Mechanisms of luminal enlargement and quantification of vessel wall trauma following balloon coronary angioplasty and directional atherectomy: A study using intracoronary ultrasound, angioscopy and angiography

Objectives: The purpose of this study was to assess the dualaction of lumen enlargement and vessel wall damage followingeither balloon angioplasty or directional atherectomy, usingintracoronary ultrasound, and angioscopy. Background: Differences in the mechanisms of action of balloonangioplasty and directional atherectomy may have a significantbearing on the immediate outcome and the restenosis rate at6 months. Methods: A total of 36 patients were studied before and aftereither balloon angioplasty (n=18) or directional atherectomy(n=18). Ultrasound measurements included changes in lumen area,external elastic membrane area and plaque burden. In addition,the presence and extent of dissections were assessed to derivea damage score. Angioscopic assessment of the dilated or atherectomizedstenotic lesions was translated into semi-quantitative dissection,thrombus and haemorrhage scores. Results: Atherectomy patients had a larger angiographic vesselsize compared with the angioplasty group (3.55±0.46 mmvs 3.00±0.64 mm, P<0.05); however, minimal lumen diameter(1.18±0.96 mm vs 0.85±0.49 mm) and plaque burden(17.04±3.69 vs 15.23±4.92 mm²) measurements didnot differ significantly. As a result of plaque reduction, atherectomyproduced a larger increase in luminal area than the angioplastygroup (5.80±1.78 mm² vs 2.44±1.36 mm², P<0.0001).Lumen increase after angioplasty was the result of ‘plaquecompression’ (50%) and wall stretching (50%). Additionally,in both groups there was indirect angioscopic evidence of thrombus‘microembolization’ as an adjunctive mechanism oflumen enlargement. Angioscopy identified big flaps in six andsmall intimal flaps in 11 of the atherectomized patients ascompared with five and 12 patients in the angioplasty group.Changes in thrombus score following both coronary interventionswere identical (0.72±3.42 points atherectomy vs –0.38±3.27points balloon angioplasty, ns). Conclusions: Lumen enlargement after directional atherectomyis mainly achieved by plaque removal (87%), whereas balloondilation is the result of vessel wall stretching (50%) and plaquereduction (50%). Despite the fact that the luminal gain achievedby directional atherectomy is twice that achieved with balloonangioplasty, the extent of trauma induced by both techniquesseems to be similar.     

NON-FIBROSITIC LUMBAR SUBCUTANEOUS NODULES: PREVALENCE AND CLINICAL SIGNIFICANCE

Lumbar subcutaneous nodules (LSNs) have been associated withfibrositis but are distinct from painful myalgic trigger pointsand tender points. One hundred and twenty-six adults (53 malesand 73 females) were examined for LSNs LSNs varied in size froma ± 3mm ‘corn kernel’ (15/47) to ±5mm ‘pea’ (21/47) to ±10 mm ‘grape’(11/47), occurred singly (22/47) and in clusters of two to sevenuni- and bilaterally. Eight of 47 LSNs overlying the posteriorsuperior iliac spines (PSIS) were tender. The results of a cross-tabularanalysis using disease as the independent variable and presenceor absence of LSNs as the dependent, found no differences(X²= 1.06, df = 2). LSNs occur near the PSIS in approximately 25%of white adults, are rarely a cause of back pain, and shouldseldom require biopsy. KEY WORDS: Fibrositis, Fibrofatty nodules, Low back pain     

Arterial remodelling: an independent pathophysiological component of atherosclerotic disease progression and regression. Insights from serial pharmacological intervention trials.

Rodriguez-Granillo et al.¹ report arterial remodelling datafrom the ‘PERSPECTIVE’ study,² an imaging substudyof the ‘EUROPA’ study.³ ‘EUROPA’ isa randomized, placebo-controlled, multicentre trial, which demonstratedthat the angiotensin-converting enzyme (ACE) inhibitor perindoprilreduced adverse clinical events in 12 218 patients with stablecoronary artery disease (CAD). The EUROPA investigators suggestedthat the clinical benefit is related to anti-atheroscleroticeffects of ACE inhibitors. However, the ‘PERSPECTIVE’substudy, which examined the impact of perindopril on atherosclerosisin a subset of 118 patients, found neither an effect on plaqueburden assessed by intravascular ultrasound     

Expanding the noninvasive coronary physiology assessment with transthoracic Doppler echocardiography.

Please see page 214 for the article by Auriti et al. (doi: 10.1016/S1525-2167(03)00014-3)to which this editorial pertains. Coronary angiography has been considered the ‘gold standard’for defining coronary anatomy for more than four decades. Nevertheless,this technique has intrinsic limitations because it only delineatescoronary ‘luminology’, and it has been clearly shownthat there is marked disparity between the severity of lesionsand their physiological effects in ischemic heart disease (CAD)^[1].Both coronary angiography and intravascular ultrasound can onlygive anatomic information and cannot provide sufficient functionalinformation which is crucial for clinical decision making, especiallyin intermediate stenoses. It conveys that physiologic variables,such as coronary flow velocity reserve (CFVR), are more widelyaccepted and used as an additional approach     

In-vivo validation of videodensitometric coronary cross-sectional area measurement using dual-energy digital subtraction angiography

Previous studies indicate that conventional geometric edge detection techniques, used in quantitative coronary arteriography (QCA), have significant limitations in quantitating coronary cross-sectional area of small diameter (D) vessels (D<1.00 mm) and lesions with complex cross-section. As a solution to this problem, we have previously reported on an in-vitro validation of a videodensitometric technique that quantitates the absolute cross-sectional area including small vessel diameter (D<1.00 mm) and any complex shape of the vessel cross-section. For in-vivo validation, plastic tubing (5–8 mm long) with different shape complex cross-section with known cross-sectional area (A=0.8–4.5 mm²) were percutaneously wedged in the coronary arteries of anesthetized pigs (40–50 kg). Contrast material injections (6–10 ml at 2–4 ml/sec) were made into the left main coronary artery during image acquisition using a motion immune dual-energy subtraction technique, where low and high X-ray energy and filtration were switched at 30 Hz. A comparison was made between the actual and measured cross-sectional area using the videodensitometry and edge detection techniques in tissue suppressed energy subtracted images. In eighteen comparisons the videodensitometry technique produced significantly improved results (slope=0.87, intercept=0.24 mm², r=0.94) when compared to the edge detection technique (slope=0.42, intercept=1.99 mm², r=0.39). Also, a cylindrical vessel phantom (D=1.00–4.75 mm) was used to test the ability to calculate and correct for the effect of the out of plane angle of the arterial segment on the cross-sectional area estimation of the videodensitometry technique. After corrections were made for the out of plane angle using two different projections, there was a good correlation between the actual and the measured cross-sectional area using the videodensitometry technique (slope=0.91, intercept=0.11 mm², r=0.99). These data suggest that it is possible to quantitate absolute cross-sectional area without any assumption regarding the arterial shape using videodensitometry in conjunction with the motion immune dual-energy subtraction technique.     

An unusual meta-regression approach with a high potential of misleading conclusions.

Yu et al.¹ systematically reviewed the literature of heartfailure disease management programmes (DMPs) with the aim toidentify crucial programme characteristics in reducing clinicaloutcomes for elderly patients with heart failure. The authorsdichotomized individual trials as ‘effective’ or‘ineffective’ based on whether a trial reporteda statistically significant result or     

Angiotensin-II receptor blockers and coronary artery disease: 'presumed innocents': reply

‘Is the jury out’ or ‘is the jury in’? The commentary by Volpe et al.¹ does not appear to recognizethat two important issues in cardiology have recently gainednew insight. First, the reduction of myocardial infarction anddeath with ACE-inhibitors in high-risk patients is greater thanthat derived from blood pressure lowering alone. A ‘bloodpressure-independent’ effect of ACE-inhibitors is supportedby two recent meta-analyses that applied meta-regression, astatistical principal that adjusts for blood pressure differenceswithin trials. One of the analysis included 179 122 patientsfrom trials with ACE-inhibitors or calcium channel blockerswith     

Will he ever be conscious again?

For relatives and doctors alike, crucial questions about thepatient who remains comatose after having been resuscitatedfrom cardiac arrest are ‘will he survive?’, ‘willhe ever be conscious again?’, and ‘will he everbe independent again?’. Reisinger et al.¹ providedata to predict outcome at an early stage that could be helpfulto address the first two questions. Attempts to predict outcome date from the first years afterthe introduction of cardiopulmonary resuscitation in 1960. Earlyretrospective case series have gradually made place for prospectivecohort studies, but methodological problems remain. The twomost important problems are the inevitability of treatment restrictionsin selected patients and the definition and validity of outcomemeasurements. In clinical cohort studies, just as in regularclinical practice,     

Echocardiographic selection of candidates for cardiac resynchronization therapy: the lack of evidence! Reply

We appreciate the interest in our work,¹ in which we have attemptedto delineate a possible algorithm to use tissue doppler imaging(TDI)-guided cardiac resynchronization therapy (CRT) as a complementto evidence-based clinical guidelines in the management of patientswith severe heart failure. Dr Soliman et al. suggest that echocardiographic left ventricle(LV) dyssynchrony can be assessed by the ‘spectral’TDI lateral-to-septal delay whereas ‘colour-encoded’TDI (regardless of the LV segment model used) is of limitedvalue because several inherited     

Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol.

I read with great interest the article ‘Cardiovascularpre-participation screening of young competitive athletes forprevention of sudden death: proposal for a common European protocol’by Corrado et al.¹ The consensus statement of the ESC workinggroups     

ANKYLOSING SPONDYLITIS: KLEBSIELLA AND HL-A B27

A search for the presence of Klebsiella-Enterobacter spp. andYersinia enterocolitica in urine and faeces of 63 patients withankylosing spondylitis was conducted because these microorganismshave been demonstrated to cross-react immunologically with HL-AB27 positive lymphocytes. The patients were graded into threegroups on the basis of disease activity. Klebsiella spp. werefound in the faeces of 13 (93%) of the 14 patients with ‘active’disease, 10 (48%) of the 21 patients with ‘probably active’disease and in one (4%) of the 28 patients with ‘inactive’disease. Positive cultures were also obtained in 47 (38%) of124 controls. It is suggested that the presence of Klebsiellaspp. in faecal cultures may be associated with ‘active’disease in patients with ankylosing spondylitis. ^* Paper read at a combined meeting of the Heberden Society,the British Association for Rheumatology and Rehabilitation,the Royal Society of Medicine Section of Rheumatology and Rehabilitationand the Irish Society for Rheumatology and Rehabilitation, Dublin,October 15, 1976.     

Diagnosis of coronary artery disease in elderly patients: safety and efficacy of dobutamine echocardiography

Coronary artery disease may be difficult to diagnose in theelderly because its clinical symptomatology is frequently atypicaland because the performance of submaximal tests makes exercisestress testing sometimes unreliable. Dobutamine stress testingmay be a useful alternative in such patients. This study comparedthe safety and accuracy of dobutamine stress echocardiographyin 73 ‘young’ (<60 years old) and 63 ‘old’( 60 years old) patients without previous myocardial infarctionundergoing diagnostic coronary angiography. The sensitivity in young patients (79%, (67–91, 95% CI))was similar to that in old patients (80% (69–91, 95% CI)).Similar levels of specificity (88% (75–101, 95% CI) vs75% (54–96, 95% CI)) were foundin the two groups. Bothgroups showed a trend to a higher sensitivity for multi-vesseldisease than for single-vessel disease. No major side effectoccurred during the entire study and peak dose (40 µg. kg^–1 . min^–1) was attained with similar frequencyin both groups (56% vs 49%). Minor side effects occurred equallyin ‘young’ and ‘old’ patients and neverpersisted more than a few minutes after ending the first infusionof dobutamine. Dobutamine echocardiography appears to be safe and accuratefor the detection of coronary artery disease regardless of age.     

Mechanisms of death in elderly patients with acute myocardial infarction exposed to fibrinolytic therapy.

We read with great interest the article ‘Effect of thrombolytictherapy on the risk of cardiac rupture and mortality in olderpatients with first acute myocardial infarction’ by Buenoet al.¹ dealing with the still unresolved question     

Myocardial infarction increases ACE2 expression in rat and humans.

We read with interest the article published by Burrell et al.,¹and the accompanying editorial² on the role of angiotensin-convertingenzyme 2 (ACE2) in the evolution of myocardial infarction (MI)in rats and humans. The demonstration of increased ACE2 geneexpression in both the viable myocardium and the ‘penumbra’     

Aortic arch morphology and hypertension in post-coarctectomy patients

We read with great interest the paper by Ou et al.¹ whoreport a significant association between the so-called ‘gothic’aortic arch morphology and resting hypertension in patientsafter successful surgical repair of aortic coarctation. Thearticle, however, raises several questions.     

MUSCLE STRENGTH, VOLUNTARY ACTIVATION AND CROSS-SECTIONAL MUSCLE AREA IN PATIENTS WITH FIBROMYALGIA

The objectives were to determine whether the low muscle strengthin fibromyalgia is due to lack of exertion and to determinethe relation between strength and muscle area. Secondarily weexamined the voluntary muscle strength of the different musclesof the leg. The twitch interpolation technique was used to estimatethe degree of central activation and the ‘true’quadriceps muscle strength. Muscle cross-sectional area wasdetermined with magnetic resonance imaging (MRI). The estimated‘true’ muscle strength was 91 Nm (S.D. = 34 Nm)in 15 fibromyalgia patients compared with 125 Nm (28 Nm) in14 healthy controls (P < 0.02). The ‘true’ strengthdivided by the sum of the maximal areas of the four belliesof the quadriceps muscle was lower, being 1.56Nm/cm² (0.32Nm/cm²)in fibromyalgia patients compared with 2.11Nm/cm² (0.39Nm/cm²)in the controls (P <0.001). The voluntary muscle strengthof the flexor muscles of the knee and of the plantar flexorsof the ankle was markedly reduced in patients, but no significantdifferences could be observed in the strength of the dorsalflexors of the ankle. In conclusion, a reduction of the estimated‘true’ quadriceps muscle strength per unit areaof about 35% was found in fibromyalgia patients. KEY WORDS: Fibromyalgia, Cross-sectional area, Muscle strength, Twitch interpolation     

Limitations of the study evaluating fibrinolytic therapy and in-hospital PCI for ST-elevation myocardial infarction.

We read with interest the article by McClelland et al.¹entitled ‘Percutaneous coronary intervention and 1-yearsurvival in patients treated with fibrinolytic therapy for acuteST-elevation myocardial infarction’. We would like tocongratulate the authors on their study, but would     

Concurrent coronary and carotid artery surgery: an open debate: reply

We read with interest the letter from Barili et al. onour work ‘Concurrent coronary artery surgery: factorsinfluencing perioperative outcome and long-term results’.¹We thank Barili et al. for their comments that need ourreply. First, we share their doubts regarding the precise impact ofasymptomatic carotid artery stenosis     

Is subendocardial ischaemia present in patients with chest pain and normal coronary angiograms? A cardiovascular MR study

I read with interest the recent article by Vermeltfoort et al.,¹ on the use of dynamic contrast enhancement in MRI to evaluatethe possible presence of subendocardial ischaemia in patientswith chest pain and normal coronary arteries (‘syndromeX’).     

Impact of the elevation of biochemical markers of myocardial damage on long-term mortality after percutaneous coronary intervention: results of the CK-MB and PCI study.

We read with great interest the paper ‘Impact of the elevationof biochemical markers of myocardial damage on long-term mortalityafter percutaneous coronary intervention: results of the CK-MBand PCI study’ by Cavallini et al.¹ This large cohort follow-up study is of particular relevancefor the