Validation of the ELAN-HF Score and self-care behaviour on the nurse-led heart failure clinic after admission for heart failure.

AIM: To validate the predictive value of the European coLlaboration on Acute decompeNsated Heart Failure (ELAN-HF) score, and to assess the effect of self-care behaviour on readmission and mortality in patients after admission with acute decompensated heart failure (ADHF). DESIGN: Quantitative, prospective, single centre, cohort study. METHODS: N-Terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured on admission and discharge, and were used together with clinical and laboratory parameters to calculate the ELAN-HF score. Patients were stratified into four risk groups (low, intermediate, high, very high) according to their ELAN-HF score. The performance of the ELAN-HF score was evaluated and compared to the original study. Self-care behaviour was assessed by the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Survival analysis was used to estimate the association between both scores and re-admission for HF and/or all-cause mortality within 180 days. RESULTS: 88 patients were included. The median age of the study population was 75 years (IQR 69-83), 43% was female. NYHA III/IV functional class was present at discharge in 68 patients (85%) and 27 patients (34%) had a left ventricular ejection fraction < 40%. Complete data and 180 day follow up was available for 80 patients. 55% reached the endpoint of readmission and/or all-cause mortality. There was a significant association between the ELAN-HF score and re-admission and/or mortality < 180 days (HR = 1.25, 95% CI 1.08-1.45, p = 0.003). The median EHFScBS-9 score was 68.1 (IQR 58.3 - 77.8). There was no significant association between the EHFScBS-9 score and readmission and/or mortality < 180 days (HR = 1.01, 95% CI 0.99-1.03, p = 0.174). CONCLUSION: This study confirms the validity and therefore the potential of the ELAN-HF score to triage patients with ADHF before discharge. Using this score may optimize the follow-up treatment on the nurse-led heart failure clinic in order to decrease readmission and mortality. Self-care behaviour was non-significantly associated with readmission and/or mortality in our study population. TRIAL REGISTRATION: This study has been registered with the ethics committee MEC-U (Nieuwegein, The Netherlands), registration nr: V.160999/W18.208/HG/mk.

The association between polypharmacy and malnutrition(risk) in older people: A systematic review.

BACKGROUND & AIM: Malnutrition adversely influences a broad range of physical and psychological symptoms. Although polypharmacy is often mentioned to be associated with malnutrition, especially in older people it is unclear to what extent. The aim of this systematic review was to investigate the extent of the association between polypharmacy and malnutrition in older people. METHODS: The methodology followed the guidelines of the Cochrane Collaboration. Literature search was performed in PubMed, CINAHL and Embase. The population of interest for this systematic review were people of 65 years and older with polypharmacy. Because there is ambiguity with regard to the actual definition of malnutrition and polypharmacy, in this systematic review all articles describing malnutrition prevalence rates were included, regardless of the criteria used. Both observational and intervention studies were screened for eligibility. Selection and quality assessment of the included full text studies was assessed by two reviewers independently. A level of evidence and methodological quality score was adjudged to each article based on this assessment. RESULTS: A total of 3126 studies were retrieved by the literature search, of which seven studies were included in this systematic review. There was considerable variation in the definition of polypharmacy between studies. Two studies defined polypharmacy as the use of five or more drugs, two studies as the use of six or more drugs, two studies provided a mean and standard deviation that corresponded to the minimum of five drugs, and one study distinguished between polypharmacy (five or more drugs) and excessive polypharmacy (ten or more drugs). However, all studies showed a statistically significant association between (the risk) of becoming malnourished and polypharmacy regardless the instrument or criterion used to define risk of malnutrition. Studies presented the associations respectively as OR ≥ 1.177, p-value ≤ 0.028, ß ≥ -0.62 and r  ≥ -0.31. CONCLUSION: This review demonstrated a statistically significant association between polypharmacy and malnutrition. Further research is required to determine the magnitude of the effect by increased number of drugs in combination with the type of drugs, on the risk of malnutrition.

[Second-degree atrioventricular block caused by Lyme disease]. / Tweedegraads atrioventriculair blok door lymeziekte.

BACKGROUND: Tick-borne diseases, including Lyme disease, are becoming increasingly common in Europe. Lyme disease has a wide variety of clinical manifestations, as a result of which physicians of diverse disciplines are coming into contact with such patients. CASE DESCRIPTION: A 58-year-old man was seen at the emergency room with a symptomatic Wenckebach-type second-degree atrioventricular (AV) block and periods of 2:1 AV block. Four weeks previously the patient had noticed a red skin lesion on his left lower leg. Under the working diagnosis of early disseminated Lyme disease with cardiac involvement, treatment with ceftriaxone was started. This diagnosis was supported by a positive Borrelia PCR and culture of a skin biopsy and positive Borreliaserology. The AV conduction disorders resolved completely after 2 weeks of treatment with antibiotics and it was not necessary to implant a pacemaker. CONCLUSION: A Borrelia infection is a reversible but rare cause of AV conduction disorders. In the event of sudden onset of symptoms or a severe or progressive AV conduction disorder, Lyme carditis should be considered, especially if the medical history or physical examination provides clues for Lyme disease.

TrimetaziDine as a Performance-enhancING drug in heart failure with preserved ejection fraction (DoPING-HFpEF): rationale and design of a placebo-controlled cross-over intervention study.

BACKGROUND: Currently, no specific treatment exists for heart failure with preserved ejection fraction (HFpEF). Left ventricular (LV) relaxation during diastole is a highly energy-demanding process, while energy homeostasis is known to be compromised in HFpEF. We hypothesise that trimetazidine - a fatty acid ß­oxidation inhibitor - improves LV diastolic function in HFpEF, by altering myocardial substrate use and improving the myocardial energy status. OBJECTIVES: To assess whether trimetazidine improves LV diastolic function by improving myocardial energy metabolism in HFpEF. METHODS: The DoPING-HFpEF trial is a randomised, double-blind, placebo-controlled cross-over intervention trial comparing the efficacy of trimetazidine and placebo in 25 patients with stable HFpEF. The main inclusion criteria are: New York Heart Association functional class II to IV, LV ejection fraction ≥50%, and evidence of LV diastolic dysfunction. Patients are treated with one 20-mg trimetazidine tablet or placebo thrice daily (twice daily in the case of moderate renal dysfunction) for two periods of 3 months separated by a 2-week washout period. The primary endpoint is the change in pulmonary capillary wedge pressure during different intensities of exercise measured by right heart catheterisation. Our key secondary endpoint is the myocardial phosphocreatine (PCr)/ATP ratio measured by phosphorus-31 magnetic resonance spectroscopy and its relation to the primary endpoint. Exploratory endpoints are 6­min walk distance, N-terminal pro-brain natriuretic peptide levels, and quality of life. CONCLUSION: The DoPING-HFpEF is a phase-II trial that evaluates the effect of trimetazidine, a metabolic modulator, on diastolic function and myocardial energy status in HFpEF. [EU Clinical Trial Register: 2018-002170-52; NTR registration: NL7830].

Diagnostic dilemmas in Fabry disease: a case series study on GLA mutations of unknown clinical significance.

Fabry disease' (FD) phenotype is heterogeneous: alpha-galactosidase A gene mutations (GLA) can lead to classical or non-classical FD, or no FD. The aim of this study is to describe pitfalls in diagnosing non-classical FD and assess the diagnostic value of plasma globotriaosylsphingosine. This is a case series study. Family 1 (p.A143T) presented with hypertrophic cardiomyopathy (HCM), absent classical FD signs, high residual alpha-galactosidase A activity (AGAL-A) and normal plasma globotriaosylsphingosine. Co-segregating sarcomeric mutations were found. Cardiac biopsy excluded FD. In family 2 (p.P60L), FD was suspected after kidney biopsy in a female with chloroquine use. Males had residual AGAL-A, no classical FD signs and minimally increased plasma globotriaosylsphingosine, indicating that p.P60L is most likely non-pathogenic. Non-specific complications and histology can be explained by chloroquine and alternative causes. Males of two unrelated families (p.R112H) show AGAL-A <5%, but slightly elevated plasma globotriaosylsphingosine (1.2-2.0 classical males >50 nmol/l). Histological evidence suggests a variable penetrance of this mutation. Patients with GLA mutations and non-specific findings such as HCM may have non-classical FD or no FD. Other (genetic) causes of FD-like findings should be excluded, including medication inducing FD-like storage. Plasma globotriaosylsphingosine may serve as a diagnostic tool, but histology of an affected organ is often mandatory.

The Dutch Childhood Oncology Group guideline for follow-up of asymptomatic cardiac dysfunction in childhood cancer survivors.

BACKGROUND: The Late Effects of Childhood Cancer task force of the Dutch Childhood Oncology Group (DCOG LATER) developed a guideline for follow-up of asymptomatic cardiac dysfunction in childhood cancer survivors (CCS). In this paper, we present the methods, available evidence and final recommendations of our guideline. MATERIALS AND METHODS: A multidisciplinary working group specified clinical questions that should be answered to get to recommendations for the guideline. We carried out short or extensive evidence summaries and determined methodological quality of studies and levels of evidence in order to answer all clinical questions. When evidence was lacking for CCS, we carefully extrapolated evidence from other populations. Final recommendations were based on evidence and consensus. RESULTS: There was high-level evidence for the increased risk of cardiac dysfunction in CCS and its main risk factors. Evidence was lacking regarding the prognosis, diagnosis and treatment of cardiac dysfunction in CCS. We recommended echocardiographic screening for asymptomatic cardiac dysfunction in CCS treated with cardiotoxic treatments and counseling about potential advantages and disadvantages of our screening recommendations. CONCLUSION: The DCOG LATER guideline recommends risk-based screening for asymptomatic cardiac dysfunction in CCS, but it should be noted that recommendations are not completely supported by evidence in CCS.

Recurrent acute pulmonary oedema after aortic and mitral valve surgery due to trachea malacia and obstructive sleep apnoea syndrome.

In this report we describe a patient with recurrent episodes of acute pulmonary oedema after aortic and mitral valve surgery. The first episode of pulmonary oedema was caused by mitral valve dysfunction. The second episode of pulmonary oedema was not clearly associated with a mitral valve problem, but reoperation was performed in the absence of another explanation. After the third episode of acute pulmonary oedema occurred, the diagnosis of obstructive sleep apnoea syndrome (OSAS) was considered and confirmed. After starting treatment with continuous positive airway pressure (CPAP) during his sleep the patient had no further episodes of acute respiratory failure. Our case demonstrates that acute pulmonary oedema after cardiothoracic surgery can be caused or at least be precipitated by OSAS and should be suspected in patients with unexplained episodes of (recurrent) pulmonary oedema. (Neth Heart J 2008;16:310-2.).

Pregnancy and the risk of torsades de pointes in congenital long-QT syndrome.

Patients with congenital long-QT syndrome (LQTS) are at increased risk of ventricular arrhythmias during stressful situations. Large-scale studies have pointed out that affected individuals are particularly at risk in the period following pregnancy (post-partum). This is recognised especially for women with an LQTS type 2. Here, we describe two cases of young women with LQTS type 2, both admitted to our institution with symptomatic torsades de pointes a few weeks after delivery. Both patients carried a mutation in the KCNH2 gene. One patient was nullipara, while the other had had an uneventful previous pregnancy. In both cases treatment with a beta-blocker did not prevent life-threatening cardiac arrhythmias. The risk of arrhythmias is thought to gradually decrease to pre-pregnancy values in the nine months after delivery. Considering the difficulties related to continuous monitoring of a patient for such a long period and the desire of these patients to have more children in the foreseeable future, ICD implantation was performed. (Neth Heart J 2008;16:422-5.).

Combination and triple therapy in patients with stable angina pectoris not adequately controlled by optimal ß-blocker therapy.

In 60 to 80% of patients with stable angina pectoris at low risk for future coronary events, monotherapy with a ß-blocker is an effective treatment. When patients with stable angina pectoris and low risk for events do not respond adequately to optimal ß-blocker monotherapy, combination therapy or even triple therapy is may be recommended, but little is known of the actual benefit of such a strategy. We reviewed the evidence from the literature on the effectiveness of combination and triple therapy. Combination therapy with a calcium antagonist or nitrate was found to be more effective than ß-blocker monotherapy in the majority of studies, but only an estimated 30% of patients objectively benefit from these combination therapies. Direct comparison shows that combination therapy of a ß-blocker with a calcium antagonist is more effective than the combination of a ß-blocker with a nitrate. An inadequate response to ß-blocker monotherapy is more effectively improved by addition of a calcium antagonist than by alternative use of a calcium antagonist. The use of triple therapy is controversial and not recommended in patients with mild angina pectoris, while for patients with severe angina pectoris not responding to combination therapy of a ß-blocker with a nitrate, triple therapy may be of advantage, although the number of patients studied has been small.

Early lumen diameter loss after percutaneous transluminal coronary angioplasty is related to coronary plaque burden: a role for viscous plaque properties in early lumen diameter loss.

OBJECTIVES: We tested the hypothesis that lumen diameter loss within 1 h after percutaneous transluminal coronary angioplasty is related to plaque volume parameters. BACKGROUND: Early lumen diameter loss after coronary balloon angioplasty may predict restenosis and may paradoxically decrease late lumen diameter loss. Viscous properties of the vessel wall, as would be determined by tissue volume and composition, may be involved in early lumen diameter loss. METHODS: Early lumen diameter loss was measured with quantitative coronary angiography as the loss in lesion lumen diameter (significant loss 0.4 mm) occurring between 5 min and a median of 40 min after successful coronary balloon angioplasty in 68 patients. Thirty-nine patients were evaluated with intravascular ultrasound at the narrowest lumen cross-section of the dilated lesion, 29 patients formed a control group without intravascular ultrasound imaging. We tested the relation between intravascular ultrasound parameters and early lumen diameter loss. RESULTS: Early lumen diameter loss of > or = 0.4 mm was present in eight patients (12%), decreasing lumen diameter from 2.26 +/- 0.36 mm to 1.73 +/- 0.43 mm. There was no difference in the frequency of early lumen diameter loss between the groups with or without intravascular ultrasound imaging. Univariate intravascular ultrasound determinants of early lumen diameter loss were media bounded area (p = 0.01), maximal plaque thickness (p = 0.02), eccentricity index (p = 0.03) and the presence of hard lesions (p = 0.02). CONCLUSION: Early lumen diameter loss in the first hour after successful coronary balloon angioplasty occurs in a small proportion of patients. It is related to hard lesion type, maximal plaque thickness and eccentricity index, favoring a role for viscous plaque properties in early lumen diameter loss.

Videodensitometric quantitative angiography after coronary balloon angioplasty, compared to edge-detection quantitative angiography and intracoronary ultrasound imaging.

AIMS: To assess the value of videodensitometric quantification of the coronary lumen after angioplasty by comparison to two other techniques of coronary artery lumen quantification. METHODS AND RESULTS: Videodensitometric quantitative angiography, edge detection quantitative angiography and 30 MHz intracoronary ultrasound imaging were performed after successful balloon angioplasty in 161 patients. Lumen cross-sectional areas were mean (SD) 2.82 (1.15) mm(2)for edge detection quantitative angiography, 3.67 (1.5) mm(2)for videodensitometric quantitative angiography and 5.32 (1.75) mm(2)for intracoronary ultrasound imaging (P<0.001). The correlation between intracoronary ultrasound imaging and videodensitometric quantitative angiography (r=0.44) was almost similar to that of intracoronary ultrasound imaging and edge detection quantitative angiography (r=0. 47). The correlation between the three techniques was not significantly influenced by the presence of ruptures and dissections on intracoronary ultrasound imaging. The absence of calcifications improved the correlation between videodensitometry and intracoronary ultrasound imaging. CONCLUSIONS: The luminal dimensions as measured by videodensitometric quantitative angiography matched intracoronary ultrasound imaging derived dimensions more closely than edge detection quantitative angiography. Videodensitometric quantitative angiography represents an on-line alternative to intracoronary ultrasound imaging for quantitative analysis regardless of the degree of vessel damage.

Greater late lumen loss after successful coronary balloon angioplasty in the proximal left anterior descending coronary artery is not explained by extent of vessel wall damage or plaque burden.

OBJECTIVES: We investigated whether the greater late lumen loss after coronary balloon angioplasty in the proximal left anterior descending artery (P-LAD) compared with that in other segments might be related to differences in vascular dimensions or morphology as determined by angiography and intravascular ultrasound imaging. BACKGROUND: The greater late lumen loss after angioplasty in the P-LAD that has been observed in several studies has not been explained. METHODS: We studied 178 patients and 194 coronary artery lesions by quantitative angiography and 30 MHz intravascular ultrasound imaging after successful balloon angioplasty. Vessel wall morphology was compared among three proximal and three nonproximal segments. Follow-up quantitative angiography for late lumen loss calculation was performed in 168 lesions. Multivariate analysis was used to determine predictors of late lumen loss. RESULTS: Absolute and relative late loss were significantly greater at the P-LAD compared with the pooled group of other segments (0.42 +/- 0.60 mm vs. 0.10 +/- 0.48 mm, p = 0.0008 and 0.14 +/- 0.24 vs. 0.03 +/- 0.17, p < 0.001). Also, a greater percentage of calcific lesions (65% vs. 44%, p = 0.034), a lower incidence of rupture (51% vs. 74%, p = 0.009) and a larger reference segment plaque area (5.4 +/- 2.2 mm2 vs. 4.7 +/- 1.9 mm2, p = 0.05) were found in the P-LAD. In multivariate analysis however, these variables were not predictive of late loss. CONCLUSIONS: Greater late lumen loss after coronary balloon angioplasty of the P-LAD is not explained by differences in atherosclerotic plaque burden or in vessel wall damage.

Coronary atherosclerosis within a myocardial bridge, not a benign condition.

In patients with myocardial bridging, the area within the bridge usually remains free from atherosclerotic disease. The case of a 47 year old man is described who had the rare combination of myocardial bridging with an atherosclerotic plaque within the area of bridging, which was detected with intravascular ultrasound but not with coronary angiography. The clinical history of the patient demonstrates that this is not a benign condition. In symptomatic patients the bridged segment should be screened for the presence of plaque with intracoronary ultrasound.

An analogue laser optical disc in comparison with cinefilm for visual analysis of coronary narrowings before and after coronary angioplasty.

This study evaluated an analogue laser optical disc (MVP) as an alternative for cinefilm angiography in the visual analysis of coronary angiograms. Visual analysis was performed independently by 5 observers using cinefilm and MVP before and after PTCA (194 coronary lesions in 88 patients) and the outcomes were compared with QCA. The mean percentage diameter stenosis on cinefilm and MVP yielded similar results compared to QCA. Regression analysis showed a good correlation between the mean cinefilm and MVP values per diameter stenosis (p < 0.001). Bland-Altman plots confirmed these findings. Qualitative analysis for detection of coronary dissections after PTCA showed an incidence of 31.3% (cinefilm) and 21.8% (MVP) (p < 0.05). The results of this study indicate that the visual analysis of the coronary angiograms using the analogue laser optical disc (MVP) yields similar results compared to the cinefilm concerning coronary lesion severity, although there is an underestimation of coronary dissections.

Arterial remodeling after balloon angioplasty of the coronary artery: an intravascular ultrasound study. PICTURE Investigators. PostTreatment IntraCoronary Transluminal Ultrasound Result Evaluation.

OBJECTIVE: Before balloon dilation, failure of compensatory enlargement and even arterial shrinkage are frequently observed at the lesion site in response to plaque accumulation. Balloon angioplasty may be regarded as artificial remodeling to enlarge the artery. The prevalence of the different types of arterial wall remodeling after applied stretch by balloon angioplasty is unknown. METHODS AND RESULTS: In 181 patients an intravascular ultrasound study was performed after coronary balloon angioplasty (n = 200 lesions). The vessel area was measured at a proximal and distal reference site and at the lesion site. Subsequently, the relative vessel area [(Vessel area lesion site)/Vessel area reference site) x 100] was calculated. Lesions were classified in three groups on the basis of their relative vessel areas: > or =105%, <105% but >95%, and < or =95%. A relative vessel area > or =105%, indicating enlargement compared with the reference site, was observed in 84 (44%) lesions. A relative vessel area <105% but >95% was observed in 43 (22%) lesions. A relative vessel area < or =95%, indicating "shrinkage" compared with the reference site, was observed in 66 (34%) lesions. CONCLUSIONS: After balloon angioplasty, the vessel area was found to be smaller compared with the reference site in 34% of the lesions. This small vessel area at the lesion site compared with a reference site may be a reflection of insufficient stretch by balloon angioplasty.

Prediction of restenosis after coronary balloon angioplasty. Results of PICTURE (Post-IntraCoronary Treatment Ultrasound Result Evaluation), a prospective multicenter intracoronary ultrasound imaging study.

BACKGROUND: Intracoronary ultrasound (ICUS) imaging is potentially suitable to identify lesions at high risk of restenosis after percutaneous transluminal coronary angioplasty (PTCA), but it has not been studied systematically. METHODS AND RESULTS: We recruited 200 patients in whom ICUS studies were performed after successful PTCA and related their ICUS parameters to 6-month follow-up quantitative coronary angiography. This was performed in 164 patients (82%), yielding 170 lesions for analysis. The overall incidence of a > or = 50% diameter stenosis at follow-up (categorical restenosis) was 29.4%. Quantitative ICUS parameters were weakly but significantly related to follow-up minimal luminal diameter on quantitative coronary angiography (lumen area: R2 = .36, P = .0001; vessel area: R2 = .29, P = .0002; plaque area: R2 = -.18, P = .021; percent obstruction: R2 = -.15, P = .05), but categorical restenosis was not significantly related to these parameters (P = .63, .77, .38, and .08, respectively). There were no significant predictors of restenosis in ICUS parameters of plaque morphology: eccentric versus concentric (P = 1.0), plaque type (hard, soft, or calcific, P = .98), or the number of calcified quadrants (P = .41). There were no significant predictors of restenosis in two predefined types of vessel-wall disruptions: (1) rupture: presence (P = .79), depth (partial versus complete, P = .85), or extent in quadrants (P = .6), and (2) dissection: presence (P = .31), depth (P = .82), or extent (P = .38). CONCLUSIONS: Qualitative ICUS parameters after PTCA did not predict restenosis. A larger lumen and vessel area and a smaller plaque area by ICUS were associated with a larger angiographic minimal lumen diameter at follow-up, but these parameters were not significantly related to categorical restenosis.

Reproducibility of quantitative measurements from intracoronary ultrasound images. Beat-to-beat variability and influence of the cardiac cycle.

OBJECTIVES: The purpose of this study was to determine the variability of quantitative measurements from intracoronary ultrasound images, and the influence of the cardiac cycle on this variability, as a basis for in vivo applications. METHODS: Two observers analysed 30 MHz cross-sectional images from 96 in-vivo coronary arterial sites. By computer-assisted contour tracing we determined lumen area, vessel area, lesion area (vessel area minus lumen area) and percent obstruction (100% x lesion area/vessel area). Intra- and inter-observer and beat-to-beat variability, and systolic to diastolic differences were calculated by paired analysis. RESULTS: Consistent intra- and inter-observer differences (bias) were small (< or = 0.9%). Random variations in the two direct parameters were < or = 21.1%, but for the two derived parameters they were up to 40%. For all four parameters, random inter-observer variability was significantly greater (up to 119% for vessel area: 19.3 vs 8.8%) than intra-observer variability, but consistent variability was similar. Consistent beat-to-beat differences were small (< or = 1.4%), random variations were 8.9% to 17.5%. Random beat-to-beat variability for all four parameters was greater in diastolic than in systolic frames (up to 47.0% difference (11.9 vs 17.5%) for lesion area). Vascular dimensions were significantly greater in systole (2%). We found an error of 0.24 mm (2SD) for intra-observer variability of calculated mean arterial diameters, which is similar to the error described in angiographic studies (0.22 mm). CONCLUSIONS: Quantitative measurements from intracoronary ultrasound images generally reproduce well. It is preferable to use directly measured parameters as opposed to derived parameters, as they are less subject to variability. Variability can be reduced by selecting systolic images.

Determinants of echodensity at the intima-media interface with intracoronary ultrasound imaging.

A thin, echodense layer (EL) is sometimes observed at the intima-media interface on intravascular ultrasonographic images. We reviewed a series of 119 histologically matched, 30 MHz, in vitro ultrasound cross sections of human coronary arteries for factors determining the occurrence of an EL. ELs were observed in 19 (27%) of 71 images with optimal gain settings, in two (17%) of 12 with high gain settings, and in none of 26 with low gain settings. In 17 (94%) of 18 cross sections with eccentric catheter positions, an EL was visible only in parts of the vessel wall that were perpendicular to the ultrasound beam. ELs were seen behind fibrous, lipid-rich, and mixed lesions but not behind calcified lesions because of acoustic shadowing. The presence or morphologic elements of the internal elastic lamina did not influence the occurrence of an EL. We conclude that the occurrence of an EL at the intima-media interface depends on acoustic factors and gain settings, and it provides no anatomic information per se.

In vitro validation of intravascular ultrasound imaging after balloon angioplasty of coronary artery stenoses.

Systematic studies of intravascular ultrasound imaging of in vitro balloon angioplasty on coronary arteries with a greater than 50% diameter stenosis on angiogram have not been performed. We used 23 plasma-perfused postmortem human coronary arteries with an angiographic diameter stenosis of > or = 50%. After balloon dilation the vessels were examined by 30-MHz intravascular ultrasound imaging (IVUS) and the presence of ruptures and dissections was noted. Ruptures were defined as disruptions of the vessel wall in a radial direction, and dissections were defined as disruptions in a circumferential direction. After pressure fixation they were studied by histology. On IVUS, 24 vessel wall disruptions were diagnosed in 14 arteries. On histology, 29 disruptions were diagnosed in 19 arteries. The sensitivity of IVUS for the detection of disruptions was 79%, the specificity was 75%. Total agreement was 79%. Accuracy was better for dissections (total agreement 96%) than for ruptures (total agreement 74%). Shadowing behind calcium and close contact of the catheter to the arterial wall were important sources of error in the IVUS analysis. We conclude that intravascular ultrasound imaging is accurate for the detection of disruptions after balloon angioplasty of angiographically significant coronary artery stenoses.