Cardiovascular magnetic resonance assessment of the aortic valve stenosis: an in vivo and ex vivo study.

BACKGROUND: Aortic valve area (AVA) estimation in patients with aortic stenosis may be obtained using several methods. This study was undertaken to verify the cardiovascular magnetic resonance (CMR) planimetry of aortic stenosis by comparing the findings with invasive catheterization, transthoracic (TTE) as well as tranesophageal echocardiography (TEE) and anatomic CMR examination of autopsy specimens. METHODS: Our study was performed in eight patients with aortic valve stenosis. Aortic stenosis was determined by TTE and TEE as well as catheterization and CMR. Especially, after aortic valve replacement, the explanted aortic valves were examined again with CMR ex vivo model. RESULTS: The mean AVA determined in vivo by CMR was 0.75 ± 0.09 cm(2) and ex vivo by CMR was 0.65 ± 0.09 cm(2) and was closely correlated (r = 0.91, p < 0.001). The mean absolute difference between AVA derived by CMR ex vivo and in vivo was -0.10 ± 0.04 cm(2). The mean AVA using TTE was 0.69 ± 0.07 with a significant correlation between CMR ex vivo (r = 0.85, p < 0.007) and CMR in vivo (r = 0.86, p < 0.008). CMR ex vivo and in vivo had no significant correlation with AVA using Gorlin formula by invasive catheterization or using planimetry by TEE. CONCLUSION: In this small study using an ex vivo aortic valve stenosis model, the aortic valve area can be reliably planimetered by CMR in vivo and ex vivo with a well correlation between geometric AVA by CMR and the effective AVA calculated by TTE.

Direct visualization of regurgitant orifice by CMR reveals differential asymmetry according to etiology of mitral regurgitation.

OBJECTIVES: This study sought to characterize the shape of regurgitant orifice area (ROA) and mitral apparatus in various forms of mitral regurgitation (MR) by cardiac magnetic resonance (CMR). BACKGROUND: ROA is an accepted parameter of MR severity. However, there are little data on the shape of the ROA in various forms of MR. METHODS: Direct assessment of ROA was performed with a 1.5-T CMR scanner using a breath-hold fast imaging with steady-state free precession. The regurgitant orifice shape and the anatomy of the mitral valve apparatus including mitral annulus, mitral leaflet angles, and mitral valve tenting area were assessed. RESULTS: We studied 74 patients. MR severity was mild in 39%, moderate in 27%, and moderate-to-severe or severe in 34%. Mitral valve pathology was degenerative in 26%, prolapse in 22%, flail in 33%, and functional in 19%. For all patients, ROA correlated significantly with regurgitant fraction (r = 0.80, p < 0.001). The ROA shape index as expressed by the ratio of the larger length to the smaller length was a median of 2.04 (interquartile range [IQR]: 1.49 to 3.08) over all patients. CMR revealed significant asymmetry of the ROA geometry in functional MR 3.91 (IQR: 2.79 to 4.84) compared with prolapse 2.14 (IQR: 1.80 to 3.04), flail 2.20 (IQR: 1.69 to 2.91), and degenerative MR 1.24 (IQR: 1.09 to 1.57), all p < 0.01. The assessment of mitral valve geometry demonstrated that patients with functional MR had significantly increased leaflet angles, mitral valve tenting area, and mitral annulus area (all p < 0.05). Of note, the orifice shape index correlated with increasing leaflet angles in patients with functional MR (r = 0.68, p = 0.005). CONCLUSIONS: Direct assessment of ROA by CMR revealed significant asymmetry of ROA in various forms of MR, particularly in patients with functional MR. The slitlike appearance in functional MR correlates with a distended mitral apparatus.

Variable phenotypes of bicuspid aortic valve disease: classification by cardiovascular magnetic resonance.

BACKGROUND: Recently, cardiovascular magnetic resonance (CMR) has been shown to allow accurate visualisation and quantification of aortic valve disease. Although bicuspid aortic valve (BAV) disease is relatively rare in the general population, the frequency is high in patients requiring valve surgery. The aim of the current study was to characterise the different phenotypes of BAV disease by CMR. METHODS: CMR studies were performed on a 1.5 T scanner in 105 patients with BAV. RESULTS: The pattern of BAV phenotypes was as follows: a raphe was identified in 90 patients (86%). Among patients with raphe, 76 patients had fusion between the right and left cusps (RL) and 14 patients had fusion between the right and the non-coronary cusps (RN). There were no significant differences in the aortic dimensions in the different BAV phenotypes. CONCLUSION: CMR allows excellent characterisation of valve phenotype in patients with BAV. The present data demonstrate that a raphe is present in the vast majority of cases and RL fusion is the predominant phenotype of BAV. No significant differences in the aortic dimensions were observed.

Electrocardiographic diagnosis of left ventricular hypertrophy in aortic valve disease: evaluation of ECG criteria by cardiovascular magnetic resonance.

BACKGROUND: Left ventricular hypertrophy (LVH) is a hallmark of chronic pressure or volume overload of the left ventricle and is associated with risk of cardiovascular morbidity and mortality. The purpose was to evaluate different electrocardiographic criteria for LVH as determined by cardiovascular magnetic resonance (CMR). Additionally, the effects of concentric and eccentric LVH on depolarization and repolarization were assessed. METHODS: 120 patients with aortic valve disease and 30 healthy volunteers were analysed. As ECG criteria for LVH, we assessed the Sokolow-Lyon voltage/product, Gubner-Ungerleider voltage, Cornell voltage/product, Perugia-score and Romhilt-Estes score. RESULTS: All ECG criteria demonstrated a significant correlation with LV mass and chamber size. The highest predictive values were achieved by the Romhilt-Estes score 4 points with a sensitivity of 86% and specificity of 81%. There was no difference in all ECG criteria between concentric and eccentric LVH. However, the intrinsicoid deflection (V6 37 +/- 1.0 ms vs. 43 +/- 1.6 ms, p < 0.05) was shorter in concentric LVH than in eccentric LVH and amplitudes of ST-segment (V5 -0.06 +/- 0.01 vs. -0.02 +/- 0.01) and T-wave (V5 -0.03 +/- 0.04 vs. 0.18 +/- 0.05) in the anterolateral leads (p < 0.05) were deeper. CONCLUSION: By calibration with CMR, a wide range of predictive values was found for the various ECG criteria for LVH with the most favourable results for the Romhilt-Estes score. As electrocardiographic correlate for concentric LVH as compared with eccentric LVH, a shorter intrinsicoid deflection and a significant ST-segment and T-wave depression in the anterolateral leads was noted.

Dilatation of the ascending aorta in bicuspid aortic valve disease: a magnetic resonance imaging study.

BACKGROUND: Bicuspid aortic valve disease (BAV) is increasingly recognized as a disease of the entire proximal aorta including both valvular and vascular complications. The aim of our study was to assess the dimensions of the thoracic aorta using MRI in a broad spectrum of BAV and tricuspid aortic valve disease (TAV) and to define the prevalence of the dilatation of the ascending aorta (AA) >or= 4.5 cm in severe BAV disease. METHODS AND RESULTS: MRI studies were performed on a 1.5 T scanner in a total of 195 consecutive patients with aortic valve disease. Eighty-four aortic valves were classified as BAV and 103 as TAV. In 8 patients, classification of the aortic valve was not possible due to poor image quality. Mean diameters of the AA were significantly greater in BAV compared to TAV (4.39+/-0.85 Vs. 3.55+/-0.47 cm, P<0.0001), whereas no differences were observed in the mean diameters of the aortic arch. Diameters of the descending aorta were slightly smaller in BAV compared to TAV (2.45+/-0.43 Vs. 2.58+/-0.31 cm, P<0.05). In BAV, AA dilatation was independent of the severity of valve dysfunction. In TAV, aortic regurgitation but not stenosis correlated weakly with AA dilatation. Prevalence of AA dilatation >or= 4.5 cm in BAV with severe aortic stenosis and regurgitation was 38% and 41%, respectively. CONCLUSION: Dilatation of the proximal aorta is a frequent finding in BAV and independent of the severity of valve dysfunction. With respect to the high prevalence of AA dilatation >or= 4.5 cm in BAV with severe valve dysfunction, careful assessment of the dimensions of the AA is crucial to identify patients in whom concomitant AA replacement is indicated according to current guidelines.

Time course of eosinophilic myocarditis visualized by CMR.

We report the diagnostic potential of cardiovascular magnetic resonance (CMR) to visualize the time course of eosinophilic myocarditis upon successful treatment. A 50-year-old man was admitted with a progressive heart failure. Endomyocardial biopsies were taken from the left ventricle because of a white blood cell count of 17000/mm3 with 41% eosinophils. Histological evaluation revealed endomyocardial eosinophilic infiltration and areas of myocyte necrosis. The patient was diagnosed with hypereosinophilic myocarditis due to idiopathic hypereosinophilic syndrome. CMR-studies at presentation and a follow-up study 3 weeks later showed diffuse subendocardial LGE in the whole left ventricle. Upon treatment with steroids, CMR-studies revealed marked reduction of subendocardial LGE after 3 months in parallel with further clinical improvement. This case therefore highlights the clinical importance of CMR to visualize the extent of endomyocardial involvement in the diagnosis and treatment of eosinophilic myocarditis.

Triphasic mitral inflow pattern and regional triphasic mitral annulus velocity in hypertrophic cardiomyopathy.

In Doppler echocardiography, a triphasic mitral inflow filling pattern with a mid-diastolic flow velocity (L) is usually related to elevated filling pressures and delayed myocardial relaxation. Furthermore, additional triphasic mitral annulus velocity with a mid-diastolic component (L') at tissue Doppler imaging (TDI) demonstrates an even more advanced diastolic dysfunction. In this puzzling case, a triphasic and restrictive mitral inflow pattern was noted in 55-year-old patient with Hypertrophic Cardiomyopathy and a history of septal myectomy. Interestingly, E' was reduced (< 0.1 m/s) and a mid-diastolic component (L') was recorded by TDI in the septal corner of the mitral annulus. However, E' was near normal (> or = 0.1 m/s) in the lateral mitral annulus. Upon contrast-enhanced cardiac MRI, severe septal scarring could be visualized as delayed hyperenhancement corresponding to the region of restrictive and triphasic diastolic function. Therefore, advanced regional diastolic dysfunction in the septum could be demonstrated by localized triphasic mitral annulus velocity as a correlate of pronounced scarring.

Cardiovascular magnetic resonance for direct assessment of anatomic regurgitant orifice in mitral regurgitation.

BACKGROUND: In patients with mitral regurgitation (MR), assessment of the severity of valvular dysfunction is crucial. Recently, regurgitant orifice area has been proposed as the most useful indicator of the severity of MR. The purpose of our study was to determine whether planimetry of the anatomic regurgitant orifice (ARO) in patients with MR is feasible by cardiovascular magnetic resonance (CMR) and correlates with invasive catheterization and echocardiography effective regurgitant orifice [ECHO-ERO] by proximal isovelocity surface area. METHODS AND RESULTS: Planimetry of ARO was performed with a 1.5-T CMR scanner using a breath-hold balanced gradient echo sequence true fast imaging with steady state precession (TrueFISP). CMR planimetry of ARO was possible in 35 of 38 patients and was closely correlated with angiographic grading (r=0.84, P<0.0001). In patients with MR grade > or =III on catheterization, CMR-ARO (0.60+/-0.29 cm(2) versus 0.30+/-0.19 cm(2), P<0.0001) as well as ECHO-ERO (0.49+/-0.17 cm(2) versus 0.27+/-0.10 cm(2)) were significantly elevated in comparison with MR grade or =III as defined by catheterization, with a sensitivity and specificity of 94% and 94%, respectively. CONCLUSIONS: CMR planimetry of the anatomic mitral regurgitant lesion in patients with MR is feasible and permits quantification of MR with good agreement with the accepted invasive and noninvasive methods. Direct measurement by CMR is a promising new method for the precise assessment of ARO area and the severity of MR.

General aneurysmatosis due to cheese consumption: complications of an endocarditis caused by Lactococcus cremoris.

We describe a case of endocarditis due to Lactococcus cremoris associated with cheese consumption, that caused multiple mycotic aneurysms. Antibiotic treatment combined with surgical and radiological interventions resulted in full recovery.

Planimetry of aortic valve area in aortic stenosis by magnetic resonance imaging.

BACKGROUND: The aim of the study was to determine whether noninvasive planimetry of aortic valve area (AVA) by magnetic resonance imaging (MRI) is feasible and reliable in patients with valvular aortic stenosis in comparison to transesophageal echocardiography (TEE) and catheterization. METHODS AND RESULTS: Planimetry of AVA by MRI (MRI-AVA) was performed on a clinical magnetic resonance system (1.5-T Sonata, Siemens Medical Solutions) in 33 patients and compared with AVA calculated invasively by the Gorlin-formula at catheterization (CATH-AVA, n = 33) as well as to AVA planimetry by multiplane TEE (TEE-AVA, n = 27). Determination of MRI-AVA was possible with an adequate image quality in 82% (27/33), whereas image quality of TEE-AVA was adequate only in 56% (15/27) of patients because of calcification artifacts (P = 0.05). The correlation between MRI-AVA and CATH-AVA was 0.80 (P < 0.0001) and the correlation of MRI-AVA and TEE-AVA was 0.86 (P < 0.0001). MRI-AVA overestimated TEE-AVA by 15% (0.98 +/- 0.31 cm2 vs. 0.85 +/- 0.3 cm2, P < 0.001) and CATH-AVA by 27% (0.94 +/- 0.29 cm2 vs. 0.74 +/- 0.24 cm2, P < 0.0001). Nevertheless, a MRI-AVA below 1,3 cm2 indicated severe aortic stenosis (CATH-AVA < 1 cm2) with a sensitivity of 96% and a specificity of 100% (ROC area 0.98). CONCLUSIONS: Planimetry of aortic valve area by MRI can be performed with better image quality as compared with TEE. In the clinical management of patients with aortic stenosis, it has to be considered that MRI slightly overestimates aortic valve area as compared with catheterization despite an excellent correlation.

Planimetry of mitral valve stenosis by magnetic resonance imaging.

OBJECTIVES: We sought to determine whether noninvasive planimetry of the mitral valve area (MVA) by magnetic resonance imaging (MRI) is feasible and reliable in patients with mitral stenosis (MS). BACKGROUND: Accurate assessment of MVA is particularly important for the management of patients with valvular stenosis. Current standard techniques for assessing the severity of MS include echocardiography (ECHO) and cardiac catheterization (CATH). METHODS: In 22 patients with suspected or known MS, planimetry of MVA was performed with a 1.5-T magnetic resonance scanner using a breath-hold balanced gradient echo sequence (true FISP). Data were compared with echocardiographically determined MVA (ECHO-MVA, n = 22), as well as with invasively calculated MVA by the Gorlin-formula at (CATH-MVA, n = 17). RESULTS: The correlation between MRI- and CATH-MVA was 0.89 (p < 0.0001), and the correlation between MRI- and ECHO-MVA was 0.81 (p < 0.0001). The MRI-MVA slightly overestimated CATH-MVA by 5.0% (1.60 +/- 0.45 cm(2) vs. 1.52 +/- 0.49 cm(2), p = NS) and ECHO-MVA by 8.1% (1.61 +/- 0.42 cm(2) vs. 1.48 +/- 0.42 cm(2), p < 0.05). On receiver-operating characteristic curve analysis, a value of MRI-MVA below 1.65 cm(2) indicated mitral stenosis (CATH-MVA < or =1.5 cm(2)), with a good sensitivity and specificity (89% and 75%, respectively). CONCLUSIONS: Magnetic resonance planimetry of the mitral valve orifice in mitral stenosis offers a reliable and safe method for noninvasive quantification of mitral stenosis. In the clinical management of patients with mitral stenosis, it has to be considered that planimetry by MRI slightly overestimates MVA, as compared with MVA calculated echocardiographically and at catheterization.

Structural and biomolecular changes in aorta and pulmonary trunk of patients with aortic aneurysm and valve disease: implications for the Ross procedure.

OBJECTIVES: A higher incidence of pulmonary autograft dilatation is assumed in patients with ascending aortic dilatation and bicuspid aortic valve disease. To examine whether structural abnormalities are present in the ascending aorta as well as in the pulmonary trunk (PT) we specifically addressed molecular mechanisms and signalling pathways for aneurysm formation in ascending aortic aneurysms and PT of patients with different aortic valve pathology undergoing an extended Ross procedure. METHODS: Wall segments resected from aortic aneurysms (20 patients, 7 bicuspid aortic valves BAV, and 13 tricuspid aortic valves TAV) and from PTs were submitted to analysis of leukocyte infiltration (immunohistochemistry), smooth muscle cell (SMC) apoptosis (in situ end-labelling of DNA-fragments TUNEL), and expression of death-promoting proteins perforin, granzyme B, Fas/FasL (immunoblotting). RESULTS: Degenerative changes including rarefication and apoptosis of SMCs were significantly more severe in BAV than TAV disease (apoptotic index 9.2+/-3.2 vs. 11.9+/-6.2, P = 0.02). Immunohistochemistry confirmed presence and activation of death-promoting mediators in aneurysmal tissue whereas pulmonary tissue displayed only few apoptotic cells, occasional Fas+cells, rarely colocalized with FasL. By Western blot analysis extracts from BAV and TAV but not pulmonary artery wall contained appreciable amounts of perforin, granzyme B, and Fas/FasL. CONCLUSION: Aneurysm formation is associated with SMC apoptosis and local signal expression of activated cells in patients with bicuspid as well as TAV. The PT itself is not pathologically involved with only minor degenerative changes. Although the disease process in the aorta appeared to be more severe in patients with BAV, there was similarity of histological and molecular changes of the pulmonary artery wall in all patients. Dilation of the pulmonary autograft seems not to be the result of histopathological and biomolecular mechanisms in the PT.

Early regression of left ventricular hypertrophy after aortic valve replacement by the Ross procedure detected by cine MRI.

AIM: The primary objective of our study was to assess the time course of left ventricular remodeling after the Ross procedure with the use of cine magnetic resonance imaging (MRI). METHODS: In a prospective study, 10 patients with isolated aortic valve disease were examined prior to aortic valve surgery, as well as at early follow-up (mean 4 weeks) and at late follow-up (mean 8 months) after pulmonary autograft aortic valve replacement (Ross procedure). The heart was imaged with a 1.5 T MR scanner along the short and long axes using a breath-hold, electrocardiogram (ECG)-triggered, cine gradient-echo sequence (FLASH). Myocardial mass and ventricular function were assessed. RESULTS: After aortic valve replacement, left ventricular myocardial mass (LVM) decreased by 13% (261 +/- 74 g to 230 +/- 65 g, p < 0.05) in the early postoperative period and by a further 16% in the late postoperative period to 192 +/- 31 g (p < 0.05). In addition, left ventricular end-diastolic and end-systolic volumes decreased from preoperative 187 +/- 89 mL (LV EDV) and 73 +/- 59 mL (LV ESV) to 119 +/- 55 mL and 56 +/- 42 mL, respectively, in the early postoperative period. In the late postoperative period, there was a further decrease to 98 +/- 30 (p < 0.05) and 33 +/- 19 mL, respectively. Ejection fraction did not change markedly after surgery (preoperatively 61 +/- 13% vs. 56 +/- 14% postoperatively). Patients with leading aortic stenosis were characterized by predominant regression of LVM and patients with leading aortic regurgitation by predominant regression of LV EDV (each p < 0.05). CONCLUSION: Cine MRI allows accurate assessment of left ventricular structure and geometry before and after aortic valve replacement with pulmonary autograft and is very sensitive in detecting relatively small changes of left ventricular myocardial mass and volumes early after hemodynamic relief as well as during serial assessment.

Left ventricular remodeling after pulmonary autograft aortic valve replacement: evaluation with color-Doppler echocardiography and magnetic resonance imaging.

The superior hemodynamic performance of the pulmonary autograft in aortic position is expected to reflect complete regression of hypertrophy and improved ventricular function. We evaluated and compared early and midterm transthoracic color-Doppler echocardiography (TTE) and magnetic resonance imaging (MRI) assessment concerning left ventricular (LV) function, LV mass regression, and performance of the semilunar valves. A total of 42 consecutive patients, mean age 36 +/- 6 years (range 15 to 56 years), were studied. TTE and MRI were performed preoperatively, at discharge, and at 6 and 12 months postoperatively. Left ventricular diameters and function and LV wall thickness and mass were assessed. There was no early and one late postoperative death. Maximum and mean LV outflow gradients were significantly reduced (p = 0.0001 and p = 0.0001, respectively). There was a significant reduction in left ventricular mass to near normal for all patients (p = 0.001) seen after 6 months. This was paralleled by significant reductions in the interventricular septum and posterior wall thickness, but difference was slight during further follow-up. There was a strong correlation between the results obtained by TTE and MRI for LV mass and ejection fraction (r = 0.86 and 0. 87, respectively). The pulmonary autograft operation gives excellent results that are translated into greater, rapid, and near complete regression of LV hypertrophy. Magnetic resonance imaging is a sensitive and noninvasive methodology that provides reliable visualization and quantification of ventricular performance.

Magnetic resonance imaging in patients diagnosed with papilledema: a comparison of 6 different high-resolution T1- and T2(*)-weighted 3-dimensional and 2-dimensional sequences.

PURPOSE: To evaluate visualization and signal characteristics of macroscopic changes in patients with ophthalmologically stated papilledema and to find a suitable high-resolution magnetic resonance imaging (MRI) protocol. METHOD: Nine consecutive patients with 12 ophthalmologically stated papilledemas underwent MRI of the head and orbits, which consisted of the following high-resolution sequences: 3-dimensional (3D), T2*-weighted (T2*w) constructive interference in steady-state sequence (CISS); 3D, T1-weighted (T1w) magnetization prepared-rapid gradient echo sequence (MP-RAGE) (with and without intravenous contrast medium); transverse 3D and 2-dimensional (2D) (2 mm), T2-weighted (T2w) turbo spin echo (TSE); transverse 2D (2 mm), contrast-enhanced T1w TSE with fat-suppression technique; and transverse 2D (5 mm), T2w TSE. A quantitative and qualitative evaluation of the papilla, optic nerve, optic nerve sheath, optic chiasm, and the brain was performed. The 6 high-resolution sequences were compared. RESULTS: The elevation of the optic disc into the optic globe in ophthalmologically stated papilledema was best visualized in T2w, 3D CISS sequence. The pathological contrast enhancement was best seen in T1w contrast-enhanced 2D TSE sequence with fat-suppression technique. The mean width of the optic nerve sheath directly behind the globe was 7.54 mm (+/- 1.05 mm) in the pathological eyes, compared to 5.52 mm (+/- 1.11 mm) in the normal eyes. In all patients, the cerebral indices calculated showed no signs of increased intracranial pressure or other abnormalities changing the volume of the brain or ventricles. The contrast of the orbital fat versus the optic nerve sheath, the optic nerve sheath versus the surrounding cerebrospinal fluid (CSF), the surrounding CSF versus the optic nerve, the optic chiasm versus the CSF, and the optic papilla versus the optic globe were best visualized in the 3D, T2*w CISS sequence. An enhancement of the swollen optic nerve head was best seen in all 12 cases in the T1w contrast-enhanced 2D TSE sequence with fat-suppression technique. CONCLUSION: An MRI protocol consisting of a 5-mm transverse T2w TSE sequence; a T2*w, 3D CISS sequence; a T1w, 3D MP-RAGE sequence with and without contrast medium; and a transverse T1w, (2-mm) 2D TSE sequence with fat-suppression technique with intravenous contrast medium is suitable to visualize the macroscopic changes in papilledema. In addition, this combination is an excellent technique for the examination of the orbits and the brain.

Peripheral arterial balloon angioplasty: effect of short versus long balloon inflation times on the morphologic results.

PURPOSE: To evaluate the effect of different balloon inflation times on angiographic results in peripheral angioplasty. MATERIALS AND METHODS: Seventy-four infrainguinal arteriosclerotic lesions were randomized prospectively to undergo balloon dilation for 30 seconds (group I) or 180 seconds (group II). Each group consisted of 37 patients. Postinterventional angiograms were evaluated by two blinded readers. Dissections were graded as follows: 1 = no dissection; 2 = minor flap; 3 = extensive dissection membrane, not flow limiting; or 4 = flow-limiting flap. The rate of major-grade dissections (grades 3 and 4), residual stenosis (>30%), and further interventions were compared with the two-tailed chi(2) test. RESULTS: In group I, major dissections were noted in 16 patients (43%) compared with five patients (14%) in group II (P =.009). Residual stenoses were found in 12 patients (32%) in group I compared with five patients (14%) in group II (P =.096). The rate of additional interventions was significantly higher in group I than in group II (20 of 37 vs nine of 37; P =.017). CONCLUSION: A prolonged inflation time of 180 seconds improves the immediate angioplasty result of infrainguinal lesions compared to a short dilation strategy. Significantly fewer major dissections and a modest reduction of residual stenoses are observed. The requirement of costly and time-consuming further interventions is significantly reduced.