Risk-scoring model to predict one-year major adverse cardiac events after percutaneous coronary intervention

Background: The aim of the present study was to develop a scoring system for predicting 1-year major adverse cardiac events [MACE], including mortality, target vessel or target lesion revascularization, coronary artery bypass graft surgery, and non-fatal myocardial infarction after percutaneous coronary intervention [PCI]

Methods: The data were extracted from a single center PCI registry. The score was created based on the clinical, procedural, and laboratory characteristics of 8206 patients who underwent PCI between April 2004 and October 2009. Consecutive patients undergoing PCI between November 2009 and February 2011 [n= 2875] were included as a validation data set

Results: Diabetes mellitus, increase in the creatinine level, decrease in the left ventricular ejection fraction, presentation with the acute coronary syndrome, number of diseased vessels, primary PCI, PCI on the left anterior descending artery and saphenous vein graft, and stent type and diameter were identified as the predictors of the outcome and used to develop the score [R[²] = 0.795]. The models had adequate goodness of fit [Hosmer-Lemeshow statistic; p value = 0.601] and acceptable ability of discrimination [c-statistics = 0.63]. The score categorized the individual patients as low-, moderate-, and high-risk for the occurrence of MACE. The validation of the model indicated a good agreement between the observed and expected risks

Conclusion: An individual risk-scoring system based on both clinical and procedural variables can be used conveniently to predict 1-year MACE after PCI. Risk classification based on this score can assist physicians in decision-making and postprocedural health care

Association between traditional risk factors and coronary artery ectasia: a study on 10057 angiographic procedures among Iranian population

Whether coronary artery ectasia [CAE] is a unique clinical finding or results from other clinical entities is still unknown. We aimed to determine the CAE prevalence, investigate the relationship between CAE and patients' demographic and clinical characteristics, and assess the prognosis at follow-up in a sample of Iranian population. Totally, 10057 patients who underwent coronary angiography were divided into three categories: normal coronary arteries without co-existing coronary artery disease; CAE without co-existing coronary artery narrowing < 50%; and coronary artery stenosis with > 50% luminal narrowing [CAS]. The prevalence of CAE was 1.5%. Compared to the normal individuals, the CAE patients were older, were more frequently male, and had higher rates of myocardial infarction [MI]. The CAE patients had a lower frequency of diabetes and MI than the CAS group. The CAE patients were largely focused between 40 to 60 years of age. The right coronary and left anterior descending arteries were the most involved arteries, and ectasia was located more frequently in the proximal part of these arteries. Patients with ectasia in the three main vessels had higher rates of MI. After a mean follow-up of 54.23 +/- 18.41 months, chest pain and dyspnea on exertion remained the main complaint in more than 97% of the patients, leading to hospital admission in more than 14%. There was no relationship between the presence of ectasia and conventional risk factors. According to our study, pure CAE may be deemed a benign feature of atherosclerosis; however, it can lead to frequent hospital admissions because of the persistence of cardiovascular symptoms

Comparison of echocardiographic markers of cardiac dyssynchrony and latest left ventricular activation site in heart failure patients with and without left bundle branch block

Several echocardiographic markers have been introduced to assess the left ventricular [LV] mechanical dyssynchrony. We studied dyssynchrony markers and the latest LV activation site in heart failure patients with and without left bundle branch block [LBBB]. Conventional echocardiography and tissue velocity imaging were performed for 78 patients [LV ejection fraction /= 3 markers was remarkably higher in the LBBB patients [73% vs. 43.9%, respectively; p value = 0.044]. The LBBB patients presented with a higher prevalence of dyssynchrony according to the frequently used echocardiographic markers. The latest activation site was different between the groups

Effectiveness of two-year versus one-year use of dual antiplatelet therapy in reducing the risk of very late stent thrombosis after drug-eluting stent implantation

Impact of 12 months' versus 24 months' use of dual antiplatelet therapy on the prevalence of stent thrombosis in patients undergoing percutaneous coronary intervention [PCI] with the drug-eluting stent [DES] is not clear. As a result, duration of dual antiplatelet therapy is still under debate among interventionists. From March 2007 until August 2008, all consecutive patients with successful PCI who received at least one DES and were treated with dual antiplatelet therapy [Clopidogrel + Aspirin] were included. All the patients were followed up for more than 24 months [mean = 35.27 +/- 6.91 months] and surveyed for very late stent thrombosis and major cardiovascular events. From 961 patients eligible for the study, 399 [42%] discontinued Clopidogrel after 12 months and 562 [58%] continued Clopidogrel for 24 months. The clinical and procedural variables were compared between the two groups. In the 12 months' use group, two cases of definite thrombosis occurred at 18 and 13 months post PCI. In the 24 months' use group, 2 cases of definite thrombosis occurred at 14 and 28 months post PCI, one of them with stenting in a bifurcation lesion. Five cases of probable stent thrombosis were detected at 21, 28, 32, 33, and 34 months after the procedure. It is of note that amongst the 10 cases of stent thrombosis, only 1[10%] thrombosis occurred when the patient was on Clopidogrel and Aspirin and all the other 9 [90%] cases of thrombosis appeared after the discontinuation of the dual antiplatelet therapy. Extended use of dual antiplatelet therapy [for more than 12 months] was not significantly more effective than Aspirin monotherapy in reducing the risk of myocardial infarction or stent thrombosis, death from cardiac cause, and stroke

Anatomy of atrioventricular node artery and pattern of dominancy in normal coronary subjects: a comparison between individuals with and without isolated right bundle branch block

Isolated right bundle branch block [RBBB] is a common finding in the general population. The atrioventricular node [AVN] artery contributes to the blood supply of the right bundle branch. Our hypothesis was that the anatomy of the AVN artery and the pattern of dominancy differ between subjects with and without RBBB. We retrospectively studied the coronary angiography of 92 patients with RBBB and 184 age- and gender-matched controls without RBBB. All the subjects had angiographically proven normal coronary arteries. The dominant circulation and precise origin of the AVN artery were determined in each subject. Obtained data were compared between the two study groups. There was no significant difference between the two groups in terms of dominancy [p value = 0.200]. Origination of the AVN artery from the right circulatory system was more common in both groups, but this pattern was more prevalent in the cases than in the controls [p value = 0.021]. There was a great variation of the AVN artery origin. In the total study population, the AVN artery was more commonly separated from a non crux origin than from the crux area. The prevalence of the non-crux origination of the AVN artery was significantly higher in the cases than in the controls [p value < 0.001]. While the origination of the AVN artery from the right circulatory system was more common in both groups, the prevalence of the right origin of the AVN artery was significantly higher in the cases than in the controls. We observed that the AVN artery most commonly originated from the dominant artery but not necessarily from the crux. The anatomy of the AVN artery but not the pattern of dominancy is somewhat different in subjects with RBBB compared with normal individuals

Percutaneous transvenous mitral commissurotomy: significance of echocardiographic assessment in prediction of immediate result

The current study aims to identify demographic, clinical characteristics, echocardiographic and/or mitral valve morphological parameters that may predict the successful result of percutaneous transvenous mitral commissurotomy [PTMC]. The medical records of 196 patients [48 males, mean age: 42.7 +/- 11.5 years] who underwent PTMC were reviewed. Prior to PTMC, a combination of transthoracic and transesophageal echocardiography were used to investigate substantial mitral valve morphological subcomponents [thickening, mobility, calcification, and subvalvular thickness] and suitability for PTMC. The second transthoracic echocardiographic assessment was performed within six weeks after PTMC. Patients were divided into two categories of successful or unsuccessful according to PTMC results. Successful PTMC was defined as: final mitral valve area [MVA] >/= 1.5 cm[2] without a post-procedure mitral regurgitation [MR] grade >2. The significant predictor of the result was identified by comparing demographic data, initial echocardiographic assessment and mitral valve morphological scores within both groups. The mean MVA increased from 1.0 +/- 0.2 cm[2] to 1.7 +/- 0.4 cm[2], and mitral valve mean gradient [MVMG] decreased from 11.5 +/- 5.2 to 5.2 +/- 3.3 mmHg [P < 0.001 for both]. Successful results were obtained in 139 [70.9%] patients compared to unsuccessful results in 57 [29.1%]. Unsuccessful results were due to suboptimal secondary MVA < 1.5 cm[2] in 50 [25.5%] patients and post-procedure MR grade >2 in 7 [3.6%]. Multiple logistic regression analysis indicated that young age, lower size of the left atrium [LA], and smaller degree of mitral valve thickness were the predictors of successful result. Pre-procedure echocardiographic assessment appears to be helpful in predicting PTMC results. Successful PTMC is influenced by the patients' age, LA size, and mitral valve thickness

Assessment of left ventricular dyssynchrony in heart failure patients regarding underlying etiology and QRS duration

Left ventricular [LV] dyssynchrony is a prevalent feature in heart failure [HF] patients. The current study aimed to evaluate the prevalence of inter and intraventricular dyssynchrony in HF patients with regard to the QRS duration and etiology. The available data on the tissue Doppler imaging [TDI] of 230 patients with refractory HF were analyzed. The patients were divided into three groups according to the QRS duration: QRS duration < 120 ms; 120-150 ms; and >/= 150 ms and the patients were re-categorized into two subgroups depending on the underlying etiology: ischemic cardiomyopathy [ICM] or dilated cardiomyopathy [DCM]. The time-to-peak myocardial sustained systolic velocity [Ts] in six basal and six middle segments of the LV was measured manually using the velocity curves from TDI. LV dyssynchrony was defined as interventricular mechanical delay >/= 40 ms and tissue Doppler velocity all segments delay >/= 105 ms; standard deviation [SD] of all segments >/= 34.4 ms; basal segments delay >/= 78 ms; SD of basal segments >/= 34.5 ms; and opposing wall delay >/= 65 ms. After adjustment for the possible confounders, interventricular dyssynchrony was more prevalent in the patients with QRS duration >/= 150 ms than in those with QRS duration 120-150 ms and < 120 ms. The patients with DCM also had a higher percentage of interventricular dyssynchrony than those with ICM in the wide QRS groups. Turning to the intraventricular dyssynchrony indices, the patients with QRS duration >/= 150 ms and 120-150 ms revealed a significantly greater delay between Ts at the basal and all segments than did those with QRS duration < 120 ms, while etiology did not influence the frequency of these indices in each QRS group. The prevalence of both inter and intraventricular dyssynchrony indices was greater in the patients with wide QRS than in those with narrow QRS duration. The underlying etiology may affect the frequency of interventricular but not intraventricular dyssynchrony indices

Measurement of atrial septal defect size: a comparative study between transesophageal echocardiography and balloon occlusive diameter method

Transcatheter closure of atrial septal defect secundum [ASD-II] has become an alternative method for surgery. We sought to compare the two-dimensional transesophageal echocardiography [TEE] method for measuring atrial septal defect with balloon occlusive diameter [BOD] in transcatheter ASD-II closure. A total of 39 patients [71.1% female, mean age: 35.31 +/- 15.37 years] who underwent successful transcatheter closure of ASD-II between November 2005 and July 2008 were enrolled in this study. Transthoracic echocardiography [TTE] and TEE were performed to select suitable cases for device closure and measure the defect size before the procedure, and BOD measurement was performed during catheterization via TEE. The final size of the selected device was usually either equal to or 1-2 mm larger than the BOD of the defect. The mean defect size obtained by TEE and BOD was 18.50 +/- 5.08 mm and 22.86 +/- 4.76 mm, respectively. The mean difference between the values of ASD size obtained by TEE and BOD was 4.36 +/- 2.93 mm. In comparison with BOD, TEE underestimated the defect size in 94.9%, but TEE value being equal to BOD was observed in 5.1%. There was a good linear correlation between the two measurements: BOD=0.773 ASD size by TEE+8.562; r2=67.9.1%. A negative correlation was found between TEE sizing and the difference between BOD and TEE values [r=-0.394, p value=0.013]. In this study, BOD was larger than ASD size obtained by two-dimensional TEE. However, TEE maximal defect sizing correlates with BOD and may provide credible information in device size selection for transcatheter ASD closure

Impact of isolated coronary artery bypass grafting on non-organic tricuspid regurgitation severity

Moderate non-organic tricuspid regurgitation [TR] concomitant with coronary artery disease is not uncommon, Whether or not TR improves after pure coronary artery bypass grafting [CABG], however, is unclear. The aim of this study was to evaluate the effect of isolated CABG on moderate non-organic TR. This study recruited 50 patients [40% female, mean age: 65.38 +/- 8.01 years, mean left ventricular ejection fraction [LVEF]: 45.74 +/- 13.05%] with moderate non-organic TR who underwent isolated CABG. TR severity before and after CABG was compared. Pulmonary arterial systolic pressure [PAPs] > 30mmHg and LVEF < 50% were considered elevated PAPs [EPAPs] and LV systolic dysfunction, respectively. Presence of Q-wave in leads II, III, and aVF was considered inferior myocardial infarction [inf. MI]. Pre-operatively, 81.5% of the patients had EPAPs, 16% right ventricle [RV] dilation, and 50% left ventricle [LV] and 16% RV systolic dysfunction. TR severity improved in 64% after CABG, whereas it remained unchanged or even worsened in others [P value < 0.001]. Patients with inf. MI showed no improvement in TR, while patients without inf. MI had significant TR regression after CABG [P value= 0.050]. Improvement of TR severity after CABG was not related to pre-operative RV size and function, LV systolic function, or PAPs reduction. Although TR severity decreased remarkably after isolated CABG, a considerable number of the patients had no TR regression. In addition, only absence of inf. MI was significantly correlated to TR improvement after CABG. Further prospective studies with long-term follow-up needed to determine the other factors predicting TR regression after isolated CABG

Transesophageal echocardiographic characteristics of secundum-type atrial-septal defect in adult patients

Given the dearth of data in the existing literature on the size and morphologic variability of secundum-type atrial-septal defect [ASD-II] in adult patients, we aimed to address this issue in a series of consecutive adult patients evaluated by transesophagesal echocardiography [TEE]. A total of 50 patients [68.0% female] with isolated ASD-II underwent TEE for the evaluation of the defect. The morphological characteristics of eh defect were evaluated, and the largest defect size was measured. The ASD rim was divided into 6 sectors: the superior-anterior, superior-posterior; superior, inferior-anterior, inferior-posterior, and inferior. The minimal length of the defect rims was determined. Mean age at the time of evaluation was 33.62 +/- 14.48 years. Mean defect diameter in the all the study patients was 20.80 +/- 8.17 mm. Thirteenmorphological variations were detected. Deficiency of one rim was detected in 14 [28%] patients, two in 16 [32%], three in 2 [4%], and four in 2 [4%]. Deficiency of the superior anterior rim was found din 24% of the patients [gamma= 0.558, P value < 0.001]. Forty-eight [96%] patients emerged for defect closure: 22 [46.2%] suitable for percutaneous closure and 26 [53.8%] for surgical closure. Two patients with small defects were recommended for medical treatment and follow-up. ASD-II is larger and more morphologically variable in adults than in children. Based on the findings of the present and previous studies and given the advantages of percutaneous treatment, it is advisable to make a decision on ASD-II closure as soon as possible before it outgrows the transcatheter closure suitability criteria

Assessment of myocardial viability: selection of patients for viability study and revascularization

The aim of this article is to review the application of current imaging techniques used for the detection of viable myocardium. Each technique is discussed briefly, and the more commonly used techniques are compared. The imaging techniques reviewed herein are dobutamine stress echocardiography, single photon emission tomography, magnetic resonance imaging, positron emission tomography with F-18 fluorodeoxyglucose, and recently introduced tissue Doppler imaging. The estimation of the amount of viable myocardium that could predict a better outcome after revascularization being a challenging issue, the present article also reviews a variety of cut-off points suggested by different investigators as adequate viable myocardium for revascularization and presents a summary of clinical, angiographical, and echocardiographic findings that could assist in selecting patients for viability study

Discrete subvalvular aortic stenosis: severity of aortic regurgitation and rate of recurrence at midterm follow-up after surgery

Discrete subaortic stenosis [DSS] is a progressive condition. Controversy still rumbles on as to whether the subaortic membrane causes aortic regurgitation [AR] and whether membrane resection reduces AR severity. We investigated the association between the left ventricular outflow tract peak gradient [LVOT-PG] and AR severity preoperatively and changes in AR severity and obstruction recurrence after surgery in DSS patients. Twenty patients were evaluated before and after surgery for DSS [mean follow-up time: 13.60 +/- 9.61 months]. The patients were evaluated via transthoracic echocardiography and transesophageal echocardiography, if necessary. The cut-off point for surgery was LVOT-PG ?50 mmHg or the presence of progressive AR. The mean age of the patients was 28.55 +/- 15.23 years, and 35% of them were male. LVOT-PG decreased from a mean of 80.83 +/- 42.72 mmHg preoperatively to 19.14 +/- 14.03 mmHg postoperatively and to 25.47 +/- 16.10 at follow-up. AR was identified in 15 [75%] patients preoperatively: mild in 8 [40%] and moderate in 7 [35%]. The postoperative change in AR severity was insignificant. The correlation between preoperative LVOT-PG and the incidence and severity of preoperative AR was not significant. AR severity had no correlation with age. Membrane recurrence occurred in 25% of the patients. Our results indicated no relationship between AR severity and LVOT-PG and the patient's age. Patient selection for surgery can, therefore, be carried out on the basis of LVOT-PG or AR severity separately. Subaortic resection may reduce AR severity in some patients, but this reduction is not significant. Future studies are required to elucidate whether or not the presence of the AR is an indication for surgery

Coronary artery bypass surgery versus medical treatment in patients with low ejection fraction and coronary artery disease

We compared the outcomes in patients with a low ejection fraction [EF] and multivessel coronary artery disease [CAD] who either underwent coronary artery bypass grafting [CABG] or received medical treatment [MT] after a viability study via dobutamine stress echocardiography [DSE]. We considered patients with CAD and left ventricular ejection fraction [LVEF] 25% [100% vs. 40%, p < 0.05]. The patients with CAD and a low EF had the same survival rate after both CABG and MT at mid-term follow-up. Long-term follow-up is needed to show the survival benefit of CABG in such patients with an acceptable extent of viable myocardium

Using workload to predict left main coronary artery stenosis in candidates for coronary angiography

Coronary angiography, albeit a safe procedure, may cause serious complications especially in patients with left main stenosis [LMS].This study was designed to investigate the efficacy of workload achieved by exercise tolerance test [ETT] in predicting LMS in candidates for coronary angiography. A total of 743 patients with a positive ETT who subsequently underwent cardiac catheterization were retrospectively studied. Different risk factors were compared among the patients with and without LMS. A multivariate forward stepwise logistic regression analysis was used to identify the main predictors of LMS. Among our 743 patients, 72% were male and 41 [5.5%] had LMS >/= 50%. Patients with LMS, by comparison with those without LMS, were older and were more likely to be male and had higher percentages of ejection fraction less than 35% [EF 7, LMS was found in 8.3% and 3.6%, respectively [P=0.006]. The risk of having LMS in the men with METs 7 [OR=3, P=0.003, 95% CI=1.50-6.00]. Among the patients with LMS, stenosis >/= 70% was found in 44% in METs 7. Lower METs correlated with an increased likelihood of significant LMS in the patients, especially if they were male, who had a positive exercise test and were suspected of coronary artery disease. It is, therefore, advisable that patients with METs