Comparison of CT-RECTOR and J-CTO scores to predict chronic total occlusion difficulty for percutaneous coronary intervention.

BACKGROUND: We sought to evaluate the ability of the CT-RECTOR and J-CTO scores to predict time-efficient guidewire (GW) crossing through a chronic total occlusion (CTO) and final procedure success. METHODS: Data from 191 consecutive CTO lesions with pre-procedural coronary computed tomography angiography (CCTA) from our center were analyzed retrospectively. The difficulty of the procedure was classified as easy, intermediate, difficult, or very difficult according to CT-RECTOR and J-CTO scores. A successful GW crossing within 30min was set as the first endpoint. Final success of the procedure was set as the second endpoint. Receiver operating characteristic curves and net reclassification improvement (NRI) were used to compare the performance of both scores in predicting both endpoints. RESULTS: The first and second endpoints were achieved in 55% and 76% of lesions, respectively. The NRI for prediction for both endpoints were 30.21% and 28.94%, respectively. Use of the CT-RECTOR score demonstrated a positive NRI for both the first (p=0.0027) and second (p=0.0190) endpoints. Compared with the J-CTO score (area under the curve: 0.76), the CT-RECTOR score (area under the curve: 0.85) yielded a higher predictive value for successful GW crossing within 30min (p=0.0018). CONCLUSIONS: Compared with J-CTO, the CT-RECTOR scoring system provides a more accurate noninvasive tool for predicting time-efficient GW crossing and final procedure success. This scoring system, which is based on CCTA, may aid in the identification of very difficult CTO lesions and downstream management.

Impact of Clinical Guideline Recommendations on the Application of Coronary Computed Tomographic Angiography in Patients with Suspected Stable Coronary Artery Disease.

BACKGROUND: Coronary computed tomographic angiography (CCTA) has been widely used in patients who are at intermediate risk for having stable coronary artery disease (SCAD), and 2013 European Society of Cardiology Guidelines on the Management of SCAD (2013G) recommended the appropriate application of CCTA. However, 2013G has not been subjected to systematic analyses for subsequent impact on clinical practice. METHODS: A total of 5320 patients suspected with SCAD were enrolled and scheduled for CCTA from March 2013 to September 2014. For each patient, pretest probability of SCAD was calculated according to updated Diamond-Forrester model (UDFM). Appropriate CCTA or appropriate stress test was determined as described in the 2013G. A generalized estimating equation model was used to determine the trends in the half-monthly rate of appropriate CCTA. RESULTS: Overall, only 61.37% of patients received appropriate CCTA, and there was insignificant change over time (P = 0.8701). The application of CCTA in patients who should have had a stress test accounted for most of the inappropriate CCTA before (22.29%) or after (19.98%) the publication of the 2013G. In all patients or any subgroup, no significant change in the adjusted half-monthly rate of appropriate CCTA was found after the publication of the 2013G (odds ratio, 1.002; 95% confidence interval, 0.982-1.021; P = 0.8678). CONCLUSIONS: These findings suggest that the 2013G have not, to date, been fully incorporated into clinical practice, and the clinical utilization of CCTA remains unreasonable to some extent.

Safety and efficacy of intravenous esmolol before prospective electrocardiogram-triggered high-pitch spiral acquisition for computed tomography coronary angiography.

BACKGROUND: In order to acquire a high quality image with a low radiation dose, prospective electrocardiogram (ECG)-triggered computed tomography coronary angiography (CTCA) requires a stable heart rate (HR) < 65 beats/min. Esmolol has the advantage of reducing HR. The objective of this article is to assess the value of intravenous esmolol treatment before prospective ECG-triggered high-pitch spiral acquisition for CTCA. METHODS: From March 2013 to June 2013, 313 patients underwent prospective ECG-triggered CTCA. Two hundred and thirty two of them received esmolol before angiography. We retrospectively analyzed clinical characteristics, esmolol dose, radiation exposure dose, and the change in HR and blood pressure in these 232 patients. RESULTS: A total of 232 patients with a HR > 65 beats/min before CTCA examination received intravenous esmolol treatment (mean dose of 57.26 ± 15.39 mg). The mean initial HR (HR1), slowest HR (HR2), and the HR 30 min after HR2 (HR3) were 75.06 ± 5.59, 60.75 ± 4.00, and 75.54 ± 5.96 beats/min, respectively (HR1 vs. HR2, P < 0.0001; HR1 vs. HR3, P = 0.377). The mean time from esmolol administration to HR2 was 24.25 ± 4.97 s and the mean effective radiation dose was 2.28 ± 0.02 mSv. CONCLUSIONS: HR could be rapidly controlled at an optimum level with intravenous esmolol before prospective ECG-triggered high-pitch spiral acquisition for CTCA. Consequently, the patients received a very low radiation dose.

[High-pitch dual-source CT in prospectively electrocardiogram-triggered spiral double scanning mode for diagnosing coronary artery patency].

OBJECTIVE: To assess the image quality, diagnostic accuracy and effective radiation dose of prospectively ECG- triggered high-pitch spiral double scanning (Double Flash) mode of computed tomography coronary angiography (CTCA) using dual-source CT for the diagnosis of significant coronary stenoses. METHODS: Patients underwent both CTCA in Double Flash mode and conventional coronary angiography (CAG) and were divided into two groups according to heart rate (HR), namely group A with HR <65/min (62 cases) and group B with HR between 65 and 80/min (52 cases). All the coronary segments were evaluated by two blinded and independent observers for image quality on a four-point scale and for the presence of significant coronary stenoses (defined as a diameter narrowing exceeding 50%). CAG served as the reference standard for analyzing the diagnostic accuracy of Double Flash mode images on the level of both patients and vessels. Radiation dose values were calculated using the dose-length product. RESULTS: A total of 114 patients were enrolled and 1725 vessel segments were displayed. In terms of image quality, the diagnosable segments accounted for 98.5% (919/933) in group A and 97.3% (770/792) in group B. In the per-patient analysis, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 100%, 90.5%, 88.2%, 100% and 96.7% in group A and were 100%, 88.5%, 94.5%, 100% and 96.2% in group B, respectively. The mean effective radiation dose was 1.63∓0.52 mSv. CONCLUSION: Double Flash spiral protocol of dual-source CTCA can acquire good image quality and yield high diagnostic accuracy for assessment of coronary artery stenoses at a low radiation dose in patients with HR between 65 and 80/min.

Prevalence of coronary artery ectasia in older adults and the relationship with epicardial fat volume by cardiac computed tomography angiography.

OBJECTIVE: Coronary artery ectasia (CAE) refers to abnormal dilation of coronary artery segments to 1.5 times of adjacent normal ones. Epicardial fat is associated with cardiovascular risk factors. The relationship between CAE and epicardial fat has not yet been investigated. This study aimed to assess the relationship between CAE and epicardial fat volume (EFV) in older people by dual-source computed tomography coronary angiography (CTCA). METHODS: We prospectively enrolled 1400 older adults who were scheduled for dual-source CTCA. Under reconstruction protocols, patients with abnormal segments 1.5 times larger than the adjacent segments were accepted as CAE. EFV was measured by semi-automated software. Traditional risk factors in CAE patients, as well as the extent of EFV, were analyzed and compared to non-CAE group. RESULTS: A total of 885 male and 515 female older patients were enrolled. CAE was identified by univariable analysis in 131 patients and significantly correlated to hypertension, smoking, hyperlipidemia, prior percutaneous coronary intervention and ascending aorta aneurysm. EFV was shown to be significantly higher in CAE patients than patients without ectasia. In multivariable analyses, EFV (P = 0.018), hypertension (P < 0.001) and hyperlipidemia (P < 0.001) were significantly correlated to CAE. There was a significant negative correlation between EFV and Markis classification. CONCLUSIONS: CAE can be reliably recognized by dual-source CTCA. Epicardial fat might play a role in etiopathogenesis and progression of CAE, providing a new target for treating ectasia.

[The influence of coronary main vessel stenting on side branches].

OBJECTIVE: To evaluate the influence of stenting main vessel on side branches and to compare the different effects on side branches between BMS and DES (Taxus and Cypher). METHODS: We reviewed the angiograms and the medical records of 183 patients who had received stent implantation in coronary main vessels and had follow-up angiograms. Any side branch was jailed by stent was evaluated. RESULTS: Side branch occlusion occurred in 8.9% in all branches (10.5% in Cypher DES group, 11.1% in Taxus DES group and 7.8% in BMS group). Spontaneous recanalization of side branches was observed in 72% (90.9% in Cypher DES, 66.7% in Taxus stent group and 66.7% in BMS). The ostial side branch stenosis before stenting and the involvement of the side branch origin within the lesion of the parent vessel are the major independent predictors for side branch occlusion. CONCLUSIONS: The influence of different DES implantations in coronary main vessels on side branches were similar and there was no difference between DES and BMS. Side branch occlusion had relatively benign clinical course. Most occluded side branches had late spontaneous reperfusion.

[Clinical efficacy and safety of emergent percutaneous coronary intervention for vein-grafts in the patients with acute myocardial infarction: comparison between age groups].

OBJECTIVE: To evaluate the efficacy and the safety of emergent primary percutaneous coronary intervention (PCI) in the saphenous vein bypass graft (SVBG) of acute myocardial infarction (AMI), and compare the results between aged -patients with non-aged patients. METHODS: Three hundred and nine consecutive AMI patients with culprit SVBG vessels, were analysed, including aged patients 213 cases(>or=70 years old), non-aged patients 96 cases(<70 years old), underwent the emergent primary PCI after confirmed below TIMI III perfusion(TIMI 0-TIMI II) in coronary angiographies. The immediate results and in-hospital outcomes were compared between two groups. RESULTS: Procedural successful rate, re-occlusion rate, and emergency re-CABG had no significant differences between two groups. The rate of slow-flow/no-reflow and in-hospital mortality rate were significantly higher in elderly group (19.7% vs 10.4%, 9.4% vs 4.2%, both P<0.05), with no difference in the rate of the using of distal protection devices between two groups. The comparison of the rate of direct stenting in slow-flow/no-reflow subgroup with normal-flow subgroup, had not showed statistic difference (73.5% vs 67.3%, P>0.05). There was no statistic difference of heavy hemorrhage between two different age groups. CONCLUSION: The primary PCI for the elderly AMI patients with infarction-related SVBG vessels, has higher risks in slow-flow/no-reflow and the mortality, even with using the distal protection devises and direct stents implantation.

[Endovascular treatment for abdominal aortic aneurysm, a primary study].

OBJECTIVE: To summarize the initial experience of endoluminal stent-grafting in the treatment of abdominal aortic aneurysm (AAA). METHODS: Stent-graft of proper shape and size was selected according to the morphology of AAA and was inserted into the lumen of abdominal aortic aneurysm through femoral artery to reconstruct the blood flow under X-ray flouroscopy among 34 cases. Data on complications and morphological changes were obtained according to a strict follow-up plan. RESULTS: The stent-grafting procedure was technically successful in all 34 patients. None of them required open repair. Five patients (14.7%) suffered from primary endoleaks after stent-graft deployment and 1 patient suffered from paraplegia and acute graft thrombosis. No other complications (kidney infarction, limbs and colon ischemia, etc) were found. The average follow-up time was 21 +/- 4.7 months. Perioperative death rate was 0% and total death rate was 3%. Two cases with primary endoleak developed into lasting endoleak during the follow-up period with a rate of late endoleak (> 30 days) of 11.7%. Secondary endoleak was found in 2 cases. One case with limb stent disconnection accepted secondary intervention. The mean max aneurysm diameter in cases without endoleak decreased significantly 6 months to 2 years after operation (P < 0.01). The aneurysm in two cases with secondary type I endoleak increased and one of them underwent secondary intraluminal treatment. CONCLUSION: Endovascular technique is a reliable method of treating AAA with micro-trauma. Endoleak is the main complication of this technique. Follow-up is an important component of the treatment plan. The aim of endoluminal repair is to completely neglect the aneurysmal lumen and prevent the aneurysm from increasing during follow-up.