Sirolimus-eluting stents for the prevention of restenosis in a worst-case scenario of diffuse and recurrent in-stent restenosis.

For recurrent in-stent restenosis (ISR), surgical revascularization or brachytherapy is still the principal therapeutic options. The present investigation explores the efficacy of a sirolimus-eluting stent to prevent restenosis in these lesions with a high risk of recurrence. In 22 consecutive patients with a recurrent and diffuse ISR, a sirolimus-eluting stent was implanted to cover the restenotic lesion. All patients were followed clinically for at least 1 year and underwent a repeat angiography after 7 months. A quantitative coronary angiographic analysis was done. The target vessel failure was 14% in the sirolimus-eluting stent group, with an angiographic late loss of only 0.39 +/- 0.54. No subacute stent thrombosis was observed, and the 1-year event-free survival was 86%. The three cases with restenosis were all focal and could be successfully treated by additional drug-eluting stent implantation. This study showed the efficacy of a sirolimus-eluting stent for the prevention of restenosis in a worst-case scenario of recurrent and diffuse ISR. The observed restenosis rate is lower than that reported after brachytherapy and suggests that sirolimus-eluting stents are a promising treatment option for ISR.     

Individuelle Prognose nach kardiopulmonaler Reanimation – ist eine frühe Vorhersage möglich?

Zusammenfassung In einer prospektiven klinischen Studie wurde der prognostische Vorhersagewert klinischer, laborchemischer und elektrophysiologischer Untersuchungsparameter bei komat?sen Patienten nach kardiopulmonaler Reanimation evaluiert. Von 1997–1999 wurden 69Patienten, 21 Frauen und 48M?nner, mittleres Alter 64 (17–90) Jahre eingeschlossen. 28Tage nach Reanimation waren 56,6% der Patienten verstorben, 43% der überlebenden entwickelten ein apallisches Syndrom. Ergebnisse: Das Fortbestehen einer komat?sen Bewusstseinslage über 48 Stunden nach Reanimation, persistierend hohe Serumkonzentrationen der Neuroproteine Neuronenspezifische Enolase (>30 ng/ml) und Sangtec 100 (>0,7 μg/l) und das Fehlen kortikaler Komplexe mittlerer Latenz (N₇₀) bei Ableitung der Medianus-SEP zeigten mit hoher Spezifit?t und Sensitivit?t frühzeitig eine individuell schlechte Prognose – Tod oder apallisches Syndrom – an. Dabei erwiesen sich die kortikalen Komplexe mittlerer Latenz allen anderen Parametern überlegen. Schlussfolgerung: Die Autoren empfehlen für die Prognosebeurteilung komat?ser reanimierter Patienten auf der Intensivstation neben der t?glichen klinisch-neurologischen Untersuchung die Ableitung der Medianus-SEP, und hier insbesondere der kortikalen Komplexe mittlerer Latenz sowie die Bestimmung der Serumkonzentration eines Neuroproteins NSE oder S 100 über einen Zeitraum von 5 Tagen nach Reanimation. Eingegangen: 3. Juli 2000 Akzeptiert: 6. November 2000     

Early diastolic strain rate predicts response to heart failure therapy in patients with dilated cardiomyopathy

The aim of this prospective study was to assess the value of speckle tracking echocardiographic (2D-STE) parameters to predict response to heart failure therapy in patients with dilated cardiomyopathy (DCM). Eighty-seven patients (mean age 51 ± 13 years) with DCM, defined as ejection fraction (EF) <45 %, left ventricular (LV) end-diastolic diameter >112 % of normal range derived from age and body surface area. Based on 2D-STE following parameters were extracted from three apical views of the LV: global longitudinal strain, systolic and diastolic strain rate (SR_E). Mechanical dispersion was calculated as standard deviation of time-to-peak strain values including all LV segments. After receiving heart failure therapy (mean 39 ± 11 months, range 3–60 months) 50 patients reached combined endpoint defined as following: death, heart transplantation, rehospitalization due to heart failure, and absence of improvement in EF. On stepwise multivariate regression analysis, SR_E was independently of EF and LV volumes predictive for combined endpoint (OR 0.44, 95 %CI 0.27–0.70, p = 0.001) with an area under the ROC-curve (AUC) of 0.91. In patients with cQRS duration ≤120 ms mechanical dispersion was predictive for combined endpoint with the highest AUC (OR 1.53, 95 %CI 1.08–2.16, p = 0.002; AUC = 0.94). In this study, SR_E, a surrogate parameter of myocardial relaxation, was able to predict a response to heart failure therapy in patients with DCM. In patients with narrow QRS complex, mechanical dispersion yielded the highest predictive value. Parameters of 2D-STE may contribute to risk stratification in this patient population.     

The functional reserve of collaterals supplying long-term chronic total coronary occlusions in patients without prior myocardial infarction.

AIMS: Chronic total coronary occlusions (CTOs) with angiographically well-developed collaterals may be considered to provide sufficient blood supply to the occluded segment, and the indication for revascularization may be questioned. Therefore, the collateral function and functional reserve in patients with a CTO without a prior Q-wave myocardial infarction (MI) were assessed. METHODS AND RESULTS: Invasive assessment of collateral function was done during successful percutaneous coronary intervention in 107 patients with a CTO and no prior Q-wave MI. Intracoronary Doppler flow velocity and pressure recordings were obtained distal to the occlusion before the first balloon inflation and collateral function indexes calculated. In 62 patients, additional pharmacological stress testing was done by intravenous adenosine (140 microg/kg/min) to assess the collateral flow reserve. Patients with normal and impaired regional dysfunction were compared. Collateral function was similar in patients with and without regional left ventricular (LV) dysfunction. In both groups, 78% collaterals provided a collateral pressure index at baseline > 0.3, sufficient to prevent ischaemia during a balloon occlusion, with a minimum of 0.2 in those with preserved LV function. A Doppler-derived function index showed a wider variation due to the high prevalence of microvascular dysfunction in CTOs. Only 7% of patients had an increase in collateral flow reserve > 2.0 during pharmacological stress, whereas coronary steal occurred in one-third independent of regional LV function. CONCLUSION: A limited increase in collateral flow and the high prevalence of coronary steal during stress underscore the functional limitation of collaterals in CTOs without prior Q-wave MI. Even presumably 'well-collateralized' CTOs may benefit from a revascularization.     

Paclitaxel-eluting stents for the treatment of chronic total coronary occlusions: a strategy of extensive lesion coverage with drug-eluting stents.

The recanalization of a chronic total coronary occlusion (CTO) is hampered by a high rate of lesion recurrence. The goal of the present study is to assess the effect of paclitaxel-eluting stents in CTOs in a strategy of extensive stent coverage and the optional use of additional bare metal stents (BMSs). In 82 consecutive patients, a CTO (duration > 2 weeks) was successfully recanalized with implantation of one or more Taxus stents. These patients underwent a repeat angiography after 5.0 +/- 1.5 months and were assessed by quantitative angiography. The patients were compared with 82 clinically and lesion-matched patients from a consecutive series of 148 patients with CTOs treated by BMS in the preceding time period. In 21 of the 82 patients, additional lesions in the target artery not directly related to the original occlusion site were treated with BMSs (hybrid approach). The history of diabetes, extent of coronary artery disease, clinical symptoms, and angiographic features were similar in the Taxus and BMS group. Periprocedural adverse events were 3.3% with Taxus and 3.3% with BMS, but 12 months MACE was significantly lower in the group with exclusive use of Taxus (13.3% vs. 56.7%; P < 0.001), mainly due to a lower target lesion revascularization of 10.0% as compared to 53.4% (P < 0.001). There was only one late reocclusion with Taxus (1.7%) as compared to 21.7% with BMS (P < 0.05). However, in the hybrid group, the MACE rate was considerably higher, with 33.3%. Our data of a 80% reduction of target vessel failure as compared to BMS, with a lower risk of late reocclusions without increased acute adverse events, demonstrate the benefit of paclitaxel-eluting stents in CTOs. However, diffuse atherosclerosis in CTOs should be covered completely by the drug-eluting stents.     

Successful high-risk coronary angioplasty in a patient with cardiogenic shock under circulatory assist with a 16F axial flow pump.

We report the case of a 75-year-old patient who suffered from subacute myocardial infarction and severely impaired left ventricular ejection fraction (EF: 17%). Using a novel 16F left ventricular assist device we performed an angioplasty of the right coronary artery, and of the left anterior descending artery. As a result of the circulatory support the patient recovered from cardiogenic shock within 8 hr. At a pump speed of 45,000 rpm the axial flow pump generated flow rates up to 3.3 l/min. The 16F pump cannula was removed using local compression. The EF was 51% at 30-day follow-up examination.     

Pulmonary Hypertension in Patients With Severe Aortic Stenosis: Prognostic Impact After Transcatheter Aortic Valve Replacement: Pulmonary Hypertension in Patients Undergoing TAVR

Objectives

The authors investigated the development of pulmonary hypertension (PH), predictors of PH regression, and its prognostic impact on short, mid-, and long-term outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).

Determinants of target vessel failure in chronic total coronary occlusions after stent implantation. The influence of collateral function and coronary hemodynamics

OBJECTIVES: The goal of this study was to assess the influence of collateral function, coronary hemodynamics, and the angiographic result on the risk of target vessel failure (TVF) after recanalization of a chronic total coronary occlusion (CTO). BACKGROUND: Collaterals may have an adverse effect on TVF. METHODS: In 111 consecutive patients, a CTO (duration >2 weeks) was successfully recanalized with stent implantation. Collateral function was assessed by intracoronary Doppler flow velocity and pressure recordings distal to the occlusion. Baseline collateral function was determined before the first balloon inflation, and recruitable collateral function after stenting during a balloon reocclusion. Finally, the coronary flow velocity reserve (CFVR) and the fractional flow reserve (FFR) were measured. RESULTS: Angiographic follow-up after 5 +/- 4 months in 106 patients showed a reocclusion in 17% and a restenosis in 36%. The major determinants of TVF were the stent length (p < 0.01) and number of implanted stents (p < 0.01). No difference was observed in baseline or recruitable collateral function between patients with and without TVF; 52% of patients had a CFVR >or= 2.0, and only 18% a CFVR >or=2.5 after percutaneous transluminal coronary angioplasty, but neither cutoff-value predicted TVF. A low FFR discriminated patients with reocclusion (0.81 +/- 07 vs. 0.86 +/- 08, p < 0.05) but not with restenosis (0.87 +/- 0.06). CONCLUSIONS: This study showed that there is no relation between a well-developed collateral supply and the risk of TVF in recanalized CTOs. This was rather determined by the stented segment length. There was also no adverse effect of the frequently observed impaired CFVR on TVF, whereas a low FFR was associated with a higher risk of reocclusion.     

Case Report: Clinical AV Nodal Reentrant Tachycardia in a Patient with Left Sided Accessory Pathway and Immediate Occurrence of Antidromic AV Reentrant Tachycardia after Slow Pathway Ablation

The only inducible arrhythmia in a patient with exclusive antegrade conducting left anterolateral accessory pathway, consists of slow/fast atrioventricular nodal reentrant tachycardia. After radiofrequency catheter ablation of the slow pathway, true antidromic AV reentrant tachycardia was easily induced by atrial pacing. Following ablation of the accessory pathway no arrhythmia could be induced.     

Additional luminal area gain by intravascular ultrasound guidance after coronary stent implantation with high inflation pressure

Aims: Studies by intravascular ultrasound demonstrated inadequate expansion in a large number of stents, which lead to the increase of inflation pressures for stenting. The present study examined whether routine use of high-pressure inflation would be sufficient for an optimum stent expansion without sonographic guidance. Methods and results: Two types of single coronary stents (Palmaz-Schatz in 54, and Wiktor in 25) were implanted with inflation pressures of 16–20 atm in 79 nonocclusive coronary lesions. IVUS before stenting was used in 78% to select the adequate stent size. Intravascular ultrasound after stenting was used to assess the minimum stent area and diameter, the reference areas, and the strut apposition to the vessel wall. The difference between the area of the expanding balloon and the stent area was calculated as the luminal deficit of the stent. Completeness of stent expansion required full strut apposition and lesion coverage, and a minimum stent area that was larger than the distal reference, and larger than 60% of the proximal reference. Intravascular ultrasound before stenting lead to an increase of the stent size in 47%. After high-pressure expansion, even with the optimized balloon size, 8% of stents had struts protruding into the lumen. The stent area (6.87 ± 1.93 mm²) was significantly smaller than both the proximal (9.59 ± 2.91 mm²; p<0.001) and distal reference area (8.23 ± 3.03 mm²; p<0.001). The criteria for complete expansion were met in 48%. The expansion with a larger high-pressure balloon in 28 stents lead to an increase of the stent area by 19% (8.19 ± 2.24; p<0.001), and full stent apposition in all cases. The criteria of stent expansion were met in 82%. A wide range of the luminal deficit upto 48% was observed, which was not related to sonographic lesion characteristics, except in lesions with complete circumferential calcifications. The different stent designs were characterized by a slightly lower luminal deficit in slotted-tube stents (23 ± 13% vs. 28 ± 12%; p=0.11) and a better index of stent symmetry as compared with the coil stent (0.87 ± 0.08 vs. 0.82 ± 0.09; p<0.05). Conclusion: Routine use of high-pressure stent expansion did not lead to a sufficient stent expansion, even when the initial stent size had been guided by intravascular ultrasound. Further stent dilatation with larger balloons under ultrasound guidance would be required to optimize the luminal area gain.