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1.
J Clin Med ; 13(11)2024 May 22.
Article in English | MEDLINE | ID: mdl-38892761

ABSTRACT

Background/Objectives: Despite procedural improvements, post-transcatheter aortic valve replacement (TAVR) conduction disorders remain high. Analyzing the data from a monocentric TAVR registry, this study aims to determine predictive factors for PPI (primary outcome), the indication for PPI, and long-term outcomes among these patients (secondary outcomes). Methods: Conducted at Clairval Hospital in Marseille, France, this retrospective study included all consecutive patients from June 2012 to June 2019. Clinical, electrocardiographic, echocardiographic, and procedural data were collected, with outcomes assessed annually. Logistic regression identified PPI predictors and survival analyses were performed. Results: Of the 1458 patients initially considered, 1157 patients were included. PPI was needed in 21.5% of patients, primarily for third-degree atrioventricular block (46.4%). Predictor factors for PPI included baseline right bundle branch block (ORadj 2.49, 95% CI 1.44 to 4.30; p = 0.001), longer baseline QRS duration (ORadj 1.01, 95% CI 1.00 to1.02, p = 0.002), and self-expandable valves (ORadj 1.82, 95% CI, 1.09 to 3.03; p = 0.021). Seven-year estimated mortality was higher in PPI (43.3%) vs. non-PPI patients (30.9%) (log rank p = 0.048). PPI was an independent predictive factor of death (ORadj 2.49, 95% CI 1.4 to 4.3; p = 0.002). Conclusions: This study reveals elevated rates of PPI post-TAVR associated with increased mortality. These results underscore the pressing necessity to refine our practices, delineate precise indications, and enhance the long-term prognosis for implanted patients.

2.
J Am Coll Cardiol ; 58(5): 467-73, 2011 Jul 26.
Article in English | MEDLINE | ID: mdl-21777742

ABSTRACT

OBJECTIVES: The aim of this study was to investigate the relationship between platelet reactivity (PR) after a loading dose (LD) of prasugrel and thrombotic events. BACKGROUND: Post-treatment PR has been shown to be strongly associated with the occurrence of major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) in the clopidogrel era. Prasugrel is a new P2Y(12)-adenosine diphosphate receptor with a higher potency on PR. METHODS: A prospective multicenter study included patients who underwent successful PCI for acute coronary syndromes and received prasugrel therapy. Vasodilator-stimulated phosphoprotein (VASP) index was measured after the prasugrel LD. High on-treatment PR was defined as a VASP index ≥50%. MACE included cardiovascular death, myocardial infarction, and definite stent thrombosis at 1 month. RESULTS: Three hundred one patients were enrolled. The mean VASP index after 60 mg of prasugrel was 34.3 ± 23.1%. High on-treatment PR was observed in 76 patients (25.2%). Patients experiencing thrombotic events after PCI had significantly higher VASP indexes compared with those free of events (64.4 ± 14.4% vs. 33.4 ± 22.7%; range: 51% to 64% and 5% to 47.6%, respectively; p = 0.001). Kaplan-Meier analysis comparing good responders and patients with high on-treatment PR demonstrated a significantly higher rate of MACE in patients with suboptimal PR inhibition (log-rank p < 0.001). Receiver-operating characteristic curve analysis found a cutoff value of 53.5% of the VASP index to predict thrombotic events at 1 month (r = 0.86, p < 0.001). Patients with minor or major Thrombolysis In Myocardial Infarction unrelated to coronary artery bypass grafting bleeding and those without had similar VASP indexes (30 ± 17.8% vs. 34.3 ± 23%, p = 0.70). CONCLUSIONS: Despite the use of prasugrel, a significant number of patients undergoing PCI in the setting of acute coronary syndromes do not achieve optimal PR inhibition. Such patients have a higher risk for MACE after PCI.


Subject(s)
Acute Coronary Syndrome/therapy , Angioplasty, Balloon, Coronary , Blood Platelets/metabolism , Phosphoproteins/metabolism , Piperazines/therapeutic use , Purinergic P2Y Receptor Antagonists/therapeutic use , Thiophenes/therapeutic use , Coronary Thrombosis/epidemiology , Female , Humans , Hypercholesterolemia/epidemiology , Male , Middle Aged , Myocardial Infarction/epidemiology , Prasugrel Hydrochloride , Predictive Value of Tests , Prospective Studies , ROC Curve , Sensitivity and Specificity , Stents
3.
Arch Cardiovasc Dis ; 104(1): 29-34, 2011 Jan.
Article in English | MEDLINE | ID: mdl-21276575

ABSTRACT

BACKGROUND: Coronary computed tomography (CCT) detects coronary obstruction with high sensitivity and might be useful for diagnosis of angina pectoris. AIM: In this pilot study, we sought to prospectively evaluate the performance of CCT as initial work up and determine the significance of this strategy according to the pretest likelihood of having coronary artery disease (CAD). METHODS: One hundred and eighty patients with chest discomfort and suspected angina were prospectively referred for CCT with a 64-slice CT scan. Invasive coronary angiography (ICA) was performed on the basis of CCT findings (stenosis>50%). Patients were classified into tertiles according to estimated pretest probability of obstructive CAD using the Duke Clinical Score (low, intermediate and high). Strategy failure was defined as unnecessary ICA or major adverse cardiac event (MACE) within 6 months in patients without significant stenosis by CCT. RESULTS: Pretest probability for CAD was 53 ± 29%. Significant stenosis was detected by CCT in 51 patients; 47 (26%) underwent ICA. Sixteen strategy failures were reported: 15 patients (10%) were referred for ICA that did not confirm significant coronary stenosis and one MACE occurred in a patient without significant stenosis by CCT. Strategy failures were 8% in low-probability, 1.7% in intermediate-probability and 15% in high-probability patients (P=0.03). CONCLUSIONS: CCT as an initial step for angina diagnosis is most effective in patients with an intermediate probability of CAD. In patients with low or high likelihood, it is associated with a high rate of unnecessary ICA but not with adverse events.


Subject(s)
Angina Pectoris/diagnostic imaging , Coronary Angiography/methods , Coronary Stenosis/diagnostic imaging , Tomography, X-Ray Computed , Aged , Angina Pectoris/etiology , Chi-Square Distribution , Coronary Stenosis/complications , Female , France , Humans , Male , Middle Aged , Pilot Projects , Predictive Value of Tests , Prognosis , Prospective Studies , Severity of Illness Index , Time Factors , Unnecessary Procedures
4.
Cardiovasc Revasc Med ; 7(4): 208-11, 2006.
Article in English | MEDLINE | ID: mdl-17174865

ABSTRACT

OBJECTIVES: We sought to compare the adequacy of paclitaxel-eluting stent (PES) and sirolimus-eluting stent (SES) expansion based on intravascular ultrasound (IVUS) imaging criteria at conventional delivery pressures. METHODS: Forty-six patients underwent SES implantation and 42 patients underwent PES implantation for de novo native coronary lesions<33 mm in length with reference lumen diameters of 2.5-3.5 mm. Stents were serially expanded with gradual balloon inflations at 14 and 20 atm. IVUS imaging was performed prior to intervention and after each balloon inflation. Stent expansion (minimal stent cross-sectional area/reference lumen cross-sectional area) was measured. Inadequate stent expansion was defined using the MUSIC criteria (all struts apposed, no tissue protrusion, and final lumen cross-sectional area>80% of the reference or >90% if minimal lumen cross-sectional area was <9 mm2). RESULTS: The baseline characteristics of the two groups were similar except for shorter lesion length, larger mean lumen cross-sectional area, larger lumen diameter, and lower plaque burden in the PES group. Stent expansion was inadequate in 80% of patients with SES versus 63% of patients with PES at 14 atm, although this was not statistically significant. After 20 atm, 48% of patients with SES remained underexpanded as compared with 35% of patients with PES. CONCLUSION: Drug-eluting stents showed significant underexpansion by MUSIC criteria at conventionally used inflation pressures. Higher balloon inflations are required especially during deployment of a SES. IVUS guidance is recommended to ensure optimal results and outcomes with both stents.


Subject(s)
Coronary Stenosis/drug therapy , Immunosuppressive Agents/administration & dosage , Paclitaxel/administration & dosage , Sirolimus/administration & dosage , Stents , Aged , Chi-Square Distribution , Coronary Stenosis/diagnostic imaging , Drug Delivery Systems , Female , Humans , Male , Middle Aged , Pressure , Treatment Outcome , Ultrasonography, Interventional
5.
Crit Care Med ; 34(5): 1358-64, 2006 May.
Article in English | MEDLINE | ID: mdl-16557157

ABSTRACT

OBJECTIVE: We sought to determine whether assessing D-Dimer might be helpful for the management of acute aortic dissection (AAD). DESIGN: Single-center retrospective case-control study. SETTING: University Hospital of Strasbourg France. PATIENTS: Patients were 94 consecutive patients admitted to our institution with confirmed AAD and in whom D-Dimer test had been performed at presentation. These patients were matched with 94 controls presenting with clinical suspicion of dissection, which was later ruled out. INTERVENTIONS: Patient characteristics and clinical course were analyzed. MEASUREMENTS AND MAIN RESULTS: Ninety-three (99%) patients with AAD had elevated D-Dimer (>400 ng/mL) with a median D-Dimer value of 8610 ng/mL (interquartile range, 2982-20,000 ng/mL). Receiver operating characteristic curves analysis showed that D-Dimer, but not C-reactive protein, troponin, lactate dehydrogenase, or leukocyte count, was predictive of a diagnosis of AAD, with a sensitivity and specificity of 99% and 34%, respectively. D-Dimer concentration positively correlated with the anatomical extension of the dissection to the different segments of the aorta (R = .47, p < .0001). A positive relationship was observed between D-Dimer and in-hospital mortality rate among patients with AAD (p = .037). On multivariate analysis, the independent predictors of in-hospital mortality were the presence of pericardial effusion (odds ratio, 6.80; confidence interval, 1.87-27.60), D-Dimer >5200 ng/mL (odds ratio, 5.38; confidence interval, 1.27-30.87), and female gender (odds ratio, 4.96; confidence interval, 1.39-19.95). CONCLUSIONS: D-Dimers are elevated in patients with AAD and provide valuable diagnostic and prognostic information. In patients with acute chest pain and elevated D-Dimer, a diagnosis of AAD should also be considered. D-Dimer might be a useful complementary tool to the current diagnostic work-up of patients with suspected AAD.


Subject(s)
Aortic Aneurysm/diagnosis , Aortic Dissection/diagnosis , Fibrin Fibrinogen Degradation Products/metabolism , Acute Disease , Aortic Dissection/mortality , Aortic Aneurysm/mortality , Biomarkers , Case-Control Studies , Female , Humans , Logistic Models , Male , Matched-Pair Analysis , Middle Aged , Multivariate Analysis , Prognosis , Retrospective Studies , Sensitivity and Specificity , Survival Analysis
6.
Am J Cardiol ; 97(1): 34-7, 2006 Jan 01.
Article in English | MEDLINE | ID: mdl-16377280

ABSTRACT

Saphenous vein graft (SVG) intervention is associated with a significantly increased rate of periprocedural complications and late clinical and angiographic restenosis. We examined the efficacy and safety of sirolimus-eluting stents (SESs; Cypher) compared with bare metal stents (BMSs) in SVG intervention. Forty-eight patients who had 50 SVG lesions and underwent standard percutaneous coronary intervention with SESs (SES group) were compared with 57 patients who had 64 SVG lesions and underwent intervention with BMSs (BMS group). All patients received distal protection devices during SVG intervention. In-hospital, 30-day, 6-month, and 1-year clinical outcomes in the 2 groups were compared. Baseline clinical and procedural characteristics were balanced between groups. There were no deaths or Q-wave myocardial infarctions during the index hospitalization, but compared with the BMS group, patients in the SES group had significantly fewer non-Q-wave myocardial infarctions (4% vs 21%, p = 0.01), which was mainly attributed to increased periprocedural creatine kinase-MB levels. At 30-day, 6-month, and 1-year follow-ups, all clinical outcomes were similar between groups. Event-free survival at 1 year was also similar between groups (p = 0.84). In conclusion, the use of SESs in patients who undergo SVG intervention with a distal protection device is clinically safe and feasible but is not associated with decreased clinical events up to 1 year compared with BMSs.


Subject(s)
Graft Occlusion, Vascular/prevention & control , Immunosuppressive Agents/administration & dosage , Saphenous Vein/transplantation , Sirolimus/administration & dosage , Stents , Aged , Angioplasty, Balloon, Coronary , Creatine Kinase, MB Form/blood , Electrocardiography , Female , Follow-Up Studies , Humans , Male , Myocardial Infarction/blood , Myocardial Infarction/therapy , Myocardial Revascularization
7.
Cardiovasc Revasc Med ; 6(4): 154-9, 2005.
Article in English | MEDLINE | ID: mdl-16326376

ABSTRACT

BACKGROUND: Bivalirudin is replacing heparin in percutaneous coronary interventions (PCIs), including vascular brachytherapy (VBT). The aim of the study was to compare bivalirudin with eptifibatide in patients with in-stent restenosis (ISR) undergoing PCI and VBT. METHODS: One hundred forty-four patients treated with bivalirudin as a single antithrombotic agent were compared with 150 patients treated with eptifibatide. Bivalirudin as a bolus of 0.75 mg/kg followed by 1.75 mg/kg/h infusion until the end of the procedure, and eptifibatide as a double bolus of 180 microg/kg followed by 2 microg/kg/min infusion for 18 h after the procedure were used. The main outcome measures were in-hospital events and 30-day clinical outcomes. RESULTS: Baseline clinical characteristics were similar except that patients in the eptifibatide group were younger (P=.02) and had more saphenous vein graft lesions (P<.001). Patients in the bivalirudin group had a higher number of lesions in the right coronary artery (P<.001) and a higher number of vessels treated (P<.001). Postprocedure creatinine phosphokinase (CPK)-MB levels were significantly lower in the bivalirudin group (P<.03). In-hospital events showed significantly less minor bleeding (P=.01) and a trend toward lower major bleeding and major adverse cardiac events (MACE) in the bivalirudin group (P=.06). Thirty-day outcomes showed a significantly lower incidence of non-Q-wave myocardial infarction (MI) in the bivalirudin group (P=.004). CONCLUSION: Bivalirudin, as a single antithrombotic agent during PCI and VBT, is associated with significantly lower postprocedural CPK-MB elevation, minor bleeding complications, 30-day non-Q-wave MI rates, and a trend toward lower major bleeding and in-hospital MACE when compared with eptifibatide.


Subject(s)
Anticoagulants/therapeutic use , Antithrombins/therapeutic use , Brachytherapy/methods , Coronary Restenosis/drug therapy , Peptide Fragments/therapeutic use , Platelet Aggregation Inhibitors/therapeutic use , Platelet Glycoprotein GPIIb-IIIa Complex/antagonists & inhibitors , Anticoagulants/administration & dosage , Antithrombins/administration & dosage , Coronary Angiography , Coronary Restenosis/diagnostic imaging , Coronary Restenosis/radiotherapy , Eptifibatide , Female , Follow-Up Studies , Hirudins/administration & dosage , Humans , Infusions, Intravenous , Male , Middle Aged , Peptide Fragments/administration & dosage , Peptides/therapeutic use , Recombinant Proteins/administration & dosage , Recombinant Proteins/therapeutic use , Retrospective Studies , Treatment Outcome
8.
Am Heart J ; 150(4): 832-7, 2005 Oct.
Article in English | MEDLINE | ID: mdl-16209990

ABSTRACT

BACKGROUND: Bivalirudin is shown to be a competent substitute for heparin in percutaneous coronary intervention (PCI). The safety and efficacy of bivalirudin in patients undergoing PCI and vascular brachytherapy (VBT) are not known. This study aimed to assess the safety and efficacy of bivalirudin as a single antithrombotic agent in patients undergoing PCI and VBT. METHODS: A total of 152 patients enrolled in the Brachytherapy and Bivalirudin Evaluation Study underwent PCI and VBT with either gamma (n = 8) or beta radiation (n = 144). The main outcome measures were in-hospital events and 30-day clinical outcomes. All patients were treated with bivalirudin (0.75 mg/kg bolus and 1.75 mg/kg per hour infusion for beta radiation, 1 mg/kg bolus and 2.5 mg/kg per hour infusion for gamma radiation) as a single antithrombotic agent during the entire procedure. RESULTS: Baseline clinical and angiographic characteristics were similar between the 2 groups. More than 90% of the patients received beta radiation. In-hospital events showed a higher prevalence of acute procedural intracoronary thrombosis in patients treated with gamma- vs beta radiation (25% vs. 0.7%, P < .001). Thirty-day outcomes including death, Q-wave, and non-Q-wave myocardial infarctions, subacute stent thromboses, and repeat revascularizations were similar in both groups. CONCLUSION: Bivalirudin, as a single antithrombotic agent during PCI and VBT with beta emitters, may be used safely, but its use in the setting of PCI and gamma radiation may not be acceptable due to an increased incidence of acute procedural intracoronary thrombosis.


Subject(s)
Angioplasty, Balloon, Coronary , Anticoagulants/therapeutic use , Brachytherapy/adverse effects , Coronary Stenosis/radiotherapy , Peptide Fragments/therapeutic use , Thrombosis/prevention & control , Angioplasty, Balloon, Coronary/adverse effects , Coronary Stenosis/therapy , Female , Hirudins , Humans , Male , Middle Aged , Recombinant Proteins/therapeutic use , Thrombosis/etiology
9.
Catheter Cardiovasc Interv ; 65(4): 469-72, 2005 Aug.
Article in English | MEDLINE | ID: mdl-15988741

ABSTRACT

Sirolimus-eluting stents (SESs) are currently being used in patients undergoing percutaneous coronary intervention (PCI). SESs have not been evaluated in the treatment of acute myocardial infarction by primary angioplasty. We report our initial experience with SESs implanted during primary angioplasty. One hundred and three patients were treated within 12 hr after onset of acute myocardial infarction (AMI) with primary angioplasty and SES implantation. Those patients were compared to 504 patients treated with bare metal stents (BMSs). Angiographic success (TIMI flow grade 3 and residual stenosis < 50%) was completed in 98% of patients with SESs and no subacute stent thrombosis was reported. In-hospital outcomes were similar in the SES and BMS groups. At 6 months, major cardiac events were less frequent in the SES group than in the BMS group (9% vs. 24%, respectively; P < 0.001), driven by a lesser need for repeat revascularization with SESs (1% vs. 10.3% with BMSs; P = 0.014). Mortality at 6 months was 7% with SESs and 11% with BMSs (P = 0.14). SESs are safe and effective for the treatment of AMI by primary angioplasty. As compared to BMSs, SESs improve long-term outcome after AMI, mainly by reducing the need for repeat revascularization.


Subject(s)
Angioplasty, Balloon, Coronary , Coated Materials, Biocompatible/therapeutic use , Immunosuppressive Agents/therapeutic use , Myocardial Infarction/therapy , Sirolimus/therapeutic use , Stents , Aged , Blood Vessel Prosthesis Implantation , Coronary Angiography , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/therapy , District of Columbia , Female , Hospital Mortality , Humans , Male , Middle Aged , Myocardial Infarction/diagnostic imaging , Postoperative Complications/diagnostic imaging , Postoperative Complications/etiology , Postoperative Complications/mortality , Retrospective Studies , Treatment Outcome
10.
Catheter Cardiovasc Interv ; 65(4): 473-7, 2005 Aug.
Article in English | MEDLINE | ID: mdl-15973656

ABSTRACT

Sirolimus-eluting stents (SESs; Cypher) have demonstrated a significant reduction in restenosis rates when compared to bare metal stents (BMSs). The purpose of this study was to evaluate the strategy of exclusive use of two SESs versus the combination of one BMS and one SES for two-vessel coronary artery disease (CAD). It was found that the selective use of one SES combined with one BMS in patients undergoing percutaneous coronary intervention that requires more than one stent is safe, feasible, and associated with favorable procedural, 30-day, and 6-month clinical outcomes when compared to the exclusive use of SESs.


Subject(s)
Coated Materials, Biocompatible/therapeutic use , Coronary Artery Disease/therapy , Immunosuppressive Agents/therapeutic use , Sirolimus/therapeutic use , Stents , Aged , Angioplasty, Balloon, Coronary , Blood Vessel Prosthesis Implantation , Combined Modality Therapy , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , District of Columbia , Female , Follow-Up Studies , Humans , Male , Middle Aged , Postoperative Complications/diagnostic imaging , Postoperative Complications/etiology , Treatment Outcome
11.
Am J Cardiol ; 96(1): 67-70, 2005 Jul 01.
Article in English | MEDLINE | ID: mdl-15979436

ABSTRACT

Bivalirudin (Angiomax) is increasingly used as a substitute for heparin in a variety of percutaneous coronary interventions, and data on its usage in saphenous vein graft interventions are limited. This retrospective, observational study evaluated the efficacy and safety of bivalirudin compared with heparin as an antithrombotic regimen in patients who underwent saphenous vein graft intervention with distal protection devices. We found that bivalirudin use is clinically safe and feasible, with fewer vascular and ischemic complications compared with heparin.


Subject(s)
Anticoagulants/therapeutic use , Coronary Artery Disease/surgery , Heparin/therapeutic use , Peptide Fragments/therapeutic use , Postoperative Complications/prevention & control , Recombinant Proteins/therapeutic use , Saphenous Vein/transplantation , Thrombosis/prevention & control , Aged , Aged, 80 and over , Anticoagulants/adverse effects , Antithrombins , Female , Hirudins/adverse effects , Humans , Male , Middle Aged , Peptide Fragments/adverse effects , Recombinant Proteins/adverse effects , Retrospective Studies , Stents , Treatment Outcome
12.
Am J Cardiol ; 95(10): 1240-2, 2005 May 15.
Article in English | MEDLINE | ID: mdl-15878001

ABSTRACT

Stent area assessed by intravascular ultrasound is a strong predictor of late outcome after percutaneous coronary intervention. Because sirolimus-eluting stents (SESs) prevent intimal regrowth within the stent, achieving a larger final stent area might no longer be noteworthy; therefore, the investigators sought to determine the relevance and impact of the final stent area with SESs.


Subject(s)
Angioplasty, Balloon, Coronary , Coronary Artery Disease/therapy , Coronary Restenosis/diagnostic imaging , Immunosuppressive Agents/administration & dosage , Sirolimus/administration & dosage , Stents , Aged , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/mortality , Coronary Restenosis/prevention & control , District of Columbia , Female , Follow-Up Studies , Humans , Male , Retrospective Studies , Treatment Outcome , Tunica Intima/diagnostic imaging , Tunica Intima/pathology , Ultrasonography, Interventional/methods
13.
Catheter Cardiovasc Interv ; 65(2): 222-6, 2005 Jun.
Article in English | MEDLINE | ID: mdl-15900554

ABSTRACT

We aimed to assess the incidence of underexpansion and the relationship between delivery pressure and expansion with sirolimus-eluting stents. Adequate stent expansion contributes to early and late improved outcomes. In 51 patients (53 lesions) with native coronary artery narrowing, balloon-expandable sirolimus-eluting stents (Cypher) were serially expanded with gradual balloon inflations [14 atm, 20 atm, and in case of minimal stent cross-sectional area (CSA)/reference lumen CSA < 50% at 20 atm, postdilatation with 0.5 mm larger balloon]. Intravascular ultrasound (IVUS) imaging was performed before intervention and after each gradual balloon inflation. Stent expansion (minimal stent CSA/reference lumen CSA) was measured. Stent expansion was 72% +/- 16% after 14 atm balloon inflation, 90% +/- 18% after 20 atm balloon inflation (P < 0.001 vs. 14 atm), and 90% +/- 18% at the end of the procedure (including optional postdilatations with 0.5 mm larger balloon; P = NS vs. 20 atm). Stent expansion addressed by MUSIC criteria (all struts apposed, no tissue protrusion, and final lumen CSA > 80% of the reference or > 90% if minimal lumen CSA was < 9 mm2) was adequate in 15% of the cases after 14 atm balloon inflation, in 60% after 20 atm balloon inflation (P < 0.001 vs. 14 atm), and in 60% at the end of the procedure (P = NS vs. 20 atm). Sirolimus-eluting stent underexpansion is common when deployed at conventional pressures. Increasing balloon delivery pressure or assessing stent expansion with IVUS seems warranted in order to ensure adequate sirolimus-eluting stent deployment.


Subject(s)
Angioplasty, Balloon, Coronary , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/therapy , Immunosuppressive Agents/administration & dosage , Sirolimus/administration & dosage , Stents , Aged , Equipment Failure , Female , Humans , Male , Middle Aged , Pressure , Prospective Studies , Treatment Outcome , Ultrasonography, Interventional
14.
Catheter Cardiovasc Interv ; 65(2): 257-62, 2005 Jun.
Article in English | MEDLINE | ID: mdl-15864805

ABSTRACT

The Washington Radiation for In-Stent Restenosis Trial in Saphenous Vein Grafts (SVG WRIST) demonstrated safety and efficacy of intravascular radiation therapy (IRT) for the treatment of in-stent restenosis (ISR) in SVG at 12 months. In this study, we aimed to examine whether the safety and efficacy of IRT is durable up to 36 months. One hundred twenty patients with diffuse ISR in SVG underwent balloon angioplasty, laser or atherectomy ablation, and/or additional stenting. After successful intervention, patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium (Ir)-192 (n = 60) or nonradioactive seeds (n = 60). The prescribed dose at 2 mm from the source was either 14 or 15 Gy in vessels 2.5-4.0 mm or 18 Gy in vessels > 4.0 mm in diameter. At 36 months, target lesion revascularization (TLR; 43% vs. 66%; P = 0.02) and target lesion revascularization-major adverse cardiac event (TLR-MACE; 49% vs. 71%; P = 0.02) rates continued to be lower in the IRT group, but both target vessel revascularization (TVR; 59% vs. 71%; P = 0.17) and TVR-MACE (63% vs. 77%; P = 0.11) rates were not. In SVG WRIST, patients with ISR treated with IRT had a marked reduction in the need for repeat TLR at 36 months, with sustained clinical benefit at 3 years despite late recurrences, which were more pronounced in the radiation group.


Subject(s)
Catheterization, Peripheral , Gamma Rays/therapeutic use , Graft Occlusion, Vascular/radiotherapy , Saphenous Vein/transplantation , Stents , Aged , Double-Blind Method , Female , Follow-Up Studies , Graft Occlusion, Vascular/diagnostic imaging , Humans , Male , Middle Aged , Radiography , Time Factors , Treatment Outcome
15.
Circulation ; 111(9): 1148-52, 2005 Mar 08.
Article in English | MEDLINE | ID: mdl-15723972

ABSTRACT

BACKGROUND: The pattern of saphenous vein graft (SVG) calcification before percutaneous intervention has not been studied. METHODS AND RESULTS: We used diagnostic and preintervention intravascular ultrasound (IVUS) to determine the incidence and magnitude of SVG calcification in 334 SVG lesions in 274 consecutive patients. Calcium was found in 133 SVGs (40%). Calcium was uniformly distributed among 48 lesion sites (14%), 43 proximal references (13%), and 42 distal references (13%). Calcium was superficial in 20 (40%) and deep in 28 (60%). Over the entire length of the SVGs, the maximum arc and length of calcium (in calcium-containing SVGs) averaged 174+/-107 degrees and 6.8+/-4.8 mm, respectively. In calcium-containing SVGs, lesion site arc and length of calcium measured 151+/-107 degrees and 4.1+/-3.7 mm, similar to the proximal and distal references (175+/-121 degrees and 4.0+/-2.3 mm and 177+/-121 degrees and 4.1+/-2.5 mm, respectively). Graft age (7.5+/-4.7 versus 10.5+/-4.7 years, P<0.0001), insulin-treated diabetes mellitus (40% versus 60%, P=0.02), and tobacco use (44% versus 55%, P=0.06) were clinical independent predictors of SVG calcification. CONCLUSIONS: Sixty-five percent of calcium-containing SVGs had reference calcium in the absence of lesion calcium. Calcium was located primarily in SVG wall and not at the plaque. These data suggest that SVG calcium is not just part of lesion formation and maturation. SVG calcium occurred more commonly in older grafts, in insulin-treated diabetic patients, and in smokers.


Subject(s)
Calcinosis/pathology , Coronary Angiography , Coronary Artery Bypass , Coronary Restenosis/pathology , Postoperative Complications/pathology , Saphenous Vein/pathology , Ultrasonography, Interventional , Aged , Calcinosis/diagnostic imaging , Calcinosis/epidemiology , Calcium/analysis , Coronary Restenosis/diagnostic imaging , Coronary Restenosis/epidemiology , Coronary Stenosis/surgery , Diabetes Mellitus, Type 2/epidemiology , Female , Hemodynamics , Humans , Hypercholesterolemia/epidemiology , Hypertension/epidemiology , Incidence , Kidney Diseases/epidemiology , Male , Middle Aged , Postoperative Complications/diagnostic imaging , Postoperative Complications/epidemiology , Postoperative Period , Risk Factors , Saphenous Vein/chemistry , Saphenous Vein/diagnostic imaging , Saphenous Vein/transplantation , Smoking/epidemiology
16.
J Invasive Cardiol ; 17(1): 5-7, 2005 Jan.
Article in English | MEDLINE | ID: mdl-15640529

ABSTRACT

Pre-treatment of patients with clopidogrel prior to coronary angiography (CAG) and possible percutaneous coronary intervention (PCI) is a standard practice. Candidates for coronary artery bypass surgery (CABG) are discharged or remain in the hospital until CABG after clopidogrel is discontinued. We investigated whether any differences exist in the rates of surgical complications and outcomes between these two groups of patients. We conclude that continued hospitalization of clopidogrel pre-treated patients does not confer any safety benefit with regard to post-operative complications and 30-day mortality. Discharging these patients after CAG may reduce hospitalization costs.


Subject(s)
Coronary Angiography , Coronary Artery Bypass , Coronary Artery Disease/therapy , Hospitalization , Platelet Aggregation Inhibitors/therapeutic use , Ticlopidine/analogs & derivatives , Aged , Clopidogrel , Coronary Artery Disease/mortality , Female , Humans , Male , Middle Aged , Retrospective Studies , Survival Analysis , Ticlopidine/therapeutic use , Treatment Outcome , Ventricular Dysfunction, Left/mortality , Ventricular Dysfunction, Left/therapy
17.
J Invasive Cardiol ; 16(12): 688-91, 2004 Dec.
Article in English | MEDLINE | ID: mdl-15596870

ABSTRACT

Whether percutaneous coronary intervention (PCI) alone is safe in patients with moderate or severe aortic stenosis (AS) and coexisting coronary artery disease (CAD), and whether aortic valve replacement (AVR) can be deferred in patients with moderate AS by undergoing PCI alone is not known. We conducted a retrospective study of surgically inoperable patients with AS who underwent PCI (moderate AS, n = 28; and severe AS, n = 28) and compared to those with AVR (n = 55). The clinical characteristics, procedural complications, in-hospital and long-term clinical outcomes of PCI were compared. Baseline and procedural characteristics were similar except that lower age, hypertension, and renal impairment were seen in the AVR group. In-hospital complications were comparable among the 3 groups. Six-month and 1-year rates of myocardial infarction (MI), non-Q-wave MI, death and out-of-hospital death were similar between AVR and moderate AS patients (p = NS) and significantly high (p < 0.04) in patients with severe AS. On multivariate analysis, severe AS was the only significant predictor of 6-month and 1-year mortality. Our study suggests that PCI is safe in patients with moderate AS and coexisting CAD but is associated with poor outcomes in patients with severe AS.


Subject(s)
Angioplasty, Balloon, Coronary , Aortic Valve Stenosis/therapy , Coronary Artery Disease/complications , Aged , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/epidemiology , Aortic Valve Stenosis/mortality , Aortic Valve Stenosis/pathology , Disease-Free Survival , District of Columbia/epidemiology , Female , Humans , Male , Medical Records , Postoperative Complications , Retrospective Studies , Severity of Illness Index , Survival Analysis
18.
Am J Cardiol ; 94(12): 1551-4, 2004 Dec 15.
Article in English | MEDLINE | ID: mdl-15589015

ABSTRACT

This study aimed to compare the outcomes of patients with late total occlusion (LTO) versus patients with recurrence in the absence of LTO after intracoronary radiation therapy for in-stent restenosis. LTO, especially in the context of acute myocardial infarction, after intracoronary radiation therapy for in-stent restenosis, is associated with negative clinical outcomes after 6 and 12 months compared with in-stent restenosis without LTO.


Subject(s)
Brachytherapy , Coronary Angiography , Coronary Restenosis/radiotherapy , Female , Humans , Male , Middle Aged , Myocardial Infarction/therapy , Stents , Treatment Failure
20.
Lancet ; 364(9444): 1519-21, 2004.
Article in English | MEDLINE | ID: mdl-15500897

ABSTRACT

Although the safety profiles of coronary stents eluting sirolimus or paclitaxel do not seem to differ from those of bare metal stents in the short-to-medium term, concern has arisen about the potential for late stent thromboses related to delayed endothelialisation of the stent struts. We report four cases of angiographically-confirmed stent thrombosis that occurred late after elective implantation of polymer-based paxlitaxel-eluting (343 and 442 days) or sirolimus-eluting (335 and 375 days) stents, and resulted in myocardial infarction. All cases arose soon after antiplatelet therapy was interrupted. If confirmed in systematic long-term follow-up studies, our findings have potentially serious clinical implications.


Subject(s)
Coronary Thrombosis/etiology , Paclitaxel/administration & dosage , Platelet Aggregation Inhibitors/therapeutic use , Sirolimus/administration & dosage , Stents/adverse effects , Aged , Angioplasty, Balloon, Coronary , Coronary Disease/therapy , Coronary Vessels , Humans , Male , Middle Aged , Myocardial Infarction/etiology
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