Relationship between post-treatment platelet reactivity and ischemic and bleeding events at 1-year follow-up in patients receiving prasugrel.

BACKGROUND: Post-treatment platelet reactivity (PR) is associated with ischemic and bleeding events in patients receiving P2Y12 receptor antagonists. OBJECTIVES: We aimed to study the relationship between post-treatment PR after a 60-mg loading dose (LD) of prasugrel and 1-year thrombotic and bleeding events. METHOD: Patients were prospectively included in this multicenter study if they had a successful percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) and received prasugrel. The platelet reactivity index (PRI) was measured using the Vasodilator-Stimulated Phosphoprotein index (VASP) after a prasugrel LD. Endpoints included the rate of thrombotic events and bleeding events at 1 year. RESULTS: Among the 301 patients enrolled, 9 (3%) were lost to follow-up at 1 year. The rates of thrombotic and bleeding events at 1 year were of 7.5% and 6.8%, respectively. Receiver-operating curve (ROC) analysis demonstrated an optimal cut-off value of 53.5% of PRI to predict thrombotic events at 1 year. Using this cut-off value we observed that patients exhibiting high on-treatment platelet reactivity (HTPR) had a higher rate of thrombotic events (22.4% vs. 2.9%; P < 0.001). In parallel the optimal cut-off value of PRI to predict bleeding was 16%. Patients with a PRI ≤ 16% had a higher rate of bleeding events compared with those with a PRI > 16% (15.6% vs. 3.3%; P < 0.001). In multivariate analysis, the PRI predicted both thrombotic and bleeding events (OR: 1.44, 95% confidence interval [CI]: 1.2-1.72; P < 0.001 and OR: 0.75, 95% CI: 0.59-0.96; P = 0.024 [respectively, per 10% increase]). CONCLUSION: Platelet reactivity measurement after a prasugrel LD predicts both ischemic and bleeding events at 1 year follow-up for ACS patients undergoing PCI.

Usefulness and clinical impact of a fractional flow reserve and angiographic targeted strategy for coronary artery stenting: FROST III, a multicenter prospective registry.

BACKGROUND: Fractional flow reserve (FFR) is correlated with angiographic and intravascular ultrasound assessments of stent placement. Post-stenting FFR has been described as a good predictor of clinical events after 6 months. OBJECTIVE: To evaluate the feasibility and clinical impact of targeting an FFR > 0.95 via incremental in-stent inflation pressures. METHODS: In this multicenter prospective study, 100 consecutive patients underwent FFR measurement at baseline, after balloon predilatation, and after stenting with 4-atm inflation pressure increments from 8 to 20 atmospheres. Inflations were stopped when FFR increased above 0.95 and angiographic stenosis was less than 20%. RESULTS: FFR > 0.95 was achieved in 81% of cases; this FFR target was reached at 8 atm in 47% of patients, 12 atm in 16 %, 16 atm in 15%, and 20 atm in 3%. Fifty percent of patients with adequate angiographic result had an FFR less than 0.95 and needed further higher inflations. FFR was correlated with residual stenosis when the total procedure was evaluated, and this correlation persisted when in-stent inflations alone were considered. Final FFR was significantly correlated with anginal status after 6 months. CONCLUSIONS: Angiography guided PCI does not allow optimization of FFR. Since optimal post stenting FFR is correlated to better anginal status at 6-months, this suggests that FFR guided PCI is required to achieve optimal functional results of PCI.

Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction.

BACKGROUND: When administered in conjunction with primary coronary stenting for the treatment of acute myocardial infarction, a platelet glycoprotein IIb/IIIa inhibitor may provide additional clinical benefit, but data on this combination therapy are limited. METHODS: We randomly assigned 300 patients with acute myocardial infarction in a double-blind fashion either to abciximab plus stenting (149 patients) or placebo plus stenting (151 patients) before they underwent coronary angiography. Clinical outcomes were evaluated 30 days and 6 months after the procedure. The angiographic patency of the infarct-related vessel and the left ventricular ejection fraction were evaluated at 24 hours and 6 months. RESULTS: At 30 days, the primary end point--a composite of death, reinfarction, or urgent revascularization of the target vessel--had occurred in 6.0 percent of the patients in the abciximab group, as compared with 14.6 percent of those in the placebo group (P=0.01); at 6 months, the corresponding figures were 7.4 percent and 15.9 percent (P=0.02). The better clinical outcomes in the abciximab group were related to the greater frequency of grade 3 coronary flow (according to the classification of the Thrombolysis in Myocardial Infarction trial) in this group than in the placebo group before the procedure (16.8 percent vs. 5.4 percent, P=0.01), immediately afterward (95.1 percent vs. 86.7 percent, P=0.04), and six months afterward (94.3 percent vs. 82.8 percent, P=0.04). One major bleeding event occurred in the abciximab group (0.7 percent); none occurred in the placebo group. CONCLUSIONS: As compared with placebo, early administration of abciximab in patients with acute myocardial infarction improves coronary patency before stenting, the success rate of the stenting procedure, the rate of coronary patency at six months, left ventricular function, and clinical outcomes.

Relation of minor cardiac troponin I elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris.

There is little information about the relation between mild cardiac troponin I (cTn-I) increase after coronary interventions and late outcome. We therefore focused on the long-term outcome and the clinical, morphologic, and procedural correlates of elevation of cTn-I compared with cardiac troponin T, creatine kinase (CK), CK-MB activity and mass, and myoglobin in 105 patients with successful elective percutaneous transluminal coronary angioplasty (PTCA) for stable or unstable angina. Patients with myocardial infarction and those with unstable angina who had a detectable increase in serum markers before PTCA were excluded. Markers were measured before and after the procedure and for 2 days. Patients were followed up to record recurrent angina, myocardial infarction, cardiac death, repeat PTCA, or elective coronary artery bypass graft surgery. Procedure success was achieved in all cases. Elevation in cTn-I (> or =0.1 microg/L) was observed in 23 of 105 patients (22%) (median peak: 0.25 microg/L); 18% had cardiac troponin T (cTn-T) release (> or = 0.1 microg/L, median peak 0.21); 11.4% CK-MB mass (> or =5 microg/L), and 7.6% myoglobin (> or =90 microg/L) release. Five and 2 patients had elevated CK and CK-MB activity, respectively. Fourteen of 18 patients with cTn-T elevation had a corresponding elevation in cTn-I (kappa 0.68; p = 0.001). Patients positive for cTn-I had more unstable angina (p = 0.042) and heparin before PTCA (p = 0.046), and had longest total time (p = 0.004) and single inflation (p = 0.01). By multivariate logistic regression, predictors of postprocedure cTnI elevation were maximum time of each inflation (odds ratio 9.2; p = 0.0012), type B lesions (odds ratio 6.6; p = 0.013), unstable angina (p = 0.041), and age > or =60 years (p = 0.032). Clinical follow-up was available in 103 patients (98%) (mean 19+/-10 months). Kaplan-Meier survival analysis showed that cTn-I elevation was not an important correlate of cardiac events (p = 0.34, by log-rank analysis). The incidence of recurrent angina, myocardial infarction, cardiac death, and repeat revascularization after 12 months was not different in patients positive or negative for cTn-I. We conclude that cTn-I elevation after successful PTCA is not associated with significantly worse late clinical outcome. Levels of cTn-I allow a much higher diagnostic accuracy in detecting minor myocardial injury after PTCA compared with other markers, but there is no association with periprocedural myocardial cell injury and late outcome when cTn-I and other markers are considered.

Doppler echocardiographic evaluation of the Omnicarbon cardiac valve prostheses.

Comprehensive 2 D/Doppler examination of 98 patients (mean age 56), implanted between September 1984 and February 1991, with normally functioning aortic (n = 49) and mitral (n = 49) Omnicarbon valves (OC) were analyzed in order to characterize the normal hemodynamic profiles of the OC valves. The mean time from implantation was 36.4 months (range 6 to 78). The following parameters were assessed (average of 5 measurements): peak transvalvular velocity (peak V), peak instantaneous gradient (peak G), mean transvalvular gradient (mean G), effective aortic valve area (ef Va), modified aortic valve area (m Va), aortic permeability index (PI), mitral valve area (Mit Va). Doppler data were correlated to prosthetic sizes (ranging from 21-29 mm for aortic OC and from 23-31 mm for mitral OC). The study establishes normal Doppler hemodynamics for each size (especially in aortic position) of OC valves and shows excellent performance. Significant correlations between peak G, mean G, Pl, and prosthetic aortic valve size (AS) were moderate. By contrast there were strong relationships between AS and ef Va (r = 0.56, p < 0.001) or mVa (r = 0.55, p < 0.001). These data should be helpful to identify OC prosthetic dysfunction.

[Lipomatous hypertrophy of the interatrial septum. Apropos of 3 cases and review of the literature]. / Hypertrophie lipomateuse du septum interauriculaire. A propos de 3 cas et revue de la littérature.

Lipomatous hypertrophy of the interatrial septum is characterised by an accumulation of fatty tissue in the interatrial septum. The authors report three cases, one presenting with sinus tachycardia and the other two being chance findings. Echocardiography associated with cardiac computerised tomography or magnetic resonance imaging usually confirms the diagnosis. In half the cases, supraventricular arrhythmias and suggestive P wave abnormalities are observed on the electrocardiogram. The diagnostic value of transoesophageal echocardiography is emphasised; it demonstrates the massive forms which may obstruct flow from the superior vena cava into the right atrium. The authors observe a discrepancy between the prevalence of this condition in autopsy series (about 1%) and the small number of cases described at echocardiography, suggesting that the diagnosis is probably missed.

[Evaluation of the left-to-right shunt in interatrial septal defects (ostium secundum) using Doppler echocardiography. Apropos of 12 cases]. / Evaluation du shunt gauche-droit dans les communications interauriculaires (ostium secundum) par échographie-Doppler. A propos de 12 cas.

In 12 patients with inter-atrial communication (ostium secundum) (IAC-OS), and ages ranging between 8 and 63 years (mean = 21 years), the ratio between pulmonary and systemic flow (QP/QS) was evaluated with the use of Doppler ultrasonography and compared with the QP/QS obtained by oxymetric measurement during catheterization. The pulmonary or systemic flow is evaluated from the diameter of the opening (d) and the velocity curve (ITV) recorded by pulsated Doppler in the aorta and the pulmonary artery; Q = d2/4 x ITV x heart rate both examinations (sonogram and catheterization) are performed in less than 24 hours. The results show a good correlation between both methods (R = 0.948) (Y = 0.756 X + 0.692). There is no significant variation between intra- or inter-observer. The findings of this study are comparable to those already published; the main difficulty in evaluating of the QP/QS by Doppler sonography are related to the measurement of the pulmonary diameter and there recording of good velocity curves. The QP/QS evaluated by Doppler sonography from a simplified calculation method advocated by Oloez et al. (QP/QS = d2 Ap x V max Ap/d2 Ao x V max Ao were compared, in retrospect, to the data provided by catheterization. The correlation is also satisfactory (R = 0.893). The Doppler ultrasonography is therefore a reliable and reproducible method in as far as the measurement of QP/QS in young or adults subjects affected with IAC OS.

[Doppler color echocardiography in the diagnosis of 4 septal perforations complicating anterior myocardial infarction]. / Apport de l'échocardiographie-doppler couleur dans le diagnostic de quatre perforations septales compliquant un infarctus antérieur du myocarde.

The 4 cases reported here are meant to illustrate the value of colour doppler-echocardiography in the diagnosis of ventricular septal rupture consecutive to an anterior myocardial infarction. With this method, the examination begins with colour doppler ultrasound superimposed on two-dimensional echocardiographic images and is completed by pulsed and continuous wave doppler velocimetry. In all 4 patients an abnormal colour doppler flow was visualized from the outset; it started in the left ventricule and crossed the ventricular septum to enter the right ventricule, thus confirming the diagnosis and locating the septal defect. This abnormal flow was easy to recognize. On the apical "4 cavity" projection it followed a semi-circular anti-clockwise course which occurred at each cardiac cycle. The flow was red at first in presystole at the apex of the left ventricule; it became blue in pre- and middle-systole while traversing the septum, then mosaic-like in middle- or end-systole around the septal defect on the right ventricular side, and finally blue again in pre-diastole within the right ventricle. The blue trans-septal flow persisted at least up to pre-diastole. The diagnosis of septal rupture was confirmed at surgery in 3 cases and at right heart catheterization in 1 case. Colour doppler-echocardiography is a simple, efficient and rapid method, superior to contrast echocardiography or pulsed doppler alone, for direct real-time visualization of the shunt. It makes the septal defect easy to locate, and it avoids invasive exploratory manoeuvres in cases where surgery is contra-indicated and/or when coronary angiography is not mandatory.