Consistent with outcomes observed in the PLATO trial overall, ticagrelor was superior to clopidogrel treatment in patients with chronic kidney disease, a history of stroke or transient ischemic attack, the elderly, and patients requiring surgical revascularization. When switching from clopidogrel to ticagrelor, patients established on clopidogrel ...
Journal of Thoracic and Cardiovascular Surgery, 2008
Object: Pexelizumab is a humanized monoclonal antibody inhibiting C5 complement. It has been post... more Object: Pexelizumab is a humanized monoclonal antibody inhibiting C5 complement. It has been postulated to improve outcomes in patients undergoing coronary artery bypass surgery and urgent reperfusion therapy for ST elevation myocardial infarction. We aimed at evaluating the risk/benefit profile of pexelizumab (bolus 1 infusion) versus placebo on top of current approaches in the management of patients with ST elevation myocardial infarction or undergoing coronary artery bypass.
The Journal of Invasive Cardiology, Dec 1, 2007
Complications of percutaneous coronary intervention include in-stent restenosis (ISR) and in-sten... more Complications of percutaneous coronary intervention include in-stent restenosis (ISR) and in-stent thrombosis (IST) which have different underlying pathophysiological processes and different treatment strategies. ISR is primarily due to excessive neointimal growth and occurs in 20-30% of bare-metal stents (BMS). Drug-eluting stents (DES) have decreased the rates of ISR (< 10%), but are potentially associated with increased IST related to delayed arterial healing and stent strut exposure. ISR of BMS typically occurs within 6 months of stent deployment. IST usually occurs within 12 months of DES deployment. We present a case of focal ISR and IST within the same BMS, confirmed with intravascular ultrasound, 5 years after deployment in a saphenous vein graft.
The Journal of Thoracic and Cardiovascular Surgery, Oct 1, 2007
The Journal of invasive cardiology
Acute stent thrombosis is a rare but serious complication of stent implantation. Although anecdot... more Acute stent thrombosis is a rare but serious complication of stent implantation. Although anecdotal reports suggest that the use of drug-eluting stents (DES) may increase the risk of stent thrombosis, this has not been borne out in randomized, controlled trials. We report a case of acute stent thrombosis following implantation of a DES, with review of the literature. Despite the initial favorable procedural result, the patient developed stent thrombosis 7 days later; intravascular ultrasound (IVUS) demonstrated incomplete deployment of the stent. We recommend the use of IVUS in the management of acute stent thrombosis in order to exclude incomplete stent expansion which may underlie acute thrombotic occlusion.
Several devices are available for percutaneous patent foramen ovale (PFO) closure. Over the past ... more Several devices are available for percutaneous patent foramen ovale (PFO) closure. Over the past 3 years our planned treatment strategy of PFO closure has been routine use of the GORE-HELEX septal occluder device, followed by 6 months of aspirin therapy. We present the safety and feasibility of routinely using this device for all patients undergoing percutaneous PFO closure, with 3-month transthoracic echocardiogram (TTE) follow up. In total, 75 adult patients (44.0 ± 11.7 years; 45.3% male) were referred for PFO closure during the study period. All patients underwent echocardiography prior to PFO closure. In 5 patients no PFO was found, and 1 patient had an atrial secundum defect closed using the Amplatzer septal occluder. Of the 69 remaining patients with PFO, 68/69 (98.6%) underwent closure with the GORE-HELEX device. Six of 69 cases required device retrieval and 5 of 6 were replaced successfully with a second GORE-HELEX device. One of the 6, a large PFO associated with atrial septal aneurysm, was replaced using the Amplatzer septal occluder. There were no major complications. At 3-month follow up, 65/68 (95.6%) had no residual shunt on TTE, and 3 patients had small residual shunts thought to be related to incomplete endothelialisation at 3 months. In conclusion, percutaneous PFO closure using the GORE-HELEX septal occluder device is safe and feasible, with no major peri-procedural complications and excellent short-term results at 3-month follow up.
Cardiovascular ultrasound, 2005
Platypnea-orthodeoxia describes the condition of combined dyspnea and hypoxia respectively, whils... more Platypnea-orthodeoxia describes the condition of combined dyspnea and hypoxia respectively, whilst in the upright position, which improves in the recumbent position. We present a case of platypnea-orthodeoxia due to a fenestrated atrial septal defect associated with an atrial septal aneurysm. Due to the fenestrated nature of the atrial septal defect, surgical rather than percutaneous correction was performed. A high index of suspicion is required to diagnose the syndrome of platypnea-orthodeoxia. Careful echocardiographic evaluation is required to identify the syndrome, and to determine suitability for percutaneous repair.
Interventional Cardiology, 2011
Interactive cardiovascular and thoracic surgery, 2011
Endothelin (ET-1) is a potent vasoconstrictor. We compared patterns of ET-1 in percutaneous coron... more Endothelin (ET-1) is a potent vasoconstrictor. We compared patterns of ET-1 in percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and correlated it with markers of inflammation. Patients with multivessel disease were enrolled in a prospective randomized study of PCI vs. on-pump CABG. Procedural myocardial injury was assessed biochemically (CK-MB) and with new late gadolinium enhancement (LGE) on magnetic resonance imaging (MRI) one week postprocedure. ET-1 was measured at baseline, 1 h, 6 h, 12 h, 24 h and one week postprocedure. Log ET-1 values were compared between PCI and CABG and between patients without significant myocardial injury. Measurement of ET-1 values was performed in 36 PCI and 31 CABG patients. Baseline ET-1 values were similar between PCI and CABG patients (0.91 ± 0.36 vs. 1.0 ± 49 pg/ml, P = 0.38). Peak values were reached at 1 h in PCI and at 24 h in CABG patients and patients undergoing CABG had significantly higher log ET-1 values...
Circulation. Cardiovascular interventions, 2013
Revascularization strategies for multivessel coronary artery disease include percutaneous coronar... more Revascularization strategies for multivessel coronary artery disease include percutaneous coronary intervention and coronary artery bypass grafting. In this study, we compared the completeness of revascularization as assessed by coronary angiography and by quantitative serial perfusion imaging using cardiovascular magnetic resonance. Patients with multivessel coronary disease were recruited into a randomized trial of treatment with either coronary artery bypass grafting or percutaneous coronary intervention. Angiographic disease burden was determined by the Bypass Angioplasty Revascularization Investigation (BARI) myocardial jeopardy index. Cardiovascular magnetic resonance first-pass perfusion imaging was performed before and 5 to 6 months after revascularization. Using model-independent deconvolution, hyperemic myocardial blood flow was evaluated, and ischemic burden was quantified. Sixty-seven patients completed follow-up (33 coronary artery bypass grafting and 34 percutaneous co...
Journal of cardiovascular medicine (Hagerstown, Md.), 2008
Guidewires used during percutaneous coronary interventions have elevated conductance, and, when i... more Guidewires used during percutaneous coronary interventions have elevated conductance, and, when in place, are electrically isolated from the body fluids by the guiding catheter. In this paper, we present an overview of two simple techniques exploiting these unique conditions to record local electrical activity in the myocardium and to pace the heart. Both actions can be accomplished with standard catheterization laboratory equipment. The operator may obtain useful, real-time information on distal ischemia and/or vitality and react quickly when an emergency pacing is required. The technical details of these techniques are elucidated and their usefulness as clinical and research tools is discussed, with an emphasis on possible future applications.
QJM, 2008
Despite proven advantages of primary percutaneous coronary intervention (PCI), thrombolysis remai... more Despite proven advantages of primary percutaneous coronary intervention (PCI), thrombolysis remains the first line treatment for ST-elevation myocardial infarction (STEMI) worldwide. Management of patients with failed thrombolysis is still debated, and data from existing randomized controlled trials are conflicting. To compare the risk/benefit profile of repeat thrombolysis (RT) vs. rescue PCI in patients with failed thrombolysis. Search of BioMedCentral, CENTRAL, mRCT and PubMed for randomized controlled trials comparing rescue PCI vs. conservative therapy and/or RT vs. conservative therapy. Outcomes of interest assessed by adjusted indirect meta-analysis: major adverse events (MAE, defined as the composite of overall mortality and re-infarction), stroke, congestive heart failure (CHF), major bleeds (MB), and minor bleeds. Overall mortality and re-infarction have been also analysed individually. Eight trials were included (1318 patients). Follow-up ranged from 'in-hospital' to 6 months. No significant difference was found for the risk of MAE [OR 0.93(0.26-3.35), P = 0.4], overall mortality [OR 1.01(0.52-1.95), P = 0.15], stroke [OR 5.03(0.64-39.1), P = 0.58] and CHF [OR 0.74(0.28-1.96), P = 0.6]. Compared with conservative therapy, rescue PCI was associated with a 70% reduction in the risk of re-infarction [OR 0.32(0.14-0.74), P = 0.008], number needed to treat 17. No difference in terms of MB was found [OR 0.5(0.1-2.5), P = 0.09], while a greater risk of minor bleeds was observed with rescue PCI [OR 2.48(1.08-5.7), P = 0.04], number needed to harm 50. Although the observed benefit is modest, these data support the use of PCI after failed thrombolysis.
Journal of Diabetes and its Complications, 1998
The objective of this study was to estimate the long-lipid levels, duration of follow-up, or the ... more The objective of this study was to estimate the long-lipid levels, duration of follow-up, or the number of samples per patient. Men demonstrated greater term intraindividual variability of lipid levels in variability than women for total cholesterol (men adult type I and type II diabetic patients. Total 9.5 Ϯ 0.5%, n ϭ 34, women 7.9 Ϯ 0.5%, n ϭ 26, p Ͻ cholesterol, triglycerides, high-density 0.01) and triglycerides (men 26.5 Ϯ 2.2%, women lipoprotein (HDL) cholesterol, low-density 20.4 Ϯ 1.4%, p ϭ 0.03). Total lipid variability was lipoprotein (LDL) cholesterol, and hemoglobin A 1c also unrelated to baseline or mean hemoglobin were measured every 3-6 months in 135 patients A 1c or to the change in hemoglobin A 1c during the attending the Austin Hospital diabetes clinic. study as a whole. However, the change in Analysis was performed on 60 diabetic patients (33 hemoglobin A 1c was associated with the change in type I and 27 type II) who had not been treated total cholesterol (r ϭ 0.30, p Ͻ 0.03) and the change with lipid lowering drugs and who met the in LDL cholesterol (r ϭ 0.27, p Ͻ 0.05). In conclusion, inclusion criteria of at least five measurements long-term intraindividual lipid variability in [mean Ϯ standard error of the mean (SEM), 9.5 Ϯ adult diabetic subjects is higher for total and HDL 0.4; range, 5-17] collected over a minimum of 4 cholesterol than previously published values in years (5.1 Ϯ 0.1; 4-6.5 years). Total variability, nondiabetic subjects. Variability of triglycerides is expressed as coefficient of variation, was 8.8 Ϯ 0.4% at least double that of total cholesterol, HDL for total cholesterol, 23.9 Ϯ 1.5% for triglycerides, cholesterol and LDL cholesterol. Biological 10.2 Ϯ 0.5% for HDL cholesterol, and 12.0 Ϯ 0.5% variability, not measurement error, accounts for for LDL cholesterol. Biological variability, derived the greatest proportion of total variability for all from total and analytical variability, was higher lipid parameters. Confidence levels calculated than previous estimates in nondiabetic subjects for from these data have implications for the initiation total cholesterol and HDL cholesterol but similar of lipid lowering therapy and in monitoring the for triglycerides and LDL cholesterol. No effects of intervention. (Journal of Diabetes and Its relationship was observed between total lipid Complications 12; 4: 208-214, 1998.) © 1998 variability and diabetes type, age, baseline or mean Elsevier Science Inc.
The Medical journal of Australia, Jan 20, 2011
Computed tomography coronary angiography is the most reliable diagnostic test for coronary athero... more Computed tomography coronary angiography is the most reliable diagnostic test for coronary atherosclerosis. Stress testing should be reserved for diagnosis of myocardial ischaemia. Revascularisation, either by stenting or bypass grafts, is commonly performed in patients with stable coronary artery disease but is a double-edged sword. In the presence of ischaemia, revascularisation improves outcomes; in its absence, outcomes are worsened. In current practice, the decision of whether to revascularise is mainly made on the basis of the angiographic appearance of the coronary lesion in question. Physiological assessment of coronary lesions by the use of a pressure wire and measurement of fractional flow reserve (FFR) often shows that lesions thought to be sufficiently severe to warrant stenting or bypass do not cause ischaemia. A recent randomised study has shown that using FFR measurements to guide coronary stenting resulted in a lower use of stents, decreased costs and superior outcomes at 2 years, compared with traditional angiographic assessment alone. We believe that changes to the methods of health reimbursement are needed in both the public and private health systems, to facilitate greater use of FFR measurement.
Journal of Nuclear Cardiology, 2004
A rise in SBP Ն10 mmHg was seen in 61 (7%) patients, while 227 (26%) had a flat response (⌬SBP Ͻ1... more A rise in SBP Ն10 mmHg was seen in 61 (7%) patients, while 227 (26%) had a flat response (⌬SBP Ͻ10 mmHg) and 578 (67%) had a drop in SBP Ն10 mmHg. The ratio of ischemic to non-ischemic scans in women was the same, irrespective of SBP response. In men there was a trend toward fewer ischemic scans among patients whose SBP rose compared with those whose SBP fell during testing (p ϭ 0.08). Men with a flat SBP response had an intermediate scan ratio. MPI Result SBP Decreased SBP Flat SBP Increased Male Female Male Female Male Female
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Papers by William J van Gaal