Mitro-aortic pathology: a point of view for a fully transcatheter staged approach

Severe aortic valve stenosis (AVS) and mitral valve regurgitation (MVR) often coexist. Although a fully percutaneous treatment for the two conditions, by means of transcatheter aortic valve implantation (TAVI) followed by MitraClip, can be appealing in selected high-risk candidates, critical and strategical reasoning should be applied. In a 3-year period we have developed a single-centre experience of 14 patients who were managed with a staged percutaneous approach to treat severe AVS and MVR. The average interval from TAVI to MitraClip repair was 101 ± 12 days. Success for TAVI was 100% and 92.9% (13/14) for MitraClip. At late follow-up, 3 patients developed MVR 3+. Estimated 1?year survival was 66.5%. Freedom from 1?year endpoint (death, stroke, major bleeding, myocardial infarction, and cardiac re-hospitalisation) was 57.9%.In our view, a fully transcatheter approach for mitro-aortic pathology is feasible and should be performed only as a staged procedure in those patients that remain symptomatic, in spite of successful TAVI. It should be emphasised that although the periprocedural success rate is satisfactory, follow-up mortality and re-hospitalisation rates remain high, even at mid-term follow-up. This most probably results from the advanced clinical picture at time of referral for treatment.     

Diagnostic Performance of First-Pass Myocardial Perfusion Imaging without Stress with Computed Tomography (CT) Compared with Coronary CT Angiography Alone,with Fractional Flow Reserve as the Reference Standard

Coronary computed tomography angiography (CCTA) in combination with first-pass CT myocardial perfusion imaging (MPI) has a better diagnostic performance than CCTA alone, compared with invasive coronary angiography as the reference standard. The aim of this study was to investigate the additional diagnostic value of first-pass CT-MPI without stress for detecting hemodynamic significance of coronary stenosis, compared with invasive fractional flow reserve (FFR). We recruited 53 patients with suspected coronary artery disease undergoing both CCTA and first-pass CT-MPI without stress and invasive FFR, and 75 vessels were analyzed. We used the same raw data for CCTA and CT-MPI. First-pass CT-MPI was reconstructed by examining the diastolic signal densities as a bull’s eye map. Invasive FFR <0.8 was considered as positive. On per-vessel analysis, the area under the receiver operating characteristic curve for CCTA plus first-pass CT-MPI and CCTA alone was 0.81 (0.73–0.90) and 0.70 (0.61–0.81), respectively (P = 0.036). CCTA plus first-pass CT-MPI without stress showed 0.73 sensitivity, 0.74 specificity, 0.53 positive predictive value, and 0.87 negative predictive value for detecting hemodynamically significant coronary stenosis. First-pass CT-MPI without stress correctly reclassified 38% of CCTA false-positive vessels as true negative. First-pass CT-MPI without stress combined with CCTA demonstrated excellent diagnostic accuracy, compared with invasive FFR as the reference standard. This technique could complement CCTA for diagnosis of coronary artery disease.     

Association of serum gamma-glutamyltransferase and premature coronary artery disease

Background

Serum gamma-glutamyltransferase (GGT) has been introduced as a predictive factor for cardiovascular disease. In this study, we investigated the association of serum GGT and premature coronary artery disease (CAD) in candidates for coronary angiography.

Methods

In this cross-sectional study, we enrolled male subjects aged ≤45 years and female subjects ≤55 years who were candidates for elective coronary angiography due to typical chest pain or a positive non-invasive test. Baseline characteristics were recorded for all the participants and serum levels of blood glucose, lipid profile and GGT were measured. Patients were divided into CAD and non-CAD groups based on angiography for further comparisons.

Results

From a total of 367 patients (age 45.1 ± 6.1 years, 161 males [43.9%]), 176 (47.9%) patients had premature CAD. A high level of GGT was significantly associated with the presence of CAD (p < 0.001). A 10-unit increase in GGT could strongly predict the presence of premature coronary artery disease (OR: 13.34, 95% CI: 7.19–24.78; p < 0.001) after adjustment for confounders. The area under the receiver operating characteristic curve for GGT was 80.9% (range 76.5–85.3) and the sensitivity and specificity of GGT at a cut-point of 22.5 IU/l was 80.1% and 70.2%, respectively. Diagnostic accuracy of GGT was 74.9%. The positive predictive value and negative predictive value for GGT was 71.3 and 79.3, respectively.

Conclusion

We observed that GGT levels in patients with typical chest pain or positive non-invasive tests could predict the presence of premature CAD in young patients.

     

Transcatheter aortic valve replacement with the 34 mm Medtronic Evolut valve

Objectives

To report our experience with the recently introduced 34?mm Evolut transcatheter aortic valve replacement (TAVR) prosthesis.

Background

A larger TAVR prosthesis has become available for the treatment of aortic stenosis (AVS) in larger native aortic annuli (up to 30?mm). Outcomes with this new device are still unreported.

Results

The first 25 transfemoral TAVRs performed by our team with the self-expandable 34?mm Evolut are presented. The majority of patients were male (84%) with a mean age of 81.3?±?5.6 years, a median logistic euro-SCORE of 14.7 (5.4-61.0), and a computed tomography measured mean perimeter-derived aortic annulus diameter of 27.1?±?1.4?mm (min. 25.0–max. 31.2?mm). We implanted one 34?mm Evolut in all patients. Median operative time and radiation time were 68.5 and 12.4?min respectively. To optimise final valve position and haemodynamic performance, at least one complete re-sheathing and re-positioning of the same valve was reported in 33.2%. New permanent pacemaker implantation (PPMI) was necessary in 28.5%. At Receiver Operating Characteristic (ROC) analysis, a minimal diameter of the left ventricular outflow tract <21.9?mm was a significant predictor for PPMI (specificity 82%; sensitivity 83%; p?=?0.005; Area Under the Curve (AUC)?=?0.9). Length of stay in hospital was 9.2?±?5.8 days and no in-hospital death was reported. At discharge, grade 1?+?para-valvular regurgitation was present in 32%, and no regurgitation in the remaining patients. Device success and early safety were 100% and 92% respectively.

Conclusions

TAVR with the 34?mm Evolut prosthesis has shown satisfactory acute outcomes. Although results are consistent with those observed with smaller Evolut prostheses, a trend for a higher PPMI rate has been noticed and could derive from a higher oversizing rate.

     

The Nordic Aortic Valve Intervention (NOTION) trial comparing transcatheter versus surgical valve implantation: study protocol for a randomised controlled trial

Background

Degenerative aortic valve (AV) stenosis is the most prevalent heart valve disease in the western world. Surgical aortic valve replacement (SAVR) has until recently been the standard of treatment for patients with severe AV stenosis. Whether transcatheter aortic valve implantation (TAVI) can be offered with improved safety and similar effectiveness in a population including low-risk patients has yet to be examined in a randomised setting.

Methods/Design

This randomised clinical trial will evaluate the benefits and risks of TAVI using the transarterial CoreValve System (Medtronic Inc., Minneapolis, MN, USA) (intervention group) compared with SAVR (control group) in patients with severe degenerative AV stenosis. Randomisation ratio is 1:1, enrolling a total of 280 patients aged 70 years or older without significant coronary artery disease and with a low, moderate, or high surgical risk profile. Trial outcomes include a primary composite outcome of myocardial infarction, stroke, or all-cause mortality within the first year after intervention (expected rates 5% for TAVI, 15% for SAVR). Exploratory safety outcomes include procedure complications, valve re-intervention, and cardiovascular death, as well as cardiac, cerebral, pulmonary, renal, and vascular complications. Exploratory efficacy outcomes include New York Heart Association functional status, quality of life, and valve prosthesis and cardiac performance. Enrolment began in December 2009, and 269 patients have been enrolled up to December 2012.

Discussion

The trial is designed to evaluate the performance of TAVI in comparison with SAVR. The trial results may influence the choice of treatment modality for patients with severe degenerative AV stenosis.

Trial registration

ClinicalTrials.gov: NCT01057173     

冠状动脉CTA和DSA对冠心病患者的临床诊断价值比较

目的:比较冠状动脉CT血管成像(CT angiography,CTA)以及数字减影血管造影(digital subtraction angiography,DSA)诊断冠心病的临床价值差异。方法:选择2013年12月至2020年3月安徽医科大学第三附属医院、安徽医科大学第四附属医院收治的60例冠心病患者为研究对象,首先对其实施多排螺旋CT冠状动脉血管造影检测(CTA),而后2 w内再对其实施DSA检测,比较两种检测方式对不同血管狭窄程度、不同性质斑块检出率的差异,最后以DSA检测结果为金标准,评估CTA对冠状动脉狭窄诊断的一致性、灵敏度、特异度、阳性预测值和阴性预测值。结果:(1)CTA检测狭窄血管共计387支,轻度狭窄152支(39.28%),中度狭窄118支(30.49%),重度狭窄105支(27.13%),闭塞12支(3.10%);DSA检测狭窄血管392支,轻度狭窄150支(38.27%),中度狭窄124支(31.63%),重度狭窄112支(28.57%),闭塞6支(1.53%),两组各血管狭窄类型比较差异无统计学意义(P0.05);(2)CTA检测斑块69个,其中钙化斑43个(62.32%),非钙化斑26个(37.68%),DSA检测斑块61个,其中钙化斑33个(54.10%),非钙化斑28个(45.50%),两种检测方式差异无统计学意义(P0.05);(3)以DSA检测为金标准,CTA对重度及以上血管狭窄诊断一致性为99.23%,特异度为98.31%,灵敏度为99.64%,阳性预测值为99.15%,阴性预测值为99.27%。结论:与DSA相比,CTA对冠心病患者血管狭窄的诊断价值相当,且属于无创检测,在冠心病早期筛查中临床应用价值更高。     

Presence and extent of cardiac computed tomography angiography defined coronary artery disease in patients presenting with syncope

Background

In syncope patients, presence of coronary artery disease (CAD) is associated with poor prognosis. However, data concerning CAD prevalence in syncope patients without known cardiovascular disease are lacking. Therefore, the aim of this study was to investigate presence and extent of CAD in syncope patients.

Methods

We included 142 consecutive patients presenting with syncope at the outpatient cardiology clinic who underwent coronary computed tomography (CT) angiography. Syncope type was ascertained by two reviewers, blinded for coronary CT angiography results. Of the patients, 49 had cardiac syncope (arrhythmia or structural cardiopulmonary disease) and 93 had non-cardiac syncope (reflex [neurally-mediated], orthostatic or of unknown cause). Cardiac syncope patients were compared with matched stable chest pain patients regarding age, gender, smoking status, diabetes mellitus type 2 and systolic blood pressure.

Results

Distribution of CAD presence and extent in cardiac and non-cardiac syncope patients was as follows: 72% versus 48% any CAD; 31% versus 26% mild, 8% versus 14% moderate and 33% versus 7% severe CAD.Compared with non-cardiac syncope, patients with cardiac syncope had a significantly higher CAD presence and extent (p = 0.001). Coronary calcium score, segment involvement and stenosis score were also higher in cardiac syncope patients (p-values ≤0.004). Compared to the chest pain control group, patients with cardiac syncope showed a higher, however, non-significant, prevalence of any CAD (72% versus 63%) and severe CAD (33% versus 19%).

Conclusion

Patients with cardiac syncope show a high presence and extent of CAD in contrast to non-cardiac syncope patients. These results suggest that CAD may play an important role in the occurrence of cardiac syncope.

     

Clinical characteristics of patients with suspected cardiac chest pain and angiographically normal coronary arteries in a secondary care hospital

Background

An important number of patients with suspected cardiac chest pain have non-obstructive coronary artery disease. Our purpose was to describe the clinical characteristics of patients with normal or near-normal coronary arteries in routine cardiological practice in a secondary care hospital.

Methods

In 2013, consecutive patients referred for invasive coronary angiography with suspected cardiac chest pain were analysed at a single-centre (Westfriesgasthuis, Hoorn, the Netherlands). Coronary arteries were defined as normal or near-normal if they showed no stenosis or only slight wall irregularities on visual assessment. Patients with a final non-cardiac diagnosis for the chest pain were excluded.

Results

A total of 558 patients were included. Of these, 151 (27%) showed normal or near-normal coronary arteries on visual assessment. This group of patients were significantly more often female (p < 0.001), younger (p < 0.001) and non-diabetic (p = 0.002). Forty percent of hospitalised patients who had normal or near-normal coronary arteries at coronary angiography showed an elevated troponin.

Conclusion

In routine cardiological practice, around 1 out of 4 patients with suspected cardiac chest pain undergoing invasive angiography had normal or near-normal coronary arteries. We suggest that premenopausal women with suspected cardiac chest pain could be considered for non-invasive coronary imaging as a first step in clinical practice.

     

冠状动脉CTA结合动态心电图夜间ST段趋势图诊断冠状动脉硬化性心脏病的价值研究

摘要 目的：探讨冠状动脉CTA结合动态心电图夜间ST段趋势图对冠状动脉硬化性心脏病（冠心病）的诊断价值。方法：回顾性分析2022年1月-2023年2月在我院疑似冠心病的患者104例,所有患者均行冠状动脉造影、冠状动脉CTA、动态心电图及临床相关实验室检查。以冠状动脉造影结果作为诊断冠心病的金标准,分析比较冠状动脉CTA、动态心电图夜间ST段趋势图及两者联合诊断冠心病的诊断效能和一致性。结果：104例疑似冠心病的患者确诊93例（89.42%）。冠状动脉CTA诊断冠心病的敏感性为90.32%,特异性为72.73%,阳性预测值为96.55%,阴性预测值为47.06%,准确率为88.46%,与冠状动脉造影的Kappa值为0.813,一致性好。动态心电图夜间ST段趋势图诊断冠心病的敏感性为84.95%,特异性为63.64%,阳性预测值为95.18%,阴性预测值为33.33%,准确率为82.69%,与冠状动脉造影的Kappa值为0.724,一致性较好。有夜间ST段动态改变的冠心病检出率（84.95%,79/93）明显高于无夜间ST段动态改变的冠心病检出率（15.05%,14/93）,差异有统计学意义（P＜0.001）。冠状动脉CTA结合动态心电图夜间ST段趋势图诊断冠心病的敏感性为96.77%,特异性为90.91%,阳性预测值为98.90%,阴性预测值为76.92%,准确率为96.15%,与冠状动脉造影的Kappa值为0.923,一致性好。结论：冠状动脉CTA结合动态心电图夜间ST段趋势图诊断冠心病的临床价值优于冠状动脉CTA或动态心电图夜间ST段趋势图单独检查。     

Coronary computed tomography angiography and [15O]H2O positron emission tomography perfusion imaging for the assessment of coronary artery disease

Determining the anatomic severity and extent of coronary artery disease (CAD) by means of coronary computed tomography angiography (CCTA) and its effect on perfusion using myocardial perfusion imaging (MPI) form the pillars of the non-invasive imaging assessment of CAD. This review will 1) focus on CCTA and [¹⁵O]H₂O positron emission tomography MPI as stand-alone imaging modalities and their combined use for detecting CAD, 2) highlight some of the lessons learned from the PACIFIC trial (Comparison of Coronary CT Angiography, SPECT, PET, and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve (FFR) (NCT01521468)), and 3) discuss the use of [¹⁵O]H₂O PET MPI in the clinical work-up of patients with a chronic coronary total occlusion (CTO).

     

多种无创检查组合在冠心病诊断中的价值

目的：评价多种无创辅助检查组合对冠状动脉粥样硬化性心脏病（冠心病）辅助诊断价值,筛选有效的冠心病确诊和排除指标,初步确定优化的冠心病早期诊断策略。方法：回顾性分析6419例冠心病患者多项无创辅助检查结果（包括静息心电图、24小时动态心电图、负荷心电图、负荷核素心肌显像、16或64排CT冠状动脉成像）,以冠状动脉造影阳性（至少一支主要冠状动脉或其主要分支的内径有≥50％的狭窄）为金标准,观察各种无创辅助检查组合对冠心病诊断的特异性、敏感性、误诊率、漏诊率、阳性预测值和阴性预测值。结果：多项无创辅助检查组合在冠心病的诊断中敏感性56．02-87．43％,特异36．13-87．61％,阳性预测值58．83．97．16％,阴性预测值30．21．73．36％,非介入手段中,敏感性和阴性预测值以动态心电图联合核素心肌灌注显像组最高,特异性和阳性预测值以动态心电图联合冠脉CT成像组最高。结论：辅助检查组合可作为无创性诊断、评价冠心病的重要方法,动态心电图可作为各级别医院冠心病筛查的基本及重要手段。     

Coronary artery anomalies detected by MSCT-coronary angiography in the adult

Background. Before coronary evaluation by modern imaging techniques was feasible, premorbid diagnoses of coronary artery anomalies (CAAs) were usually made fortuitously by invasive coronary angiography (ICA). However, this technique is limited by its invasive and projectional nature. Coronary magnetic resonance angiography (CMRA) and multi-slice computed tomography (MSCT) broadened clinical information by enabling visualisation of the coronary arteries in their anatomical environment. Methods. This case series visualises and reviews anomalous coronary artery from the opposite sinus (ACAOS) and coronary artery fistulae. All CAAs were detected by means of 64-slice dual source computed tomography after 1000 cardiac scans at the Erasmus MC, Rotterdam, the Netherlands. Results. Eight ACAOS cases, one anomalous left coronary artery from the pulmonary artery (ALCAPA) and one congenital aneurysm of an aortic sinus were found. Seven out often detected CAAs were considered malignant whereas three CAAs of the ACAOS type (retroaortic path) were considered benign. Significant coronary artery disease was found in three out of eight ACAOS cases. In one of the ACAOS cases complete evaluation of the anomalous coronary artery was limited by motion artifacts. All five cases of right ACAOS were referred for MSCT because the right coronary artery could not be located by invasive angiography. Conclusion. All CAAs were easy to diagnose because of 3D imaging and high temporal and spatial resolution. High resolution made it possible to not only depict coronary artery abnormalities, but also to quantify luminal and vessel properties such as stenosis grade, aspects of plaque, anomalous vessel length, luminal area ratio and the asymmetry ratio. Because of its comprehensiveness, MSCT can be an effective imaging modality in patients suspected of coronary artery abnormalities caused by coronary artery disease, CAAs, or a combination of both. (Neth Heart J 2008;16:369-75.)     

冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值对2型糖尿病患者合并冠状动脉病变的诊断价值

摘要 目的：探究冠状动脉CT血管造影（CTA）联合血清同型半胱氨酸（HCY）、胱抑素C（Cys-C）、载脂蛋白B/载脂蛋白A1（ApoB/ApoA1）比值对2型糖尿病（T2DM）患者合并冠状动脉病变的诊断价值。方法：回顾性选取2018年8月到2021年8月间我院收治的358例T2DM患者,均行常规生化指标、CTA检查、冠状动脉造影（CAG）检查,根据CAG检查结果为金标准将T2DM患者分为未合并冠脉病变组（190例）和合并冠脉病变组（168例）,比较两组血清HCY、Cys-C、ApoB/ApoA1比值,分析CTA与CAG诊断冠脉狭窄结果的一致性,应用受试者工作特征（ROC）曲线评估冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值对T2DM合并冠状动脉病变的诊断价值。结果：与未合并冠脉病变组比较,合并冠脉病变组血清HCY、Cys-C、ApoB、ApoB/ApoA1比值水平明显更高（P＜0.05）,ApoA1明显更低（P＜0.05）。以CAG为金标准,CTA诊断冠脉狭窄程度与CAG一致性较高（Kappa值0.748）。ROC曲线评估冠状动脉CTA诊断T2DM合并冠脉病变的AUC、灵敏度、特异度、准确度依次为0.802、74.40%、83.71%、79.11%。三项血清指标联合AUC、准确度显著优于单一指标（P＜0.05）。冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值诊断T2DM合并冠脉病变的价值显著优于各项指标单一诊断或三项血清指标联合诊断（P＜0.05）。结论：冠状动脉CTA联合血清HCY、Cys-C、ApoB/ApoA1比值诊断T2DM患者合并冠状动脉病变的价值较高,相较各项指标单一应用而言更具优势。     

Electrocardiographic chest wall mapping in the diagnosis of coronary artery disease.

Chest wall mapping of ST segment changes, inverted U waves, and Q waves using 16 electrocardiographic electrodes was performed at rest and during and after bicycle ergometry in 150 patients presenting with chest pain suggestive of angina. All patients underwent coronary angiography. The presence or absence of appreciable coronary artery disease (greater than or equal to 50% stenosis) was detected with a sensitivity of 98% and a specificity of 88%. The identification of lesions in individual coronary arteries was also possible with a sensitivity and specificity of 87% and 85% respectively for the territory of the left anterior descending and diagonal artery, 71% and 85% respectively for the right coronary artery, and 85% and 80% respectively for the circumflex artery. This test appears to be a reliable non-invasive screening method for selecting patients for angiography.     

Ultrasound diagnostic schema for the determination of increased risk for chromosomal fetal aneuploidies in the first half of pregnancy

The aim of the study was to develop an early ultrasound diagnostic schema for the determination of increased risk for fetal chromosomal aneuploidies. The study was conducted on a population of 1318 pregnant women divided into 2 groups: 1255 women with the normal course of pregnancy and 63 women with diagnosed fetal abnormalities. There were 34 cases of chromosomal abnormalities (trisomy 21, 18, 13; triploidy; unbalanced inversion 9; deletion 16) and 29 cases of structural malformations. The estimation of the range of normal values was performed for the nuchal translucency (NT) measurement between 11 and 13 weeks and the nasal bone length (NB) measurement between 12 and 20 week. The results obtained in the collective set of normal pregnancies constituted the basis for the calculation of the range of normal values. The measurements of NB and NT showed a linear value increase with the pregnancy course. The following test characteristics (correlation to CRL) were recorded: NB - sensitivity 60%, specificity 98%, positive predictive value (PPV+) 43%, negative predictive value (NPV-) 98.9%. For the assumption that the test outcome means the presence or absence of the nasal bone in the ultrasound scan the sensitivity was 40%, but specificity 100%; NT - sensitivity 63.6%, specificity 98.2%, PPV+ 38.9%, NPV - 98.2%; NT + NB - presents similar characteristic to the NB or NT alone - sensitivity 55.6%, specificity 98.6%, PPV+ 50%, NPV - 98.9%. The following test characteristics for chromosomal aberration markers (correlation to BPD) were observed: NB - sensitivity 68.4%, specificity 97.4%, PPV+ 56.5%, NPV - 98.4%; NT - sensitivity 73.9%, specificity 97.9%, PPV+ 54.8%, NPV- 99.2%; NT + NB - sensitivity 94.7%, specificity 98.9%, PPV+ 90%, NPV - 99.7%, respectively. The "genetic sonogram" protocol for the structural defect detection was analysed: sensitivity was 80%, specificity 100%, PPV+ 100%, NPV - 99.7%. It is concluded that the new biometric parameter--nasal bone length (NB) and the corrected one--nuchal translucency thickness (NT) are useful markers for fetal abnormalities, especially for chromosomal aberrations. High predictive values of the diagnostic schema for the detection of aneuploidies and structural defects indicate that its application in correlation with the biparietal diameter (BPD) is highly recommended. The proposed schema is an effective algorithm for prenatal diagnostics characterised by high prognostic values. The possible introduction of the schema could result in a decrease of the invasive procedure rates, which could minimise the rate of miscarriages as a complication of amniocenteses.     

Une stratégie combinée coroscanner-scintigraphie myocardique peut permettre de réduire avec sécurité le recours à la coronarographie chez les patients ayant un résultat équivoque à l’un des tests

ObjectivesCT-coronary angiography (CTCA) and myocardial perfusion scintigraphy (MPS) have both high negative predictive values in detecting coronary artery disease (CAD) but suboptimal predictive positive values, leading to unnecessary invasive coronary angiography (ICA) in case of equivocal findings. Combining these two tests may obviate their inherent limitations.Patients and methodsSixty-seven patients at mostly intermediate risk of CAD were subjected to either CTCA (45 patients) or MPS (22 patients) at first test, followed by the second test because of equivocal results of the first test. A discordant defect between the two tests was considered as false positive, hence likely to exclude CAD, and a concordant defect as true positive, likely to confirm CAD. All patients with concordant defects were referred to subsequent ICA. All patients with discordant defects (except for seven of them who underwent ICA too) were subjected to a mean follow-up of 730 ± 377 days.ResultsDiscordant findings between CTCA and MPS were found in 41 patients, from whose 7/7 had no significant stenosis at the invasive angiography and 34/34 had no major cardiac event during follow-up. Concordant findings were found in 26 patients. Invasive coronary angiography revealed significant stenoses in 14/26 patients; 9/14 of them needed revascularization.ConclusionA strategy combining CTCA and MPS may safely reduce referral to ICA in patients with equivocal findings at a single examination.     

Homocysteine, vitamins B6, B12, folate, and risk of coronary artery disease in patients undergoing diagnostic coronary angiography

Summary. Homocysteine and vitamins B were correlated with coronary artery disease in patients undergoing diagnostic coronary angiography. 160 patients having ≧1 stenosis (G1), 55 patients having normal coronary arteries (G2) and 171 healthy volunteers (G3) were prospectively recruited. Homocysteine levels were significantly higher in patients, particulary in those with normal coronary angiograms, than in healthy subjects (13.8 ± 6.3 μmol/L in G1 (p < 0.0001) and 15.2 ± 8.8 μmol/L in G2 (p < 0.0001) versus 10.1 ± 3.1 μmol/L in G3). Homocysteine levels were not related to the extent of coronary artery disease. In patients with normal angiogram, vitamin B12 and folate levels were significantly higher compared with the other groups (p < 0.05 and p < 0.001, respectively) showing that vitamin B deficiency was not involved in the hyperhomocysteinemia. In conclusion, homocysteine and vitamins B levels do not contribute to discriminate for the presence of coronary artery disease in patients undergoing diagnostic coronary angiography. Homocysteine levels, however, were higher in patients referred for coronary angiography than in healthy controls. Received November 7, 1998, Accepted February 20, 1999     

Instantaneous wave-free ratio and fractional flow reserve in clinical practice

Objectives

To compare fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) measurements in an all-comer patient population with moderate coronary artery stenoses.

Background

Visual assessment of the severity of coronary artery stenoses is often discordant in moderate lesions. FFR allows reliable functional severity assessment in these cases but requires adenosine-induced hyperaemia with associated additional time, costs and side effects. The iFR is a hyperaemia-independent index.

Methods and results

Between November 2015 and February 2017, 356 consecutive patients were included in whom 515 coronary stenoses were measured using both iFR and FFR. Mean iFR and FFR were 0.90?±?0.09 and 0.86?±?0.08, respectively. iFR correlated well with FFR [r?=?0.75; p?<?0.001]. Receiver operating characteristic analysis identified an area under the curve of 0.92. An iFR-only strategy with a treatment cut-off ≤0.89 revealed a diagnostic classification agreement with the FFR-only strategy in 420 lesions (82%) with a sensitivity of 87%, a specificity of 80%, a positive predictive value of 56% and a negative predictive value of 96%.

Conclusions

Real-time iFR measurements have good negative predictive value compared to FFR, but moderate diagnostic accuracy (82%). It exposes fewer patients to adenosine, reduces procedure time and costs. Further prospective trials are needed to evaluate specific clinical settings, cut-off values and endpoints.

     

Erythropoietin stimulates the coronary collateral development in patients with coronary chronic total occlusion

Objective

Erythropoietin (EPO) improves cardiac function and induces neovascularisation in post-myocardial infarction heart failure. The aim of this study was to analyse the association between the serum erythropoietin level and coronary collateral development in patients with coronary artery disease and chronic total occlusion.

Methods

A total of 168 patients consisting of 117 with coronary artery disease (CAD, (62 with chronic total occlusion (CTO), 55 without CTO)) and 51 with healthy coronary arteries were included in the study. The patients were assigned as coronary artery disease without CTO (group 0), CAD with CTO (group 1: poor collateral development, group 2: good collateral development) and normal coronary arteries (group 3).

Results

There was a significant positive correlation between serum EPO levels and the Rentrop scores in angiography (r = 0.243, p = 0.001). Similarly, a positive correlation was found between serum EPO levels and the Syntax scores (r = 0.253, p = 0.001). Echocardiography revealed a negative correlation between serum EPO levels and the cardiac ejection fraction (r = ?0.210, p = 0.006).

Conclusions

Serum EPO is a useful biomarker for coronary collateral development in patients with CTO.

     

Trends in patient characteristics and clinical outcome over 8 years of transcatheter aortic valve implantation

Aim

In the evolving field of transcatheter aortic valve implantations (TAVI) we aimed to gain insight into trends in patient and procedural characteristics as well as clinical outcome over an 8?year period in a real-world TAVI population.

Methods

We performed a single-centre retrospective analysis of 1,011 consecutive patients in a prospectively acquired database. We divided the cohort into tertiles of 337 patients; first interval: January 2009–March 2013, second interval: March 2013–March 2015, third interval: March 2015–October 2016.

Results

Over time, a clear shift in patient selection was noticeable towards lower surgical risks including Society of Thoracic Surgeons predicted risk of mortality score and comorbidity. The frequency of transfemoral TAVI increased (from 66.5 to 77.4%, p?=?0.0015). Device success improved (from 62.0 to 91.5%, p?<?0.0001) as did the frequency of symptomatic relief (≥1 New York Heart Association class difference) (from 73.8 to 87.1%, p?=?0.00025). Complication rates decreased, including in-hospital stroke (from 5.0 to 2.1%, p?=?0.033) and pacemaker implantations (from 10.1 to 5.9%, p?=?0.033). Thirty-day mortality decreased (from 11.0 to 2.4%, p?<?0.0001); after adjustment for patient characteristics, a mortality-risk reduction of 72% was observed (adjusted hazard ratio [HR]: 0.28, 95% confidence interval [CI]: 0.13–0.62). One-year mortality rates decreased (from 23.4 to 11.4%), but this was no longer significant after a landmark point was set at 30 days (mortality from 31 days until 1 year) (adjusted HR: 0.69, 95% CI: 0.41–1.16, p?=?0.16).

Conclusion

A clear shift towards a lower-risk TAVI population and improved clinical outcome was observed over an 8?year period. Survival after TAVI improved impressively, mainly as a consequence of decreased 30-day mortality.