Evaluation of intermediate coronary stenosis with intravascular ultrasound and fractional flow reserve: Its use and abuse

Clinical decision making in patients with intermediate coronary stenosis is still debated. Intravascular ultrasound (IVUS) examination and/or functional assessment of coronary stenosis by fractional flow reserve (FFR) are currently used to define the severity of such lesions. There are very few studies with a small sample size that have a head‐to‐head comparison between IVUS and FFR in the evaluation of angiographically de novo intermediate lesions. There are no randomized, controlled trials to demonstrate the superiority of IVUS versus FFR in providing improved clinical outcomes in comparison with angiography alone. However, the issue of superiority might be irrelevant, because IVUS and FFR could be complementary techniques to be used in the catheterization laboratory to provide critical anatomic and functional data that permit more accurate decisions in the management of the patient. © 2009 Wiley‐Liss, Inc.     

冠状动脉严重钙化病变旋磨术后植入药物洗脱长支架的长期临床疗效观察

目的 探讨冠状动脉（简称“冠脉”）旋磨术联合药物洗脱长支架用于治疗严重冠脉钙化病变的安全性及有效性。方法 入选2010年1月至12月因严重冠脉钙化而行冠脉旋磨术联合药物洗脱长支架植入治疗的患者。观察患者的手术成功率,围术期并发症及术后主要心血管事件（包括心源性死亡、心肌梗死、靶病变血运重建）的发生率。结果 共21例严重冠脉钙化病变患者接受了冠脉旋磨术联合药物洗脱长支架植入治疗,年龄（65.2±6.9）岁。合并高血压病16例（76.2%）,糖尿病7例（33.3%）,肾功能不全1例（4.8%）。旋磨部位共植入35枚国产药物支架（1.75枚/部位）,最短支架长度为28mm,病变部位平均支架总长度为48（29～66）mm,仅1例因旋磨头未能通过病变而放弃,手术成功率为95.2%（20/21）。术中1例出现冠脉痉挛,1例出现胸痛伴心率减慢;术后1例出现消化道出血。住院期间无心血管事件发生,平均随访26个月,仅1例（4.8%）患者于术后第2个月发生急性心肌梗死,余患者病情稳定。结论 冠脉旋磨术联合药物洗脱长支架植入术治疗严重冠脉钙化病变可取得很高的手术成功率,是治疗钙化病变安全、有效的方法。     

The impact of age on fractional flow reserve-guided percutaneous coronary intervention: A FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) trial substudy

Background

Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) improved outcomes compared with an angiography-guided strategy in patients with multivessel coronary artery disease (CAD). However, the effect of age on FFR has not been well-studied. We aimed to evaluate the impact of age on the favorable results of routine FFR-guided PCI for multivessel CAD.

Methods

We compared 1 year outcomes between FFR-guided PCI and angiography-guided PCI in the 512 patients enrolled in the FAME study < 65 years old compared to the 493 patients ≥ 65 years old. We also evaluated the effect of age on the FFR result of varying degrees of visually estimated coronary stenosis.

Results

The 1-year rate of death, myocardial infarction or repeat revascularization in the angiography-guided group tended to be higher than in the FFR-guided group for both those patients < 65 (17.2% vs. 12.0%, P = 0.098) and those ≥ 65 years old (19.7% vs. 14.3%, P = 0.111) with no significant interaction based on age (P = 0.920). Older patients had higher FFR in vessels with 50% to 70% stenosis (0.83 ± 0.11 vs. 0.80 ± 0.13, P = 0.028) and in vessels with 71% to 90% stenosis (0.69 ± 0.15 vs. 0.65 ± 0.16, P = 0.002). The proportion of functionally significant lesions (FFR ≤ 0.80) in vessels with 71% to 90% stenosis was significantly lower in elderly compared to younger patients (75.3% vs. 84.1%, P = 0.013).

Conclusions

FFR-guided PCI is beneficial regardless of age, however, older patients have fewer functionally significant lesions, despite a similar angiographic appearance.     

Virtual Coronary Intervention: A Treatment Planning Tool Based Upon the Angiogram

ObjectivesThis study sought to assess the ability of a novel virtual coronary intervention (VCI) tool based on invasive angiography to predict the patient’s physiological response to stenting.BackgroundFractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) is associated with improved clinical and economic outcomes compared with angiographic guidance alone. Virtual (v)FFR can be calculated based upon a 3-dimensional (3D) reconstruction of the coronary anatomy from the angiogram, using computational fluid dynamics (CFD) modeling. This technology can be used to perform virtual stenting, with a predicted post-PCI FFR, and the prospect of optimized treatment planning.MethodsPatients undergoing elective PCI had pressure-wire–based FFR measurements pre- and post-PCI. A 3D reconstruction of the diseased artery was generated from the angiogram and imported into the VIRTUheart workflow, without the need for any invasive physiological measurements. VCI was performed using a radius correction tool replicating the dimensions of the stent deployed during PCI. Virtual FFR (vFFR) was calculated pre- and post-VCI, using CFD analysis. vFFR pre- and post-VCI were compared with measured (m)FFR pre- and post-PCI, respectively.ResultsFifty-four patients and 59 vessels underwent PCI. The mFFR and vFFR pre-PCI were 0.66 ± 0.14 and 0.68 ± 0.13, respectively. Pre-PCI vFFR deviated from mFFR by ±0.05 (mean Δ = ?0.02; SD = 0.07). The mean mFFR and vFFR post-PCI/VCI were 0.90 ± 0.05 and 0.92 ± 0.05, respectively. Post-VCI vFFR deviated from post-PCI mFFR by ±0.02 (mean Δ = ?0.01; SD = 0.03). Mean CFD processing time was 95 s per case.ConclusionsThe authors have developed a novel VCI tool, based upon the angiogram, that predicts the physiological response to stenting with a high degree of accuracy.     

药物洗脱支架置入术与冠状动脉旁路移植术治疗冠心病多支病变的临床对比研究

目的:探讨药物洗脱支架(DES)治疗冠心病多支冠状动脉(冠脉)病变患者的临床疗效,并与冠脉旁路移植术进行比较.方法:入选2005-01-2008-01在我院行血管重建术的215例冠心病多支冠脉病变患者,其中114例行DES置入术(DES组),101例行冠脉旁路移植术 (CABG组).比较2组住院期和随访期不良心血管事件(死亡、非致死性心肌梗死、再次血管重建术和脑血管意外)的发生情况.结果:2组的临床和冠脉病变特征相似, 与DES组比较,CABG组左主干病变(29.2%∶5.0%,P<0.01)、LVEF<50%发生率(39.7%∶19.2%,P<0.01) 和完全血管重建率(81.2%∶58.8%, P<0.01)较高.住院期2组总体不良心血管事件发生率无明显差异,但CABG组住院期病死率有增高趋势(6.9%∶1.8%,P＞0.05).平均临床随访12～36(17±9)个月,2组总体不良心血管事件发生率仍无明显差异(9.6% ∶13.4%,P＞0.05) ,但DES组再次血管重建的发生率较CABG组有增高趋势(9.8%∶2.1%,P＞0.05).结论:DES置入术应用在冠心病多支冠脉病变患者中安全可行,总体不良心血管事件发生率与CABG无明显差异.     

药物洗脱支架与冠状动脉旁路移植术治疗无保护左主干病变的临床疗效对比

目的:评估药物洗脱支架(DES)置入与冠状动脉旁路移植术(CABG)治疗无保护左主干病变的临床疗效。方法:分析2003-10-2010-09期间行血运重建的282例无保护左主干患者的临床资料,其中接受DES者143例(DES组),接受CABG者139例(CABG组),比较2组住院期和随访期心脑血管不良事件(死亡、非致死性心肌梗死、脑卒中和再次血运重建,即MACCE)的发生情况。结果:DES组手术成功率为100%,住院期间1例发生非致死性心肌梗死,无一例死亡、脑血管意外或需再次血运重建;CABG组手术成功率为95.7%,住院期间有1例发生非致死性急性心肌梗死,无一例需再次血运重建,共有6例死亡;CABG组住院期死亡率明显高于DES组(4.3%∶0,P<0.05),住院期CABG组总MACCE发生率也明显高于DES组(5.0%∶0.7%,P<0.05);随访期平均(17±8)个月,DES组临床心绞痛复发率和再次血运重建率较CABG组有增高趋势(7.8%∶2.7%,7.0%∶1.8%),但差异无统计学意义,其总MACCE发生率显著高于CABG组(14.8%∶7.1%,P<0.05);剔除新发病变及病变进展病例后,2组总MACCE发生率(7.8%∶7.1%)差异无统计学意义。结论:DES治疗无保护左主干病变安全和有效,可以作为CABG的一种替代治疗手段。     

老年慢性肾功能不全患者冠状动脉内药物洗脱支架术远期疗效

目的观察>65岁慢性肾功能不全患者行冠状动脉内药物洗脱支架术的远期疗效。方法将585例年龄> 65岁行冠状动脉介入治疗(PCI)的患者,根据肌酐清除率分为慢性肾功能不全组(355例)和对照组(230例),前者又分药物脱支架组和普通金属支架组,记录各例患者住院期一般资料、冠状动脉造影和PCI情况及随访期所有原因死亡、中风和主要心脏不良事件。比较药物洗脱支架和普通金属支架对慢性肾功能不全组患者的临床疗效。结果与对照组比较,慢性肾功能不全组患者年龄增大,体重减轻,女性、吸烟和不稳定性心绞痛较多。平均随访17个月,慢性肾功能不全组较对照组所有原因病死率(8．17％和3．48％,P<0．05)和心源性病死率(6．48％和2．17％, P<0．05)显著增高,但主要心脏不良事件(13．80％和10．86％,P>0．05)及靶血管再次血运重建率(5．63％和6．08％,P>0．05)无显著差异。慢性肾功能不全组中,药物洗脱支架组(224例)较普通金属支架组(131例)主要心脏不良事件发生率(8．92％和19．84％,P<0．05)和靶血管再次血运重建率(3．12％和9．92％,P<0．05)显著减少,但心源性死亡(4．91％和8．39％,P>0．05)和所有原因死亡(6．25％和11．45％,P>0．05)发生率无显著性差异。结论年慢性肾功能不全患者行PCI术后死亡率增加;与普通金属支架比较,药物洗脱支架可以显著降低靶血管再次血运重建和主要心脏不良事件发生率,但对心源性死亡和所有原因死亡无明显影响。     

Late and very late thrombosis of drug-eluting stents: evolving concepts and perspectives

Coronary stents are the mainstay of percutaneous coronary revascularization procedures and have significantly decreased the rates of acute vessel closure and restenosis. Stent thrombosis (ST) after percutaneous coronary intervention is an uncommon and potentially catastrophic event that might manifest as myocardial infarction and sudden death. Optimization of stent implantation and dual antiplatelet therapy have markedly reduced the occurrence of this complication. Bare-metal stent (BMS) thrombosis occurs in <1% of the cases, usually within the first month after implantation. The advent of drug-eluting stents (DES) has raised concerns regarding later occurrence of ST, beyond the traditional 1-month timeframe, especially in complex lesion subsets that were excluded from randomized trials that compared BMS to DES. There is widespread controversy regarding the actual incremental risk associated with DES. Recent studies suggest a 0.5% increased long-term thrombosis risk with DES; however, the clinical significance of these events remains under debate. The degree of protection achieved by dual antiplatelet therapy and optimal duration of treatment are under investigation. Novel stent designs might potentially decrease the incidence of this event. In this review, we will describe the current knowledge of the pathophysiology of late DES thrombosis, although many aspects remain incompletely understood.     

The truth and consequences of the COURAGE trial

Percutaneous coronary intervention (PCI) has played an integral role in the therapeutic management strategies for patients who present with either acute coronary syndromes or stable angina pectoris. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial enrolled patients with chronic stable angina and at least 1 significant (> or =70%) angiographic coronary stenosis who were randomly assigned to an initial treatment of either PCI in conjunction with optimal medical therapy or optimal medical therapy alone. Although the initial management strategy of PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events, improvement in angina-free status and a reduction in the requirement for subsequent revascularization was observed. An in-depth analysis of the COURAGE trial design and execution is provided.