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Aims To investigate the clinical and angiographic outcome of patients with mild coronary lesions treated with balloon angioplasty or coronary stenting (coronary plaque sealing, i.e. dilatation of angiographically non-significant lesions) compared to moderate and severe stenoses.Methods and results Patients with chronic stable angina and a single de novo lesion in a native coronary vessel scheduled to undergo percutaneous coronary intervention (PCI) were selected from 14 different studies. Off-line analysis of angiographic outcomes was assessed in all patients using identical and standardised methods of data acquisition, analysis and definitions. Clinical endpoints were adjudicated by independent clinical events committees. All quantitative coronary angiographic (QCA) analyses were performed in the same core laboratory. Stenosis severity prior to PCI was categorised into three groups: <50% diameter stenosis (DS), 50–99%DS and >99%DS pre. A total of 3812 patients were included in this study; 1484 patients (39%) were successfully treated with balloon angioplasty (BA) only and stented angioplasty was performed in 2328 patients (61%).One-year mortality and rate of non-fatal myocardial infarction (MI) (Kaplan–Meier) did not differ between BA and stented angioplasty for any of the stenosis severity categories. Following BA, the combined event rate (death and non-fatal MI) was 4.8, 4.6 and 0% in the <50, 50–99 and >99%DS categories, respectively. Following stented angioplasty, the combined event rate was 3.1, 4.4 and 4.8% in the same categories. The need for repeat revascularisation corrected for stenosis severity in the Cox proportional-hazards regression model was reduced by 20% after stented angioplasty (hazard ratio (HR) 0.80, 95%CI 0.69–0.93).Conclusion The concept of plaque sealing is appealing from the theoretical point of view. However, with current technology, plaque sealing cannot prevent death and future non-fatal MIs in the long-term because 1-year event rates after PCI of non-significant stenoses remain unacceptably elevated when compared with the estimated 1-year probability of a non-fatal MI in lesions with a <50%DS. Moreover, major adverse cardiac events at 1-year after PCI are not directly related to the degree of pre-procedural stenosis severity. [ABSTRACT FROM PUBLISHER]

Study objectives To compare the long-term angiographic, clinical and economic outcome of direct stenting vs stenting after balloon predilatation.Patient population and methods Four hundred patients with coronary stenoses in a single native vessel were randomized to direct stenting vs stenting after predilatation. A major adverse cardiac and cerebral event (MACCE) was defined as death, myocardial infarction, stent thrombosis, target restenosis, repeat target- and non-target vessel-related percutaneous coronary intervention, target lesion revascularization, coronary artery bypass surgery and stroke.Results Stents were successfully implanted in 98.3% of patients randomized to direct stenting vs 97.8% randomized to stenting preceded by predilatation. The primary success rate of direct stenting was 88.3%, vs 97.8% for stenting preceded by balloon dilatation \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((P=0.01)\) \end{document}. The angiographic follow-up at 6 months included 333 of the 400 patients (83%). The binary in-stent restenosis rate was 23.1% of 163 patients randomized to direct stenting vs 18.8% of 166 patients randomized to balloon predilatation \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((P=0.32)\) \end{document}. By 185±25 days, MACCE had occurred in 31 of 200 (15.5%) patients randomized to direct stenting, vs 33 of 200 (16.5%) randomized to predilatation \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \((P=0.89)\) \end{document}. At 6 months, costs associated with the direct stenting strategy (Euros 3222/patient) were similar to those associated with predilatation (Euros 3428/patient, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P=0.43\) \end{document}). However, procedural costs were significantly lower. It is noteworthy that, on multivariate analysis, a baseline C-reactive protein level >10mgl−1was a predictor of restenosis (odds ratio: 2.10, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P=0.025\) \end{document}) as well as of MACCE (odds ratio: 1.94, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P=0.045\) \end{document}).Conclusions Compared to stenting preceded by balloon predilatation, direct stenting was associated with similar 6-month restenosis and MACCE rates. Procedural, but not overall 6-month costs, were reduced by direct stenting. An increased baseline CRP level was an independent predictor of adverse long-term outcome after coronary stent implantation. [ABSTRACT FROM PUBLISHER]

Introduction Quantitative angiographic assessment after balloon angioplasty is a poor predictor of immediate and long-term outcome. However, the measurement of blood flow velocity during angioplasty has been proved clinically useful.Aims To analyse the value of the maximal stenotic flow velocity and the presence of stenotic flow velocity acceleration (aSV) for the long-term outcome after balloon angioplasty.Methods and Results Patients undergoing single lesion angioplasty within the DEBATE trial were included. aSV was defined as acceleration in the stenotic coronary flow velocity >50% baseline velocity assessed at a reference site of the target vessel. After balloon angioplasty diameter stenosis, minimal lumen diameter (MLD) and coronary flow velocity reserve were similar between the aSV (n=54) and non-aSV group (n=125). At follow-up, the aSV group had a higher restenosis rate (52% vs 30%, P=0·006) The presence of aSV was the strongest independent predictor of restenosis (OR 3·08, 95% CI 1·35 to 7·05, P=0·008). The best predictive cut-off value of SV was 101cm.s−1 (sensitivity of 46%, specificity of 81%, positive predictive value of 85% and a negative predictive value of 58%).Conclusion Following angioplasty, SV appears to be exquisitely sensitive to the changes experienced at the treated area without depending on the status of the microcirculation. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

In order to study the safety of ‘rescue’ strategies in the treatment of patients with failed thrombolysis, all 548 patients admitted with evolving myocardial infarction to the Thoraxcenter, Rotterdam, from January 1997 until April 1999 were reviewed. Of these patients, 49% had received thrombolysis. Of patients treated with thrombolysis and not referred from other hospitals (n=154) 36% received rescue therapy for failed thrombolysis. Three rescue therapies were used after failed thrombolysis: percutaneous coronary intervention (74%), retreatment with thrombolysis (39%) and platelet glycoprotein (GP) IIb/IIIa receptor blockers (53%), often in combination. Platelet GP IIb/IIIa receptor blockers were administered in 64% of patients treated with rescue percutaneous coronary intervention. Major bleeding occurred in 14% of all thrombolysis treated patients, and in 30% of patients who received multiple rescue therapies. Bleeding was related to heparin usage and platelet GP IIb/IIIa receptor blockers, as was the insertion of catheters for percutaneous coronary intervention or intra-aortic balloon pumps. Major bleeding resulted in one death due to a ruptured ventricle, one haemorrhagic stroke, and three cases of tamponade for which surgery was needed. Four of these patients had received combination rescue therapy. Rescue therapy is a widely used strategy for failed thrombolysis, but is associated with a high bleeding rate. Alternative reperfusion strategies to avoid failed thrombolysis should be considered in high risk patients. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Aims The BRIE trial is a registry evaluating the safety and performance of90 Sr delivered locally (Beta-Cath TM system of Novoste) to de-novo and restenotic lesions in patients with up to two discrete lesions in different vessels.Methods and Results In total, 149 patients (175 lesions) were enrolled; 62 treated with balloons and 113 with stents. The restenosis rate, the minimal luminal diameter and the late loss were determined in three regions of interest: (a) in a subsegment of 5mm containing the original minimal luminal diameter pre-intervention termed target segment; (b) the irradiated segment, 28mm in length, and (c) the entire analysed segment, 42mm in length, termed the vessel segment. Binary restenosis was 9·9% for the target segment, 28·9% for the irradiated segment, and 33·6% for the vessel segment. These angiographic results include 5·3% total occlusions. Excluding total occlusions binary restenosis was 4·9%, 25% and 29·9%, respectively. At 1 year the incidence of major adverse cardiac events placed in a hierarchical ranking were: death 2%, myocardial infarction 10·1%, CABG 2%, and target vessel revascularization 20·1%. The event-free survival rate was 65·8%. Non-appropriate coverage of the injured segment by the radioactive source termed geographical miss affected 67·9% of the vessels, and increased edge restenosis significantly (16·3% vs 4·3%, P=0·004). It accounted for 40% of the treatment failures.Conclusion The results of this registry reflect the learning process of the practitioner. The full therapeutic potential of this new technology is reflected by the restenosis rate at the site of the target segment. It can only be unravelled once the incidence of late vessel occlusion and geographical miss has been eliminated by the prolonged use of thienopyridine, the appropriate training of the operator applying this new treatment for restenosis prevention, and the use of longer sources. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Aims Intracoronary radiation is a promising therapy potentially reducing restenosis following catheter-based interventions. Currently, only limited data on this treatment are available. The feasibility and outcome in daily routine practice, however, is unknown.Methods and Results In 100 consecutive patients, intracoronary beta-radiation was performed with a 90Strontium system (Novoste Beta-Cath™) following angioplasty. Predominantly complex (73% type B2 and C) and long lesions (length 24·3±15·3mm) were included (37% de novo, 19% restenotic and 44% in-stent restenotic lesions). Radiation success was 100%. Mean prescribed dose was 19·8±2·5Gy. A pullback procedure was performed in 19% lesions. Geographic miss occurred in 8% lesions. Periprocedural thrombus formation occurred in four lesions, dissection in nine lesions. During hospital stay, no death, acute myocardial infarction, or repeat revascularization was observed. Major adverse cardiac events occurred predominantly between 6 and 12 months after the index procedure with major adverse cardiac event-free survival of 66% at 12 months (one death, 10 Q-wave myocardial infarctions, 23 target vessel revascularizations; ranked for worst event).Conclusion Routine catheter-based intracoronary beta-radiation therapy after angioplasty is safe and feasible with a high acute procedural success. The clinical 1-year follow-up showed delayed occurrence of major adverse cardiac events between 6 and 12 months after the index procedure. Copyright 2001 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Aims We sought to compare the effect of intracoronary β-radiation on the vessel dimensions in de novo lesions using three-dimensional intravascular ultrasound quantification after balloon angioplasty and stenting.Methods and Results Forty patients (44 vessels; 28 balloon angioplasty and 16 stenting) treated with catheter-based β-radiation and 18 non-irradiated control patients (18 vessels; 10 balloon angioplasty and 8 stenting) were investigated by means of three-dimensional volumetric intravascular ultrasound analysis post-procedure and at 6–8 months follow-up. Total vessel (EEM) volume enlarged after both balloon angioplasty and stenting (+37mm3 vs +42mm3, P=ns), but vessel wall volume (plaque plus media) also increased similarly (+33mm3 vs +49mm3, P=ns) in the irradiated patients. Lumen volume remained unchanged in both groups (+3mm3 vs −7mm3, P=ns). In the stent-covered segments, neointima at follow-up was significantly smaller in the irradiated group than the control group (8mm3 vs 27mm3,P =0.001, respectively), but the total amount of tissue growth was similar in both groups (33mm3 vs 29mm3, P=ns).Conclusions Intracoronary β-radiation induces vessel enlargement after balloon angioplasty and/or stenting, accommodating tissue growth. Additional stenting may not play an important role in the prevention of constrictive remodelling in the setting of catheter-based intracoronary β-radiotherapy. [ABSTRACT FROM PUBLISHER]

Aims The purpose of this study is to compare the long-term outcome (up to 20 years) of coronary artery bypass surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in a consecutive patient series at a single centre. Survival is similar after CABG and PTCA up to 8 years follow-up in patients with multivessel disease, with a reduced need for repeat revascularization after CABG. As coronary artery disease is a lifetime disease, longer-term follow-up of these revascularization therapies is necessary to help clinical decision-making.Methods and Results The CABG study population consisted of the first 1041 consecutive patients who underwent a first elective coronary bypass surgery between 1970 and 1980. The PTCA study population consisted of 702 consecutive patients who underwent a first elective coronary angioplasty procedure between 1980 and 1985. Mortality and subsequent revascularization up to 20 years were captured. Survival rates were adjusted using proportional hazards methods to account for baseline differences.Results The unadjusted survival rates were 92%, 77%, 57% and 49% after CABG at respectively, 5-, 10-, 15- and 17 years and 91%, 80%, 64% and 59% after PTCA. In the multivessel disease subgroup, survival was similar with a benefit apparent after CABG in the first 8 years of follow-up. The therapy chosen, CABG or PTCA, was a univariate predictor of mortality in favour of PTCA (RR: 1·28; 95% CI: 1·10–1·49), but after correction for baseline characteristics, the relative risk of mortality for CABG vs PTCA was comparable (RR: 1·03; 95% CI: 0·87–1·24). The adjusted survival curves in the subgroup of diabetic elderly patients with multivessel disease were similar after the tenth year with only a slightly better survival in the CABG population in the first 10 years. Repeat intervention was more frequently required after PTCA during the first 8 years, but after this time more frequently in the CABG group.Conclusion When comparing CABG and PTCA it can be concluded that both strategies are equally effective in terms of 20-year survival. In particular, after more than 10 years all differences tend to disappear. While repeat intervention was significantly higher in the first year after PTCA, after 7–8 years, reintervention was greater in patients who had initial CABG. [ABSTRACT FROM PUBLISHER]

Aims Plaque composition is a major determinant of coronary related clinical syndromes. In vitro experiments on human coronary and femoral arteries have demonstrated that different plaque types were detectable with intravascular ultrasound elastography. The aim of this study was to investigate the feasibility of applying intravascular elastography during interventional catheterization procedures.Methods and Results Data were acquired in patients (n=12) during PTCA procedures with an EndoSonics InVision echoapparatus equipped with radiofrequency output. The systemic pressure was used to strain the tissue, and the strain was determined using cross-correlation analysis of sequential frames. A likelihood function was determined to obtain the frames with minimal motion of the catheter in the lumen, since motion of the catheter prevents reliable strain estimation. Minimal motion was observed near end-diastole. Reproducible strain estimates were obtained within one pressure cycle and over several pressure cycles. Validation of the results was limited to the information provided by the echogram. Strain in calcified material (0·20%±0·07) was lower (P<0·001) than in non-calcified tissue (0·51%±0·20).Conclusion In vivo intravascular elastography is feasible. Significantly higher strain values were found in non-calcified plaques than in calcified plaques. [ABSTRACT FROM PUBLISHER]

Aims This study was conducted to analyse flow velocity parameters and predictors of a suboptimal coronary flow reserve (<2·5) following balloon angioplasty.Methods Two hundred and twenty-five patients underwent sequential intracoronary Doppler as part of the DEBATE I study. Of these, 183, with complete angiography and Doppler at the 6-month follow-up, were included. Univariate and multivariate logistic analysis was performed to identify independent predictors of post-procedural suboptimal coronary flow reserve, defined as coronary flow reserve <2·5.Results Forty-eight per cent (n=88) of the patients achieved a suboptimal coronary flow reserve. These patients had higher baseline velocities (cm.s−1) before balloon angioplasty (18±9 vs 14±6, P=0·004), after balloon angioplasty (22±11 vs 14±5,P <0·001) and at follow-up (19±9 vs 16±6, P=0·011) than the optimal coronary flow reserve group. Although the suboptimal group had lower hyperaemic velocities (cm.s−1) after balloon angioplasty than the optimal group (42±17 vs 49±16, P=0·008), these velocities became similar at follow-up. Increasing age (odds ratio, OR 1·071, P=0·0002), female gender (OR 2·52,P =0·014) and increasing pre-procedural baseline average peak velocities (OR 1·056,P <0·001) were found to be independent predictors of a suboptimal coronary flow reserve following balloon angioplasty.Conclusion A suboptimal coronary flow reserve was associated with (1) a chronically elevated baseline average peak velocity (2) a transient deficit in the hyperaemic average peak velocity (3) the elderly, and female gender. [ABSTRACT FROM PUBLISHER]

Aims Coronary stenting is limited by a 10%–60% restenosis rate due to neointimal hyperplasia. Sirolimus is a macrocyclic lactone agent that interacts with cell-cycle regulating proteins and inhibits cell division between phases G1 and S1. The hypothesis tested in this study is that local delivery of sirolimus with an eluting stent can prevent restenosis.Methods and Results Fifteen patients were treated with 18mm sirolimus eluting BX VELOCITY™ stents. Quantitative angiography and three-dimensional quantitative intravascular ultrasound were performed at implantation and at the 6 months follow-up. All stent implantations were successful. One patient died on day 2, of cerebral haemorrhage and one patient suffered a subacute stent occlusion due to edge dissection (re-PTCA, CKMB 42). At 9 months no further adverse events had occurred and all patients were angina free. Quantitative coronary angiography revealed no change in minimal lumen diameter and percent diameter stenosis and hence no in-lesion or in-stent restenosis. Quantitative intravascular ultrasound showed that intimal hyperplasia volume and percent obstruction volume at follow-up were negligible at 5·3mm3and 1·8%, respectively. No edge effect was observed in the segments proximal and distal to the stents.Conclusion Implantation of a sirolimus-eluting stent seems to effectively prevent intimal hyperplasia. [ABSTRACT FROM PUBLISHER]

Background Studies have reported benefit of oral therapy with the phosphodiesterase inhibitor, trapidil, in reducing restenosis after coronary angioplasty. Coronary stenting is associated with improved late outcome compared with balloon angioplasty, but significant neointimal hyperplasia still occurs in a considerable proportion of patients. The aim of this study was to investigate the safety and efficacy of trapidil 200mg in preventing in-stent restenosis.Methods Patients with a single native coronary lesion requiring revascularization were randomized to placebo or trapidil at least 1h before, and continuing for 6 months after, successful implantation of a coronary Wallstent. The primary end-point was in-stent neointimal volume measured by three-dimensional reconstruction of intravascular ultrasound images recorded at the 6 month follow-up catheterization.Results Of 312 patients randomized at 21 centres in nine countries, 303 (148 trapidil, 155 placebo) underwent successful Wallstent implantation, and 139 patients (90%) in the placebo group and 130 (88%) in the trapidil group had repeat catheterization at 26±2 weeks. There was no significant difference between trapidil and placebo-treated patients regarding in-stent neointimal volume (108·6± 95·6mm3vs 93·3±79·1mm3;P=0·16) or % obstruction volume (38±18% vs 36±21%;P=0·32), in angiographic minimal luminal diameter at follow-up (1·63±0·61mm vs 1·74±0·69mm;P=0·17), restenosis rate (31% vs 24%;P=0·24), cumulative incidence of major adverse cardiac events at 7 months (22% vs 20%;P=0·71) or anginal complaints (30% vs 24%;P=0·29).Conclusion Oral trapidil 600mg daily for 6 months did not reduce in-stent hyperplasia or improve clinical outcome after successful Wallstent implantation and is not indicated for this purpose. [ABSTRACT FROM PUBLISHER]

Aims This study reports the clinical outcome, up to 17 years, of the first 856 consecutive patients treated by coronary angioplasty at a single centre and attempts to identify a subgroup of patients at low risk of adverse events.Methods and Results Follow-up status was established via hospital and general practitioner records and the civil registry. Median follow-up was 16 years. The overall 5-, 10-, 15- and 17-year survival was 90%, 78%, 64% and 58%, respectively and corresponding event-free survival was 53%, 33%, 22% and 19%. After 32% of patients had experienced a major adverse cardiac event in the first year, the annual coronary re-intervention incidence thereafter and, even beyond year 10, remained at 2%–3%. Using multivariable Cox regression, significant independent predictors of mortality were advanced age, diabetes, multivessel disease and impaired left ventricular function at the time of PTCA. A subgroup of 26% of the patients with none of these risk factors had a survival rate similar to the general Dutch population matched for age and gender (at 5 years: 96%, at 10 years: 89% and at 15 years: 83%).Conclusion Although the majority of patients (>80%) experienced a further cardiac event during the 17 years after their first angioplasty procedure, in those non-diabetics under 60 years with single-vessel disease and good left ventricular function, prognosis was similar to the general population. [ABSTRACT FROM PUBLISHER]

Aims This study is the contribution by the Thoraxcenter, Rotterdam, to the European32P Dose Response Trial, a non-randomized multicentre trial to evaluate the safety and efficacy of the radioactive Isostent™ in patients with single coronary artery disease.Methods and Results The radioactivity of the stent at implantation was 6–12μCi. All patients received aspirin indefinitely and either ticlopidine or clopidogrel for 3 months. Quantitative coronary angiography measurements of both the stent area and the target lesion (stent area and up to 5mm proximal and distal to the stent edges) were performed pre- and post-procedure and at the 5-month follow-up. Forty-two radioactive stents were implanted in 40 patients. Treated vessels were the left anterior descending coronary artery (n=20), right coronary artery (n=10) or left circumflex artery (n=10). Eight patients received additional non-radioactive stents. Lesion length measured 10±3mm with a reference diameter of 3·07±0·69mm. Minimal lumen diameter increased from 0·98±0·53mm pre-procedure to 2·29±0·52mm (target lesion) and 2·57±0·44mm (stent area) post-procedure. There was one procedural non-Q wave myocardial infarction, due to transient thrombotic closure. Thirty-six patients returned for angiographical follow-up. Two patients had a total occlusion proximal to the radioactive stent. Of the patent vessels, none had in-stent restenosis. Edge restenosis was observed in 44%, occurring predominantly at the proximal edge. Target lesion revascularization was performed in 10 patients and target vessel revascularization in one patient. No additional clinical end-points occurred during follow-up. The minimal lumen diameter at follow-up averaged 1·66±0·71mm (target lesion) and 2·12±0·72 (stent area); therefore late loss was 0·63±0·69 (target lesion) and 0·46±0·76 (stent area), resulting in a late loss index of 0·65±1·15 (target lesion) and 0·30±0·53 (stent area).Conclusion These results indicate that the use of radioactive stents is safe and feasible, however, the high incidence of edge restenosis makes this technique currently clinically non-applicable. [ABSTRACT FROM PUBLISHER]

Aim Leukocytes have been implicated in restenosis following percutaneous transluminal coronary angioplasty. We investigated the link between the activated status of circulating neutrophils and restenosis after angioplasty.Methods and Results The population of 108 patients with single, de novo lesions located in native coronary arteries were treated with elective balloon angioplasty (n=44) or stenting (n=64). Pre-, post-procedure and 6-month follow-up, angiograms were analysed by an independent core laboratory. Blood samples were collected immediately before treatment and the antigen CD66, which is specifically expressed by activated neutrophils, was measured. Overall, the average expression of CD66 was 6·4±3·6 of mean fluorescence intensity. In the stepwise linear regression model, which included biological, clinical and angiographic variables, absolute gain showed a direct association (P<0·001) with relative late loss (relative late loss=absolute late loss÷pre-procedure reference diameter), whereas CD66 expression was inversely associated with relative late loss (P=0·004). CD66 expression also showed an inverse association with relative late loss in the balloon angioplasty treated patients (P=0·002, β=−0·49). In the stent subgroup, only reference vessel diameter and acute gain were independent predictors of relative late loss.Conclusion Our results confirm the beneficial role of activated neutrophils pre-procedure in the restenotic process after balloon angioplasty. The lack of a relationship between CD66 expression by neutrophils and relative late loss after stenting suggests that this leukocyte may be involved in the remodelling process. [ABSTRACT FROM PUBLISHER]

Aims We investigated the influence of tensile stress on plaque growth after balloon angioplasty with and without beta-radiation therapy.Methods and Results Thirty-one consecutive patients successfully treated with balloon angioplasty were analysed qualitatively and quantitatively by means of an ECG-gated three-dimensional intravascular ultrasound post-procedure and at follow-up. Eighteen patients were irradiated with catheter-based beta-radiation (90Sr/90Y source) and 13 were not (control). Studied segments were divided into 2mm subsegments. Thus 184 irradiated and 111 non-irradiated subsegments were included. Tensile stress was calculated according to Laplace's law. The radiation dose was calculated by means of dose–volume histograms. Plaque growth was positively correlated to tensile stress in both the radiation and control groups (r=0·374,P =0·0001 and r=0·305, P=0·001). Low-dose subsegments (<6Gy) had a significant correlation (r=0·410, P=0·0001) whereas no correlation was observed in the effective-dose subsegments (≥6Gy). Multivariate analysis identified tensile stress as the only independent predictor of plaque increase in non-irradiated subsegments, whereas actual dose and plaque morphology were stronger predictors in irradiated subsegments.Conclusion The results of this study suggest that plaque growth is related to tensile stress after balloon angioplasty. Intracoronary brachytherapy may alter the biophysical process on plaque growth when the prescribed dose is effectively delivered. [ABSTRACT FROM PUBLISHER]

Aims A randomized trial was performed to assess the safety and efficacy of a laser guidewire, in the treatment of chronic coronary occlusions.Methods and Results In 18 European centres, 303 patients with a chronic coronary occlusion were randomized to treatment with either the laser guidewire (n=144) or conventional guidewires (mechanical guidewire, n=159). The primary end-point of the study was treatment success, defined as reaching the true lumen distal to the occlusion by the allocated wire within 30min of fluoroscopic time: laser guidewire vs mechanical guidewire; 52·8% (n=76) vs 47·2% (n=75), P=0·33. Serious adverse events following the initial guidewire attempt were 0% (laser guidewire) and 0·6% (mechanical guidewire), respectively. Angioplasty (performed following successful guidewire crossing) was successful in 179 patients (91%, laser guidewire n=79, mechanical guidewire n=100), followed by stent implantation in 149 (79%). At the 6-month angiographic follow-up, the difference in binary restenosis rate (laser guidewire vs mechanical guidewire; 45·5% vs 38·3 %, P=0·72) or reocclusion rate (25·8% vs 16·1%, P=0·15) did not reach statistical significance. At 1, 6 and 12 months, angina and event-free survival were 69%, 35% and 24% (laser guidewire) vs 74%, 40% and 31% (mechanical guidewire).Conclusion Although laser guidewire technology was safe, the increase in crossing success did not reach statistical significance. [ABSTRACT FROM PUBLISHER]

Aims To assess the value of videodensitometric quantification of the coronary lumen after angioplasty by comparison to two other techniques of coronary artery lumen quantification.Methods and Results Videodensitometric quantitative angiography, edge detection quantitative angiography and 30MHz intracoronary ultrasound imaging were performed after successful balloon angioplasty in 161 patients. Lumen cross-sectional areas were mean (SD) 2·82 (1·15)mm2for edge detection quantitative angiography, 3·67 (1·5)mm2for videodensitometric quantitative angiography and 5·32 (1·75)mm2for intracoronary ultrasound imaging (P<0·001). The correlation between intracoronary ultrasound imaging and videodensitometric quantitative angiography (r=0·44) was almost similar to that of intracoronary ultrasound imaging and edge detection quantitative angiography (r=0·47). The correlation between the three techniques was not significantly influenced by the presence of ruptures and dissections on intracoronary ultrasound imaging. The absence of calcifications improved the correlation between videodensitometry and intracoronary ultrasound imaging.Conclusions The luminal dimensions as measured by videodensitometric quantitative angiography matched intracoronary ultrasound imaging derived dimensions more closely than edge detection quantitative angiography. Videodensitometric quantitative angiography represents an on-line alternative to intracoronary ultrasound imaging for quantitative analysis regardless of the degree of vessel damage. [ABSTRACT FROM PUBLISHER]

Aims Evaluation of angiographical and intracoronary Doppler-derived parameters of coronary stenosis severity.Methods and Results A total of 225 patients with one-vessel disease were studied before PTCA and at 6 months follow-up. Exercise electrocardiography was performed to document presence (n=157) or absence (n=138) of an ST segment shift (≥0·1mV). Intracoronary blood flow velocity analysis was performed to determine the proximal/distal flow velocity ratio, the distal diastolic/systolic flow velocity ratio and coronary flow velocity reserve. Receiver operator characteristic curves were calculated to assess the predictive value of these variables compared with the exercise test. The distal coronary flow velocity reserve demonstrated the best linear correlation for both percentage diameter stenosis and minimum lumen diameter (r=0·67 and r=0·66;P<0·01), compared to the diastolic/systolic flow velocity ratio (r=0·19 and r=0·14;P<0·01) and the proximal/distal flow velocity ratio (r=0·03 and r=0·07; not significant). The areas under the curve were 0·84±0·02; 0·82±0·03 and 0·83±0·03 for diameter stenosis, minimum lumen diameter and coronary flow velocity reserve, respectively. Logistic regression analysis revealed that the percentage diameter stenosis or minimum lumen diameter and coronary flow velocity reserve were independent predictors for the result of stress testing.Conclusions The distal coronary flow velocity reserve is the best intracoronary Doppler parameter for evaluation of coronary narrowings. Angiographical estimates of coronary lesion severity and distal coronary flow velocity reserve are good and independent predictors for the assessment of functional severity of coronary stenosis, emphasizing the complementary role of these parameters for clinical decision making. [ABSTRACT FROM PUBLISHER]

Background The 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors competitively inhibit biosynthesis of mevalonate, a precursor of non-sterol compounds involved in cell proliferation. Experimental evidence suggests that fluvastatin may, independent of any lipid lowering action, exert a greater direct inhibitory effect on proliferating vascular myocytes than other statins. The FLARE (Fluvastatin Angioplasty Restenosis) Trial was conceived to evaluate the ability of fluvastatin 40mg twice daily to reduce restenosis after successful coronary balloon angioplasty (PTCA). Methods Patients were randomized to either placebo or fluvastatin 40mg twice daily beginning 2–4 weeks prior to planned PTCA and continuing after a successful PTCA (without the use of a stent), to follow-up angiography at 26±2 weeks. Clinical follow-up was completed at 40 weeks. The primary end-point was angiographic restenosis, measured by quantitative coronary angiography at a core laboratory, as the loss in minimal luminal diameter during follow-up. Clinical end-points were death, myocardial infarction, coronary artery bypass graft surgery or re-intervetion, up to 40 weeks after PTCA. Results Of 1054 patients randomized, 526 were allocated to fluvastatin and 528 to placebo. Among these, 409 in the fluvastatin group and 427 in the placebo group were included in the intention-to-treat analysis, having undergone a successful PTCA after a minimum of 2 weeks of pre-treatment. At the time of PTCA, fluvastatin had reduced LDL cholesterol by 37% and this was maintained at 33% at 26 weeks. There was no difference in the primary end-point between the treatment groups (fluvastatin 0·23±0·49mm vs placebo 0·23±0·52mm,P=0·95) or in the angiographic restenosis rate (fluvastatin 28%, placebo 31%, chi-squareP=0·42), or in the incidence of the composite clinical end-point at 40 weeks (22·4% vs 23·3%; logrankP=0·74). However, a significantly lower incidence of total death and myocardial infarction was observed in six patients (1·4%) in the fluvastatin group and 17 (4·0%) in the placebo group (log rankP=0·025). Conclusion Treatment with fluvastatin 80mg daily did not affect the process of restenosis and is therefore not indicated for this purpose. However, the observed reduction in mortality and myocardial infarction 40 weeks after PTCA in the fluvastatin treated group has not been previously reported with statin therapy. Accordingly, a priori investigation of this finding is indicated and a new clinical trial with this intention is already underway. [ABSTRACT FROM PUBLISHER]

Although myocardial contrast echo been used recently in human studies, no study is available at the present time which relates contrast echo findings to the degree of coronary artery stenosis. The present study is the first attempt to determine whether a quantitative relationship exists between regional myocardial echo contrast disappearance rate (‘washout’) and the severity of coronary artery stenosis. Manual injection of sonicated iopamidol (Iopamiro® 370) into the left main coronary artery with simultaneous cross-sectional echo registration provided the myocardial echo-contrast images. From the digitized images, an echo contrast time–intensity curve was constructed for the proximal basal interventricular septum (region I) and the mid-distal portion of the inter ventricular septum (region II). From these curves, T50 was calculated after Fourier transformation and mono-exponential curve fitting. The percentage stenosis area (%A) of the left descending coronary artery (LAD) was calculated from routine coronary arteriograms using a computer-based system. Thirty patients (22 men, 8 women; mean age 58±10 years) were included in the study. Group I (n=7) had normal LAD, group II (n=18) had LAD stenosis of varying degrees. Five patients were not suitable for quantitative evaluation. A curvilinear relation was found between T50 and %A. (T50=3.0 × e; r=0.78; P<0.05). Patients with asynergy had significantly longer T50 (8.2±2.5 s) than did patients without asynergy (4.2±1.5 s) (P<0.05). All patients with > 75% LAD % A had prolonged T50. T50 might be useful index for studying regional myocardial perfusion during cardiac catherterization. [ABSTRACT FROM PUBLISHER]

Coronary angioplasty was performed in 23 patients in whom within 10 days after acute myocardial infarction severe angina recurred despite continuing maximal pharmacological therapy. Initial success was achieved in 83% (19 of 23 patients). In three of the four failures bypass surgery was carried out as an emergency. There were no deaths, but myocardial infarction was a complication in 13% (three of 23 patients). At 6 months follow-up angina had recurred in 32% (6 of 19 patients) despite initial successful angioplasty. In 16 of the 19 patients, angiography was repeated and restenosis was seen in 31%, 5 of 16 patients, all of whom had recurrent symptoms.We conclude that, while coronary angioplasty is an effective initial therapy for selected patients with early post-infarction angina, its exact long-term value remains to be decided. [ABSTRACT FROM PUBLISHER]

In this paper we report the sequelae of a patient with an anomalous right coronary artery (RCA)originating from the pulmonary artery (PA) in association with a normal heart, operated upon at the age of 13 years. Three years after the end-to-side reimplantation of the RCA, with a rim of thePA, into the aorta, the surgical result has been evaluated by cineangiography. Before operation both coronary arteries were tortuous and increased in size. Afterwards the left coronary artery showed a normalized calibre, although the RCA remained tortuous with no decrease of the internal diameter. The notable postoperative changes in shape and size of the LCA may be due to the disappearanceof the steal phenomenon. The lack of involutive changes in the RCA could be explained by its thinner wall. Left ventricular wall motion, evaluated under resting conditions and during an atrial pacing stress test, was found to be normal. [ABSTRACT FROM PUBLISHER]

This is the fourth reported case of congenital arteriovenous fistula between the internal mammary artery and pulmonary artery. Precise and complete diagnostic evaluation is required to localize, delineate and appreciate the haemodynamic significance of this type of arteriovenous shunt. A brief review of the literature is given with suggestions for diagnosis. [ABSTRACT FROM PUBLISHER]

In this study it is argued that the clinical manifestations of unstable angina pectoris, with at its extreme end impending myocardial infarction, may be due to increased coronary arterial vasomotion superimposed on a pre-existing obstruction in a coronary artery.As nifedipine, a powerful calcium antagonist, has initially proven its efficacy in relieving the symptoms of Prinzmetal's angina, a condition in which severe spasm of the coronary artery is now proven to be the main cause, the drug was given to two groups of patients in whom abnormal vasomotion was suspected and its effects scrutinized.Twelve patients with symptoms of coronary artery disease (CAD) were studied with repeated arteriograms after injection of 0.15 mg nifedipine in the left coronary artery. Two control cine-angiograms were made prior to drug administration and two cinefilms were repeated 30 s and 5 min after administration of nifedipine. The mean diameter of the normal, stenotic and poststenotic segments showed a statistically significant increase after drug administration. Vasodilalion persisted after coronary O2 saturation, and presumably coronary flow, had returned to normal.In 52 other patients, who were seen in the coronary care unit for impending myocardial infarction and who had been treated with maximal beta-adrenergic blockade, nitrates and bedrest, but who remained symptomatic, nifedipine 60 mg orally for 24 h was added to the treatment. Within 2 h after administration 42 of the 52 became asymptomatic. In the 10 non-responders, all with extensive multi-vessel disease, two sustained a myocardial infarction and eight received urgent coronary artery bypass grafting in an effort to alleviate their symptoms. All had severe 3 vessel disease in contrast to the responders in whom 1 or 2 vessel disease was predominant.These data show that increased coronary artery vasomotion can be influenced by nifedipine. The excellent clinical response to the drug in this group of patients with unstable angina pectoris indicates that nifedipine may become the preferred agent to be used particularly when the cause of the angina pectoris is suspected to be the result of abnormal coronary vasomotor tone. [ABSTRACT FROM PUBLISHER]