Angiographic and clinical outcomes of stent postdilatation in ST-elevation myocardial infarction.

INTRODUCTION: Stent postdilatation is commonly performed to optimise stent deployment during percutaneous coronary intervention (PCI). However, it is controversial in the setting of acute myocardial infarction (AMI) due to the theoretically increased risk of thrombus embolization causing no-reflow. This study aimed to evaluate the immediate angiographic effects and long-term clinical outcomes of stent postdilatation in the setting of ST-elevation myocardial infarction (STEMI). METHODS: This was a single-centre retrospective observational study involving patients who presented with STEMI and received primary PCI, from July 2009 till June 2010. The angiographic endpoints were final TIMI coronary flow (TMF) and TIMI myocardial perfusion (TMP) score. The clinical endpoint was a composite endpoint of major adverse cardiac events (MACEs) i.e. AMI, target vessel revascularisation or cardiac death at one, six and twelve months after PCI. RESULTS: One hundred and sixty patients with a mean age of 62 years were included in this study. Seventy-one patients (44.4%) had stent postdilatation and 89 patients (55.6%) did not. Patient demographics, risk factors, clinical presentation and baseline angiographic and procedural characteristics, were similar among these two subgroups. There was also no significant difference in the proportions of patients achieving grade III in final TMF (60/71 vs. 74/89, respectively, p>0.05) and final TMP (52/71 vs. 64/89, respectively, p>0.05), as well as the MACE-free survival probability by Kaplan-Meier estimate (85.1% vs. 86.9%, p=0.95), between the two subgroups. CONCLUSION: Stent postdilatation does not seem to have any detrimental effects on patients' final angiographic results and long-term clinical outcomes, in the setting of STEMI.

Negative coronary CT angiography for chest pain assessment predicts low event rate in 5 years.

INTRODUCTION: Coronary CT angiography (CTA) is becoming a popular investigation for chest pain. A negative coronary CTA is known to have a good negative predictive value for major adverse cardiovascular events in short term. The data on the long-term outcomes of negative coronary CTA are lacking. We aim to investigate the long-term prognostic value of negative coronary CTA in the evaluation of chest pain. METHODS: This was a retrospective observational study involving 259 cases of coronary CTA on our registry from July 2004 to November 2006. All coronary CTA were performed with GE 16-slice CT and then GE 64-slice CT scanner in late 2006. A negative coronary CTA was defined as no single coronary segment with stenosis ≥50% based on American Heart Association 16-segment model. The end point of the study was defined as a composite of major cardiovascular events such as myocardial infarction, myocardial death or revascularisation. RESULTS: Seventy cases of 259 on the registry were diagnosed as negative studies. Mean follow-up period was 4.64 ± 0.6 years (range from 3.4 to 5.7 years). Of these negative studies, only one patient suffered from the end point during the follow-up. Thus, the negative predictive value of a negative coronary CTA for a long-term major cardiovascular event was 0.986 (95% confidence interval: 0.92-0.99). CONCLUSIONS: A negative coronary CTA in patients with a low or intermediate pretest probability for significant coronary artery disease predicts a low rate of major cardiovascular events within a 5-year period.

Adjunctive balloon dilatation after stent deployment: beneficial or deleterious?

The practice of adjunctive balloon post-dilatation is not consistent among interventionalists, particularly in the setting of acute myocardial infarction (AMI). There have been some concerns about the risks of adjunctive balloon post-dilatation, particularly in the setting of acute coronary syndrome (ACS). This review will examine the data on the angiographic and clinical effects, and the risks of adjunctive balloon post-dilatation of stents in the treatment of coronary artery disease.

Comparison of fluoroscopic coronary angiography and multi-slice coronary angiography in the characterization of anomalous coronary artery.

Anomalous coronary arteries with an inter-arterial course are associated with sudden cardiac death. We reported a study comparing the accuracy of fluoroscopic coronary angiography (FCA) with that of multi-slice computed tomography (MSCT) coronary angiography in determining the proximal course of anomalous coronary arteries. Twelve patients with thirteen anomalous coronary arteries had both FCA and MSCT coronary angiography were included in this study. Twelve cardiologists individually reviewed FCAs of anomalous coronary arteries and determined the proximal course of anomalous coronary arteries as retro-aortic, inter-arterial or ante-pulmonary. Their diagnoses were compared with MSCT coronary angiography which was regarded as the reference standard in this study. On MSCT coronary angiography, there were six anomalous left circumflex arteries with a retro-aortic course, five anomalous right coronary arteries and one anomalous left anterior descending artery with inter-arterial courses, and a single anomalous left main artery with an ante-pulmonary course. The percentage of correct diagnosis made by 12 cardiologists based on FCA findings was 93/156 or 60%. None of the cardiologists was correct in determining the proximal course of all anomalous coronary arteries. The median number of anomalous coronary arteries with their proximal courses correctly identified by the cardiologists was 7.5 (range 3-12). In conclusion, FCA was limited in delineating the proximal course of anomalous coronary arteries in comparison with MSCT coronary angiography.

CT coronary angiography predicts the outcome of percutaneous coronary intervention of chronic total occlusion.

BACKGROUND: The success rate of percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is relatively low. Further evaluation of CTO lesion with CT coronary angiography (CT-CA) may help to better select patients that would benefit from percutaneous revascularization. We aimed to test the possible association between failed PCI and transluminal calcification of CTO as assessed by CT-CA. METHODS: Patients with CTO awaiting PCI were scanned with a 16-slice CT. A cardiologist and a radiologist assessed transluminal calcification of CTO lesions on CT images while an interventional cardiologist at a core laboratory assessed conventional variables of invasive fluoroscopic coronary angiography (FCA) associated with failed PCI of CTO. The significance of CT and FCA variables in association with failed PCI were analyzed. RESULTS: In a cohort of 39 patients with 43 CTO lesions, 24 lesions were successfully revascularized. Transluminal calcification > or =50% as assessed on CT-CA was strongly associated with failed PCI (odds ratio [OR] of PCI success = 0.10, 95% confidence interval [CI]: 0.02-0.47, P = 0.003). Blunt stump as seen on FCA was also associated with failed PCI (OR of PCI success = 0.24, 95% CI: 0.07-0.86, P = 0.029). There was no significant evidence to support that the duration of CTO, presence of side branch and bridging collaterals, and the absence of microchannels as assessed with FCA were associated with failed PCI. On multivariate analysis, transluminal calcification > or =50% on CT-CA was the only significant predictor of failed PCI. CONCLUSIONS: Heavy transluminal calcification as assessed with CT-CA is an independent predictor of failed PCI of CTO. CT-CA may have a role in the work-up of CTO patients prior to PCI.

Combining warfarin and antiplatelet therapy after coronary stenting in the Global Registry of Acute Coronary Events: is it safe and effective to use just one antiplatelet agent?

AIMS: To identify factors associated with the use of single or dual antiplatelet therapy in patients prescribed warfarin following coronary stenting and to investigate whether single (aspirin or thienopyridine) vs. dual antiplatelet therapy plus warfarin leads to an excess of adverse outcomes. METHODS AND RESULTS: We analysed data from 800 patients with an acute coronary syndrome who underwent coronary stenting (130 patients received a drug-eluting stent) and were discharged on warfarin and either dual (n = 580) or single (n = 220) antiplatelet therapy. The use of single antiplatelet therapy was more common in Europe than in the USA (34 vs. 17%, P < 0.001). There was no difference in major bleeding in hospital or in 6-month mortality or myocardial infarction. In the single antiplatelet group, the use of either aspirin or thienopyridine (clopidogrel or ticlopidine) in combination with warfarin resulted in similar outcomes. CONCLUSION: Use of single vs. dual antiplatelet therapy and warfarin following stenting is common. In this observational study, there was no difference in mortality or myocardial infarction at 6 months; however, larger trials are needed to assert any firm recommendations.

Percutaneous revascularization of chronic total occlusions: review of the role of invasive and non-invasive imaging modalities.

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has a lower success rate than PCI of non-occluded coronary stenosis. Failure to cross the occlusive lesion with a guide wire is the main cause of unsuccessful PCI of a CTO. Multi-imaging modalities may provide valuable information for PCI of CTO. This paper reviews the role of invasive and non-invasive imaging modalities such as intravascular ultrasound, optical coherent reflectometry, CT coronary angiography and cardiac magnetic resonance imaging in facilitating percutaneous coronary intervention of CTO.

Giant single coronary system with coronary cameral fistula diagnosed on MSCT.

Anomalous single coronary artery with coronary fistula is a rare finding. This is a case report of an unusual single coronary artery arising from left coronary sinus and terminating into right ventricle through a coronary cameral fistula to form a left to right shunt. This case report also illustrates how well the non-invasive CT coronary angiography with a 16-slice CT scanner characterizes the anatomy of anomalous coronary artery with a coronary cameral fistula.

Multislice CT to evaluate coronary stent patency: a case report.

This is a case report on the ability of 16-slice computed tomography in assessing the patency of coronary stent and diagnosing an asymptomatic stenotic lesion with soft plaque morphology. These findings were confirmed with a selective coronary angiography. Identification of lesion morphology facilitated our decision on prophylactic and direct stenting to the lesion.