Site-specific intravascular ultrasound analysis of remodelling index and calcified necrosis patterns reveals novel blueprints for coronary plaque instability.

AIMS: Post-mortem pathological studies have shown that a "vulnerable" plaque is the dominant patho-physiological mechanism responsible for acute coronary syndromes (ACS). One way to improve our understanding of these plaques in vivo is by using histological "surrogates" created by intravascular ultrasound derived virtual histology (IVUS-VH). Our aim in this analysis was to determine the relationship between site-specific differences in individual plaque areas between ACS plaques and stable plaques (SP), with a focus on remodelling index and the pattern of calcifying necrosis. METHODS AND RESULTS: IVUS-VH was performed before percutaneous intervention in both ACS culprit plaques (CP) n=70 and stable disease (SP) n=35. A total of 210 plaque sites were examined in 105 lesions at the minimum lumen area (MLA) and the maximum necrotic core site (MAX NC). Each plaque site had multiple measurements made including some novel calculations to ascertain the plaque calcification equipoise (PCE) and the calcified interface area (CIA). CP has greater amounts of positive remodelling at the MLA (RI@MLA): 1.1 (±0.17) vs. 0.95 (±0.14) (P<0.001); lower values for PCE 30% vs. 54% (P<0.001) but a higher CIA 5.38 (±2.72) vs. 3.58 (±2.26) (P=0.001). These features can provide discriminatory ability between plaque types with area under the curve (AUC) measurements between 0.65-0.86. The cut-off values with greatest sensitivity and specificity to discriminate CP morphologies were: RI @ MLA >1.12; RI @ MAX NC >1.22; PCE @ MLA <47.1%; PCE @MAX NC <47.3%; CIA @ MLA >2.6; CIA @ MAX NC >3.1. CONCLUSIONS: Determining the stage of calcifying necrosis, along with the remodelling index can discriminate between stable and ACS related plaques. These findings could be applied in the future to help detect plaques that have a vulnerable phenotype.

Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial.

BACKGROUND: Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure. METHODS: In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3-5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518. FINDINGS: Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09-2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70-1·89, p=0·59). INTERPRETATION: Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially. FUNDING: Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK).

Construction and validation of a plaque discrimination score from the anatomical and histological differences in coronary atherosclerosis: the Liverpool IVUS-V-HEART (Intra Vascular UltraSound-Virtual-Histology Evaluation of Atherosclerosis Requiring Treatment) study.

AIMS: New markers to help stratify coronary atherosclerosis are needed. Although attempts have been made to differentiate active lesions from those that are stable, none of these has ever been formalised into a discriminatory score. The aim of this study was to analyse the differences between culprit ACS lesions and culprit stable angina lesions with intravascular ultrasound-derived virtual histology and to construct and validate a plaque score. METHODS AND RESULTS: Prior to percutaneous coronary intervention (PCI), we performed volumetric, intravascular ultrasound-derived virtual histology (IVUS-VH) analysis in acute coronary syndrome (ACS) culprit lesions (AC - n=70) and stable angina culprit lesions (SC - n=35). A direct statistical comparison of IVUS-VH data and multiple logistic regression analysis was undertaken. Four main factors were found to be associated (p<0.05) with an AC lesion phenotype: necrotic core/dense calcium (NC/DC) ratio; minimum lumen area <4 mm2 (MLA <4); remodelling index @MLA >1.05 and VH-TCFA presence. Calculation of each logistic regression coefficient and the equation produces an active plaque discrimination score with an AUC of 0.96 on receiver operating characteristics (ROC) analysis. Validation of the score in 50 independent plaques from the Thoraxcenter in Rotterdam revealed an AUC of 0.71, confirming continued diagnostic ability. CONCLUSIONS: We have found four features on IVUS and VH that can predict and discriminate ACS culprit lesion phenotypes from those that are clinically stable. Subsequently, we have constructed and validated the Liverpool Active Plaque Score based upon these features. It is hoped this score may help diagnose active coronary plaques, in the future, to help prevent major adverse cardiac events.

The association of heart valve diseases with coronary artery dominance.

BACKGROUND AND AIM OF THE STUDY: Aortic stenosis (AS) is thought to be caused by calcific degeneration of the aortic valve. Clinical observations suggest an association between a left dominant coronary circulation and AS, a situation previously investigated at necropsy and with small observational studies. Mitral regurgitation (MR) and aortic regurgitation (AR) are both disorders with multiple etiologies, but neither has any known association with coronary artery dominance. METHODS: The coronary angiogram database of a tertiary referral centre was reviewed for consecutive left heart catheter data acquired over a six-year period. The severity of AS was classified by measured pressure gradient (in mmHg) as none (0), mild (< 30), moderate (30-49), or severe (> 49). Both, MR and AR were assessed visually by the operator. RESULTS: A total of 1,891 patients was included. In the AS group there was a significant association with a left dominant coronary circulation (p < 0.0001), and the proportion of patients with left dominance increased with the severity of AS (p < 0.005). There was no significant association of AR with coronary artery dominance (p = 0.84). MR was associated with a reduced prevalence of left dominance (p < 0.005). CONCLUSION: AS was associated with a left dominant coronary circulation, and the incidence of left dominance was increased with the severity of AS, but the opposite situation was true for MR. The reasons for these observations remain unclear.

A randomized comparison of TR band and radistop hemostatic compression devices after transradial coronary intervention.

BACKGROUND: The transradial route for coronary intervention has proven to be safe, effective, and widely applicable in different clinical situations. Several compressive hemostatic devices have been introduced that have shown to be safe and are effective in achieving hemostasis. METHODS: Seven hundred ninety patients were randomly assigned to receive either TR band or Radistop hemostatic compression devices after transradial coronary procedure. The outcome measures were patient tolerance of the device, local vascular complications, and the time taken to achieve hemostasis. RESULTS: The mean age was 62.88 years, and 74.2% of the patients were men. Patient age, height, weight, wrist circumference, body mass index, male sex, hypertension, diabetes, hypercholesterolemia, and smoking incidences were similar in both groups. There were significantly more patients reporting no discomfort in the TR band group compared to the Radistop group (77% vs. 61%; P = 0.0001). Patients in the Radistop group reported significantly more pain across all categories of severity and three patients in the Radistop group were crossed over to TR band because of severe discomfort. Oozing and ecchymosis were seen in about 16% of the patients. Local small hematoma and large hematoma were seen in 5.4% and 2.2% patients respectively, and similar in both groups. Radial artery occlusion at the time of discharge was seen in 9.2% of the patients though only 6.8% showed persistent occlusion at the time of follow-up. The time taken to achieve hemostasis was significantly longer in the TR Band group (5.32 ± 2.29 vs. 4.83 ± 2.23 hr; P = 0.004). There was significantly higher incidence of radial artery occlusion in patients with smaller wrist circumference, the patients who experienced radial artery spasm during the procedure, and patients with no heparin administration during the procedure. CONCLUSIONS: We have shown in a randomized comparison of Radistop and TR band that both devices are safe and effective as hemostatic compression devices following transradial procedures. However, more patients felt discomfort with the Radistop device and the time taken to achieve hemostasis was longer with TR band. © 2010 Wiley-Liss, Inc.

Impact of length and hydrophilic coating of the introducer sheath on radial artery spasm during transradial coronary intervention: a randomized study.

OBJECTIVES: The aim of this study was to assess the impact of length and hydrophilic coating of the introducer sheath on radial artery spasm, radial artery occlusion, and local vascular complications in patients undergoing transradial coronary procedures. BACKGROUND: Radial artery spasm is common during transradial procedures and the most common cause for procedural failure. METHODS: We randomly assigned, in a factorial design, 790 patients scheduled for a transradial coronary procedure to long (23-cm) or short (13-cm) and hydrophilic-coated or uncoated introducer sheaths. The primary outcome measure was clinical evidence of radial artery spasm, and secondary outcome measures were patient discomfort and local vascular complications. RESULTS: Procedural success was achieved in 96% of the cases, and radial artery spasm accounted for 17 of 33 failed cases. There was significantly less radial artery spasm (19.0% vs. 39.9%, odds ratio [OR]: 2.87; 95% confidence interval [CI]: 2.07 to 3.97, p < 0.001) and patient reported discomfort (15.1% vs. 28.5%, OR: 2.27; 95% CI: 1.59 to 3.23, p < 0.001) in patients receiving a hydrophilic-coated sheath. No difference was observed between long and short sheaths. Radial artery occlusion was observed in 9.5% of the patients and was not influenced by sheath length or coating. A local large hematoma or arterial dissection was seen in 2.6% of the patients with no difference in groups allocated at randomization. Younger age, female sex, diabetes, and lower body mass index were identified as independent predictors of radial artery spasm. CONCLUSIONS: Hydrophilic sheath coating, but not sheath length, reduces the incidence of radial artery spasm during transradial coronary procedures.

Reduction in mortality and target-lesion revascularisation at 2 years: a comparison between drug-eluting stents and conventional bare-metal stents in the "real world".

BACKGROUND: Long-term safety of drug-eluting stent (DES) is still a concern. We aimed to assess the impact of DES use on all-cause mortality and target-lesion revascularisation (TLR) in routine clinical practice. METHODS: Retrospective analysis of all patients undergoing percutaneous coronary intervention with stent implantation at our institution between January 2003 and December 2004. To account for differences in patient characteristics, logistic regression was used to produce a propensity score for DES group membership. Patients receiving DES were then matched to patients receiving bare metal stents (BMS) with identical propensity scores. These two groups were then compared with respect to the incidence of TLR and all-cause mortality. RESULTS: During the study period 995 patients received DES. Of these, 82 patients had combined DES and BMS use and were therefore excluded; leaving 913 DES patients compared to 2105 BMS patients. Patients who received DES were more likely to be diabetic, hypertensive, had more lesions treated, restenotic lesions treated, left anterior descending and left main stem interventions, long lesions treated, small diameter lesions treated, and American Heart Association C-type lesions treated. After performing propensity-matching, to account for differences in patient characteristics, we were able to successfully match 777 DES patients to 777 BMS patients. The TLR rates at 24 months were significantly lower for DES patients (DES-4.2% vs BMS-9.2%, p<0.001). All-cause mortality was also significantly lower for DES patients (DES-1.8% vs BMS-4.0%, p=0.01). CONCLUSIONS: In routine clinical practice DES implantation continued to demonstrate a significant reduction in the need for repeat intervention at 24 months. All-cause and cardiac mortality was also significantly lower for DES patients compared to BMS patients.

Lesion complexity and angiographic outcomes in radial access percutaneous coronary intervention.

BACKGROUND: Percutaneous coronary intervention (PCI) is increasingly performed from the radial arterial (RA) access site. Few studies have examined the interaction between a default radial approach, lesion complexity, and angiographic outcome. This study investigates lesion complexity, arterial access route, and angiographic outcome in routine clinical practice by default radial operators. METHODS: All cases of PCI over a 12-month period (Jan 2005 to Jan 2006) at our regional cardiac center were prospectively entered into a database detailing arterial access route, target vessel and lesion characteristics, and lesion-specific angiographic outcome. Angiographic success was defined as residual stenosis <50% for balloon angioplasty alone or <20% for a stented lesion in the presence of TIMI 3 flow in the target vessel. All procedures carried out by default radial operators were selected for further retrospective analysis. Reasons for not completing a case via the radial route were recorded. Radial and femoral cases by default radial operators were evaluated on grounds of lesion complexity and angiographic outcome for each treated lesion. RESULTS: RA was the intended route in 91.5% of 1,324 procedures (91.5% of 2,239 lesions), and the final route in 90.1% of procedures (90.2% of lesions). There were 19 crossover procedures (30 lesions), all from radial to femoral access (FA). Crossovers were due to failed radial artery cannulation or sheath placement (9 procedures), inability to advance the guide catheter into the aortic root (7 procedures), and other guide catheter handling or support issues (3 procedures). Counting crossovers as failures, angiographic success rate was 96% among lesions for which RA was the primary intention. Complexity of cases was high (80.1% of RA lesions ACC/AHA type B2 or C). CONCLUSIONS: A default radial approach is compatible with successful treatment of a wide range of coronary lesions, with a low incidence of crossover to femoral access. When the radial approach fails, it is usually due to access problems rather than issues of guide catheter handling and support.

Circumstances and mode of in-hospital death following 9,914 consecutive patients undergoing percutaneous coronary interventions in the northwest of England.

AIM: To better describe the epidemiological causes of in-hospital death after percutaneous coronary intervention (PCI) in the present stent era. METHODS: Systematic review of all in-hospital deaths following PCI in North West England from 2001 to 2003. Sixty-two in-hospital deaths (0.6%) were identified from 9,914 consecutive PCIs performed during the study period. The medical records of 4 patients were missing, leaving 58 patients to be reviewed with a standard data extraction tool to determine a circumstance and a mode of death. Medical records were reviewed at each center and cases were discussed at regional consensus meetings. All the collected data were validated by random cross-checking of data by exchange site visits. Multivariate logistic regression was used to identify risk factors for deaths related to procedural complications. RESULTS: Low output failure was the most common mode of death, occurring in 42 patients (72.4%). The circumstance of death was a procedural complication in 35 patients (60.3%), and preexisting acute cardiac disease in 23 patients (39.7%). Significant predictors of death from procedural complications were treatment of left main stem (odds ratio [OR] 13.8; p < 0.001) or graft lesions (OR 5.6; p < 0.001), and female sex (OR 3.0; p = 0.002). CONCLUSIONS: Procedural complications account for over half of all post-PCI deaths. We have identified several risk factors that may help reduce the number of deaths related to procedural complications.

Postdilatation following coronary stent deployment: lesion and procedural characteristics associated with an increase in stent dimensions.

UNLABELLED: Adjunctive balloon postdilatation following stent deployment is often used to optimize stent expansion. However, the benefit of this strategy with modern stent delivery systems is not known. We investigated angiographic and procedural factors associated with a favorable response to postdilatation after coronary stent deployment. METHODS: We performed a prospective study recruiting 385 patients (490 lesions) who underwent stent deployment. Quantitative coronary angiography was used to measure the minimal lumen diameter (MLD) within the stent before and after postdilatation. Optimal stent deployment was defined as a stent MLD greater than or equal to 90% of the reference vessel diameter. RESULTS: Postdilatation was performed in 41.2% (202/490) of cases, with an increase in stent MLD from mean (SD) 2.50 (0.40) to 2.70 (0.38) mm, p < 0.0001. Optimal stent deployment increased from 35.6% (72/202) to 56.5% (115/202). The percentage increase in stent MLD with postdilatation was greatest in cases with a residual stenosis of > 20% after coronary stenting or a stent deployment pressure < or = 14 atm. Vessel size and predilatation had no impact on the response to postdilatation. In those cases where postdilatation was not performed, optimal stent deployment was achieved in 64.9% (187/288) of cases. CONCLUSION: A significant proportion of patients did not achieve optimal stent deployment with modern stent delivery systems. The increase in stent MLD with postdilatation was greater in cases with lower stent deployment pressures and more significant residual stenoses.

High-speed rotational atherectomy during transradial percutaneous coronary intervention.

UNLABELLED: There has been an exponential growth in the number of percutaneous coronary intervention (PCI) procedures carried out via the transradial route. Traditionally, high-speed rotational atherectomy (HSRA) has been performed through 8 and 9 Fr catheters, which has limited its use during radial PCI. AIM: To review the applicability and outcomes of HSRA as a primary debulking tool during radial PCI. METHODS: Case-note review and retrospective analysis of all patients undergoing HSRA during transradial PCI. Twenty-nine consecutive procedures in 28 patients were performed between January 2005 and April 2007. RESULTS: Eighteen (64%) of the patients were males, and the mean age was 71 +/- 9.4 years (46-89). Three procedures were urgent, and 14 proceeded to HSRA, though this was not the initial strategy. The majority of procedures, 23 (79.3%), were carried out using a 6 Fr system, and a 7 Fr system was used in the remainder of cases. There were 15 lesions in the left anterior descending artery, 11 in the right coronary artery and 3 in the left circumflex. Lesion classification was type C in 21, and type B2 in 5. HSRA was carried out successfully in all cases, with uneventful subsequent stent deployment. A 1.5 mm burr was used in 25 lesions, 1.25 mm in 4, and 1.75 mm in 2 lesions. The vessel diameter was 2.7 +/- 0.5 mm (range 2.25-4.0 mm), and the mean length of stents used was 23.5 +/- 6.7 mm (range 18-63 mm). The mean procedure time was 94 +/- 35 minutes (range 50-180). CK-MB postprocedure was available in 26 patients; no patients experienced a greater than two-fold rise in CK-MB. There were no major procedural complications. One patient had evidence of minor brachial artery dissection when the guide catheter was upsized to 7 Fr, but there were no sequelae. Another patient had evidence of pericardial effusion after the procedure that was treated successfully with pericardial drain with no consequences. There were no major adverse cardiac events. CONCLUSION: Transradial HSRA can be carried out safely with good results. In this series, the procedure was not the initial strategy in the majority of patients, but allowed successful revascularization. Use of the transradial route should not preclude consideration of HSRA in suitable patient subgroups.

Impact of periprocedural creatine kinase-MB isoenzyme release on long-term mortality in contemporary percutaneous coronary intervention.

OBJECTIVE: To evaluate the incidence of periprocedural creatine kinase-MB (CK-MB) release and its impact on longterm mortality in contemporary percutaneous coronary intervention (PCI) at a tertiary referral center. METHODS: Retrospective analysis of 4,958 patients undergoing PCI with deployment of at least 1 stent at our center between January 1, 2003 and December 31, 2005. Patients admitted with acute ST-elevation myocardial infarction or cardiogenic shock (n = 617), and patients with no available CK-MB levels (n = 477) were excluded, leaving 3,864 patients for analysis. The outcome measure was all-cause mortality obtained from the National Strategic Tracing Service with patients followed up to June 30, 2006 (mean follow up 22 months). The association between CK-MB level and mortality was examined using Cox proportional hazards analysis. RESULTS: CK-MB elevation above the upper limit of normal (ULN) was detected in 29.4% patients. A total of 127 deaths were observed during follow up. By multivariate analysis, periprocedural CK-MB was independently associated with an increased risk of death (adjusted hazard ratio for every 10 units: 1.09; 95% CI: 1.05-1.12; p < 0.001). The relationship between the level of CK-MB and mortality was further examined by applying strata of CK-MB levels to the multivariate analysis (adjusted hazard ratio: 1.30, 1.76 and 2.26 for CK-MB levels of 1-3, 3-5 and > 5 the ULN, respectively). CONCLUSION: In the current era of PCI, periprocedural myonecrosis, evidenced by CK-MB elevation, is common and is associated with less favorable long-term mortality.

Percutaneous coronary intervention for chronic total occlusions: improved survival for patients with successful revascularization compared to a failed procedure.

BACKGROUND: There are limited data on the impact of successful chronic total occlusion (CTO) revascularization by percutaneous coronary intervention (PCI) on survival. We performed a retrospective study comparing the survival between patients with a successful and a failed CTO revascularization by PCI. METHODS: Between January 1, 2000 and June 30, 2004, 543 of 5803 (9.4%) patients underwent PCI for a CTO at our center. A CTO was defined as an occlusion of the artery present for at least 3 months with Thrombolysis in Myocardial Infarction flow grade 0 or 1. Patient records were linked to a national database to monitor all deaths during follow up. Propensity matching was used to balance out case mix differences. RESULTS: Technical success for CTO was 377 of 543 (69.4%). In-hospital mortality was 0.3% and 1.2% for the CTO success and CTO failure patients, respectively. During a mean (SD) follow up of 1.7 (0.5) years, the mortality rate was 2.5% in the CTO success patients and 7.3% in the CTO failure patients. The crude hazard ratio for death with CTO failure was 3.92 (95% confidence intervals 1.56-10.07; P = 0.004). The rates of coronary artery bypass were 3.2% vs. 21.7% (P < 0.001) for the CTO success and CTO failure patients, respectively. Our propensity matched 157 CTO success to CTO failure patients and the associated hazard ratio for death with CTO failure was 4.63 (95% confidence interval 1.01-12.61; P = 0.049). Multivariate analysis showed that CTO failure was an independent predictor of death. CONCLUSION: Patients with a successful revascularization of a CTO by PCI have an increased survival rate compared to patients with a failed CTO procedure.

QT peak prolongation is not associated with left ventricular hypertrophy in teenage professional football players.

OBJECTIVE: QT peak prolongation is associated with left ventricular hypertrophy (LVH) in patients with hypertension. This study tests the hypothesis that QT peak prolongation correlates with LV mass index in apparently healthy young football players. METHODS: QT peak and other ECG criteria for LVH were assessed in 117 male professional footballers (mean age 16.4 years +/- SD 0.76). Their left ventricular mass index (LVMI) was assessed by transthoracic echocardiography. Heart rate-corrected QT peak (QTpc) interval was measured in lead I using Bazett's formula. Spearman (2-tailed) test and UNIANOVA was used to assess if there were correlations between QT peak and the various echocardiographic and ECG indices of LVH. RESULTS: Echocardiographic LVH, defined as LVMI > or = 134 g/m(2), was seen in 79 (70.5%) subjects. ECG-defined LVH was present in 54 (50 %) players by Sokolow-Lyon criteria, in 19 (16 %) players by Romhilt Score, in 5 (4 %) players by Cornell voltage criteria, and in 7 (6 %) players by Cornell product >2436 mm ms. There was no correlation between QT peak (QTpc) and LVMI on echocardiography (Spearman r = 0.058, 2-tailed P = 0.54). In addition, there was no relation between LVH and QTpc of lead I using any of the following ECG criteria: Sokolow-Lyon (P = 0.6), Romhilt (P = 0.3), Cornell voltage (P = 0.8), or Cornell product (P = 0.6). CONCLUSION: QT peak interval, which is associated with pathological LVH in hypertensive patients and is a measure of risk of cardiac death, does not correlate with LVH characterized by myocyte hypertrophy in young apparently healthy professional footballers.

Stent expansion: a combination of delivery balloon underexpansion and acute stent recoil reduces predicted stent diameter irrespective of reference vessel size.

BACKGROUND: There is a strong inverse relationship between final vessel diameter and subsequent risk of treatment failure after coronary stent deployment. The aim of this study was to investigate the magnitude by which stent delivery balloon underexpansion and stent elastic recoil contributed to suboptimal final vessel geometry. METHODS: A prospective angiographic study recruiting 499 lesions (385 patients) undergoing coronary stent implantation was performed. Quantitative coronary angiography (QCA) was used to measure the minimal lumen diameters of the delivery balloon during stent deployment (MLD1) and of the stented segment following balloon deflation (MLD2). The expected balloon diameter for the deployment pressure was determined from the manufacturer's reference chart. Delivery balloon deficit was measured by subtracting the MLD1 from the expected balloon size and stent recoil was calculated by subtracting MLD2 from MLD1. Delivery balloon deficit and stent recoil were examined as a function of reference vessel diameter (RVD) and balloon-vessel (BV) ratio. RESULTS: The final stent MLD was a mean 27.2% (SD = 7.2) less than the predicted diameter. The mean delivery balloon deficit was 0.65 mm (SD = 0.27) and the mean stent recoil was 0.28 mm (SD = 0.17). Percentage delivery balloon deficit and stent recoil were independent of RVD. Delivery balloon deficit increased with higher BV ratios. Stent recoil was independent of BV ratio and the use of predilatation. CONCLUSION: Failure to achieve predicted final stent diameter is a real problem with contribution from delivery balloon underexpansion and stent recoil. On average the final stent MLD is only 73% of the expected diameter, irrespective of vessel size.

Late stent thrombosis associated with coronary aneurysm formation after sirolimus-eluting stent implantation.

Stent thrombosis is a rare but potentially fatal complication of coronary stent implantation. Its occurrence late after drug-eluting stent (DES) deployment has led to concerns regarding their long-term safety. We report a case of late stent thrombosis 26 months after sirolimus-eluting stent (SES) (Cypher, Cordis Corp., Miami, Florida) implantation. This was associated with marked positive vessel remodeling and coronary aneurysm formation involving the stented segment of the coronary artery. The patient was on dual antiplatelet therapy at the time.

Transulnar access for coronary angiography and intervention: an early review to guide research and clinical practice.

Access for coronary angiography and intervention is increasingly achieved via the radial artery due to the significant risks of femoral access. However, anatomical and size variation mean the radial artery is not always suitable. The ulnar artery is occasionally used as an alternative in such cases, and while ulnar artery puncture may be relatively easy, there are anatomical particulars that could lead to complications following this access route. In the absence of accepted guidelines, this paper examines the available data on ulnar access for coronary procedures. A structured literature search was undertaken to gather peer-reviewed articles and conference abstracts relating to ulnar access. Data from each source were examined in a prescribed way with reference to technical aspects, procedural success or failure, catheter size and complications. A total of 9 publications and 2 conference abstracts were identified, detailing 483 transulnar coronary procedures in 463 cases. There were no randomized, controlled trials. Success occurred in 90.9% of procedures, predominantly using catheter sizes of 4, 5 and 6 Fr, with complications of any type occurring in 4.6% of procedures. Transulnar access may be acceptable in selected cases, but larger data sets are required, preferably of registry or randomized and controlled trial formats.

A study comparing the incidence and predictors of creatine kinase MB and troponin T release after coronary angioplasty. Does Clopidogrel preloading reduce myocardial necrosis following elective percutaneous coronary intervention?

BACKGROUND: To investigate the incidence and associated factors for enzyme release following percutaneous coronary intervention comparing assessment with creatine kinase MB (CK-MB) and troponin T (TnT). METHOD: TnT and CK-MB were measured post procedure in a consecutive series of 933 patients undergoing elective percutaneous coronary intervention between 1/4/2003 and 1/5/2004 at a single regional cardiac centre. RESULTS: CK-MB level significantly correlated to TnT levels (R=0.747, p<0.001) and a CK-MB level of above 3 times the upper limit of the local reference range (>3 x ULN) was predicted with 95% sensitivity (48% specificity) at a TnT level of 0.11. Multivariate predictors of >3 x ULN CK-MB release for uncomplicated percutaneous coronary intervention (n=898) were multi-vessel angioplasty (OR=2.51, 95% CI=1.57 to 4.01; p<0.001), saphenous venous graft angioplasty (OR=5.5, 95% CI=1.94 to 13.00; p=0.005) and lack of Clopidogrel preloading (OR=2.02, 95% CI=1.30 to 4.38; p=0.027). CONCLUSIONS: TnT was found to be a sensitive although not a highly specific marker of CK-MB release. In this study a TnT level above a threshold of 0.11 would identify 95% of the prognostically important 3-fold CK-MB releases. Replacing the >3 x ULN CK-MB threshold with a TnT level of 0.1 ng/l following percutaneous coronary intervention would increase the apparent rate of myocardial infarction from 11% to 20%. Lack of Clopidogrel preloading was independently associated with a >3 x ULN CK-MB release following uncomplicated elective percutaneous coronary intervention.

Mid-term survival after cardiac surgery in elderly patients: analysis of predictors for increased mortality.

This study examines and quantifies the potential risk factors for increased mid-term mortality in elderly patients (> or = 75 years old) undergoing cardiac surgery. We undertook a retrospective analysis of 840 consecutive elderly patients who underwent cardiac surgery (CABG and/or Valve) between April 1997 and March 2002. Deaths occurring as a function of time were described using the product limit methodology of Kaplan and Meier. Cox proportional hazards analysis was used to identify preoperative risk factors for mortality with hazard ratios (HR). One hundred and sixty-two (19.3%) deaths occurred during the study period, with a total follow-up of 1866 patient years (mean 2.2 years, SD 1.5 years). Observed freedom from death in the elderly patients at 5 years was 71.7%, compared to 70.9% for the age- and sex-matched general population (P=0.252). Multivariate analysis for independent predictors of increased mortality found that renal dysfunction (HR 3.2; P<0.001), valves(s) surgery (HR 1.8; P<0.001), cerebrovascular disease (HR 1.8; P=0.003), and catastrophic state (HR 2.2; P=0.011) were the major risk factors. We have identified and quantified several risk factors, which need to be considered when assessing patients for cardiac surgery.