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Factors of restenosis after percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO) have not been fully explored. In particular, although the last ACC/AHA guidelines on PCI suggest that a minimum diameter stenosis of 10% with an optimal goal of as close to 0% as possible should be the new benchmark for lesions treated by stenting, angiographic success of PCI for CTO remains in the literature most often defined as a30% residual diameter stenosis. Whether an optimized immediate post-PCI angiographic result (OAR) defined by a minimal diameter stenosis as close to 0% is associated with a lower restenosis rate in this subset of coronary lesions remains unknown.Therefore, we assessed by quantitative coronary analysis (QCA) both the immediate post-PCI and 6-month follow-up angiographic results of 170 successfully treated true CTO.Post-PCI QCA immediate residual diameter stenosis was30% in all 170 CTOs and OAR defined as a ≤10% residual stenosis was achieved in 133 (78%). Global binary restenosis rate was 21% in the 170 lesions. Restenosis rates were 46% and 14% in the non-OAR group and in the OAR group, respectively (p0.0001). Multivariate analysis showed that a non-OAR, a younger age and a retrograde approach were independent factors of restenosis.Thus, an optimized immediate angiographic result with a minimal diameter stenosis as close to 0% as possible appears to be associated with a lower rate of restenosis after CTO PCI.

Objectives: To propose an original approach based on simultaneous dual vascular access site (DAS) using 2 small-size guiding catheters to easily perform complex 2-stent techniques for bifurcation coronary lesions (BL). Background: Simultaneous kissing stenting and classic crush technique require large 7 or 8Fr guiding catheters leading to large amounts of contrast medium, vascular access site complications, and sometimes frictions or criss-cross of the 2-stent delivery systems. Methods: DAS was used in 30 patients with BL (11 radio-radial, 16 radio-femoral, and 3 femoro-femoral). Among 60 guiding catheters, the size was 5Fr in 28, 6Fr in 30, and 7Fr in 2 cases of double adjacent BL. When 2 different size catheters were used, contrast medium injections were done using the smallest size catheter. DAS patients were compared with a group of 30 BL patients treated using a single femoral vascular access site (SAS) with 7 or 8Fr catheters. Results: Success rate was 100% in all patients. Contrast volume used was smaller in DAS than in SAS patients (277 ± 156 cc vs. 380 ± 165 cc,P = 0.01). No vascular access site complication occurred in the sub-group of the 11 DAS radio-radial patients. Postintervention hospitalization duration was shorter in DAS than in SAS (1.9 ± 2 vs. 2.8 ± 2 days,P = 0.048). Conclusion: DAS allows to successfully perform complex stenting technique of BL using small-size guiding catheters leading to decreased contrast medium volume, decreased vascular access site complications rates, and shortened hospitalization duration. (J Interven Cardiol 2012;25:439–446)

Summary Background Previous studies have evaluated return to work after acute ST-segment elevation myocardial infarction (STEMI) treated medically, after bypass surgery or after percutaneous coronary intervention (PCI) for stable coronary artery disease. However, there are few data regarding return to work after acute STEMI treated by direct PCI. Aims To analyse the factors influencing return to work after STEMI treated by direct PCI. Methods Two hundred consecutive patients who underwent direct PCI for acute STEMI and who were employed at the time of their STEMI were studied. Stents were used in 94% of patients and glycoprotein IIb/IIIa inhibitors in 77%. Results Among the 200 patients, 152 (76%) patients returned to work and 48 (24%) did not. Patients who did not return to work did not differ from those who returned to work in terms of time from onset of chest pain to PCI, STEMI location, left ventricular function, extent of vessel disease, PCI technique and success, completeness of revascularization, duration of hospital stay, intrahospital complications and performance of cardiac rehabilitation. Multivariable analysis showed that older age, daytime onset of chest pain, manual labour, rapid call-out of the emergency medical team, unmarried status and a limited number of risk factors were independent predictors of non-return to work. Conclusion Age, sociopsychological and occupational factors appear to be the strongest predictors of return to work after STEMI treated by direct PCI. Clinical and procedural factors as well as cardiac rehabilitation appear to have no impact on return to work in this subset of patients.

AIMS The authors tested the value of stress single-photon emission computed tomography (SPECT) imaging performed systematically for detecting angiographic restenosis in asymptomatic patients who underwent direct percutaneous coronary intervention (PCI) for acute ST segment elevation myocardial infarction (STEMI). Angiographic restenosis of the infarct-related artery after direct PCI for STEMI is often silent and the strategy for follow-up evaluation of asymptomatic patients remains debated. METHODS A total of 149 patients successfully treated by direct PCI (96% stenting) for STEMI with no symptoms during the follow-up systematically underwent both rest thallium 201/stress Tc 99m setamibi myocardial perfusion imaging and coronary angiogram at 6 months. Patients were followed up for 2.5+/-0.5 years after 6 months control for cardiac events. RESULTS In the 149 patients, the sensitivity, specificity, positive and negative predictive values and accuracy of SPECT imaging were 48, 61, 35, 72 and 57%, respectively, for detecting binary angiographic restenosis defined as > or =50% diameter stenosis. Whether stress testing was maximal or performed after withheld anti-ischemic drugs did not improve the results. Reversible ischemia at SPECT in the infarct territory did not predict long-term cardiac events. CONCLUSION These data suggest a poor correlation between stress SPECT imaging and angiographic restenosis at 6 months in patients treated by direct PCI for STEMI who remain asymptomatic at follow-up. The long-term clinical prognostic value of SPECT reversible ischemia in the infarct territory appears also limited in this peculiar subset of patients. These findings should be taken into account in the strategy of the clinical follow-up of this population.

SummaryThe prognosis of patients with myocardial infarction (MI) and normal coronary arteries (NCA) in the presence of an inherited coagulation disorder is unknown. The purpose of this study was to compare the clinical thrombosis outcome of patients with (GpI) or without (GpII), inherited coagulation disorders, who suffered from an acute MI with NCA. Eighty two consecutive patients (mean age 49 ± 15 years; 29 females) with MI, but NCA, were recruited. Twelve patients (15%) had an inherited coagulation disorder. GpI and GpII were statistically similar regarding age (45 ± 11 vs 50 ± 16 years-old), gender (33 vs. 36% female), tobacco consumption (50 vs. 53%), diabetes mellitus (8 vs. 10%), hypertension (25 vs. 17%), obesity (8.3 vs. 14%), family history of coronary heart disease (33 vs. 19%), hypercholesterolemia (50 vs. 21%; p = . 08), left ventricular ejection fraction (58 ± 13 vs. 61 ± 13%) and spasm (8.3% vs. 17%). All patients were initially treated with antiplatelet agents with the exception of one (8%) in GpI, and 6 (9%) in GpII who were taking oral anticoagulant therapy (ns). The mean follow-up was 57 ± 26 (range from 2-91 months). During the outcome, 12/78 (15.4%) thrombosis events occurred, including venous thrombosis or pulmonary embolism (1/12 vs. 1/66), reinfarction (2/12 vs. 4/66), and stroke (2/12 vs. 2/66), with two events in one patient (GpI). Kaplan-Meier event-free survival, with combined end-point, defined as venous thrombo-embolic event, reinfarction, or stroke differed between the two groups: 4/12 (33.3%) in GpI and 7/66 (10.6%) in Gp II (p Presented in part at the 52nd Annual Scientific Session of the American College of Cardiology; March 30-April 2, Chicago USA 2003, Abstract.

Objectives The purpose of this study was to evaluate the clinical outcome of a large cohort of patients who suffered an acute myocardial infarction with absolutely normal epicardial coronary arteries at the post-myocardial infarction coronary angiogram. The aetiological and prognostic factors in this population were also analysed. Background Few data exist concerning the outcome, and aetiological and prognostic factors, of patients with myocardial infarction and angiographically absolutely normal coronary arteries. Methods Ninety-one patients (34 females/57 males; mean age 50±13 years, range 24–78 years) admitted with an acute myocardial infarction had absolutely normal coronary arteries at the angiogram performed 6·2±4 days (range 1–15 days) after the myocardial infarction, defined by smooth contours and no focal reduction (NC). Of the 91 NC patients, 71 were evaluated prospectively, alongside a systematic search of all aetiological factors reported in the literature. The NC patients were matched for age, sex, and the same period of myocardial infarction onset with a group of 91 patients with coronary artery stenosis (>50% diameter stenosis) at the angiogram performed 7·3±4 days (range 1–15 days) after the myocardial infarction (SC). Results The percent of smokers was similar between the two groups; higher prevalence rates of coronary heart disease family history, obesity, hypertension, hypercholesterolaemia and diabetes mellitus were found in SC ( P =0·043 to 0·0001). In NC, coronary spasm was found in 15·5%, congenital coagulation disorders in 12·8%, collagen tissue disorders in 2·2%, embolization in 2·2%, and oral contraceptive use in 1·1%. Left ventricular ejection fraction at hospital discharge was higher in NC (60%±13%) than in SC (55%±13%, P =0·04). The mean follow-up was 35 months (range 1–100 months). Kaplan–Meier event-free survival, with the combined end-point defined as death, reinfarction, heart failure and stroke was 75% in NC vs 50% in SC ( P

To evaluate clinical and angiographic outcomes after successful recanalization of chronic total coronary occlusion (CTO) with implantation of a long total stent length (SL).Routine follow-up angiogram (RFUA) data after successful recanalization of CTO with a long SL are lacking.RFUAs were performed at 6 months after successful recanalization of 106 CTOs using drug-eluting stents (DESs) with a long SL (≥ 20 mm) in 102 consecutive patients.Mean number of stents was 3.9 ± 1.8 and mean total SL was 78 ± 32 mm (range, 23-174 mm). Sirolimus-eluting stents (SESs) were used in 100 lesions. In-stent total reocclusion occurred in 2 cases (1 SES and 1 non-SES DES). Restenosis rate was 18% in the 100 SES subgroup (total SL, 79 ± 33 mm; range, 23-174 mm; mean number of stents, 3.9 ± 1.8); younger age and longer total SL were found to be independent predictors of restenosis (longer age: hazard ratio, 0.939; 95% confidence interval, 0.885-0.996; P=.035; longer total SL: hazard ratio, 1.017; 95% confidence interval, 1.00-1.03; P=.045). Restenosis type was diffuse in only 11% and 89% were successfully treated by repeat percutaneous coronary intervention. During a median follow-up of 2 years (interquartile range, 1-4.3 years), major cardiac events other than those angiographically driven at RFUA occurred in 2 patients.Angiographic restenosis rate remains acceptable in patients with complex CTO successfully treated by DES despite a long SL.

We propose a modified simultaneous kissing stenting technique (MSKS) based on systematic implantation of a protective stent in the proximal main vessel (PMV) proximally to the bifurcation before simultaneous kissing stenting (SKS).SKS has been proposed in large-size coronary vessel bifurcation lesions (BLs) when the PMV can accommodate two stents. SKS implies, however, low-pressure simultaneous final balloon inflations to avoid retrograde PMV dissection or rupture and therefore may not ensure optimal final stent apposition.From January 2005 to May 2008, a total of 97 patients with 100 BLs (true bifurcation in 92%) who underwent MSKS were enrolled in a prospective registry. Drug-eluting stents were used for distal main vessel and side branch. Drug-eluting or large-size bare-metal stents were used as proximal protective stents.Immediate procedural success rate was 100%. Global restenosis rate was 10% (5% in the main vessel and 8% in the side branch) at follow-up angiogram performed at 7 months in all patients (100%). No patient had early or late stent thrombosis. Two cases of non-fatal very late stent thrombosis occurred at 46 and 64 months. Over a mean 4.5-year follow-up period, target lesion revascularization rate was 11%, with only 3% driven by clinical ischemia.Protective stent systematic implantation in the PMV represents a newly modified SKS technique that allows safe finalization of the procedure by high-pressure kissing balloon final inflation, ensuring optimal stent apposition with high immediate procedural success and low rates of long-term events.

To propose an original approach based on simultaneous dual vascular access site (DAS) using 2 small-size guiding catheters to easily perform complex 2-stent techniques for bifurcation coronary lesions (BL).Simultaneous kissing stenting and classic crush technique require large 7 or 8Fr guiding catheters leading to large amounts of contrast medium, vascular access site complications, and sometimes frictions or criss-cross of the 2-stent delivery systems.DAS was used in 30 patients with BL (11 radio-radial, 16 radio-femoral, and 3 femoro-femoral). Among 60 guiding catheters, the size was 5Fr in 28, 6Fr in 30, and 7Fr in 2 cases of double adjacent BL. When 2 different size catheters were used, contrast medium injections were done using the smallest size catheter. DAS patients were compared with a group of 30 BL patients treated using a single femoral vascular access site (SAS) with 7 or 8Fr catheters.Success rate was 100% in all patients. Contrast volume used was smaller in DAS than in SAS patients (277 ± 156 cc vs. 380 ± 165 cc,P = 0.01). No vascular access site complication occurred in the sub-group of the 11 DAS radio-radial patients. Postintervention hospitalization duration was shorter in DAS than in SAS (1.9 ± 2 vs. 2.8 ± 2 days,P = 0.048).DAS allows to successfully perform complex stenting technique of BL using small-size guiding catheters leading to decreased contrast medium volume, decreased vascular access site complications rates, and shortened hospitalization duration.

No reflow phenomenon is not uncommon in patients with acute ST-segment elevation myocardial infarction (STEMI) directly revascularized by PCI with immediate stenting (IS). We previously showed in a pilot study that a minimalist immediate mechanical intervention (MIMI), based on the use of guidewire

Objectives No reflow has been reported in 12–30% of the patients directly revascularized by angioplasty for acute ST elevation myocardial infarction with the highest incidence after primary stenting in patients with initial thrombolysis in myocardial infarction (TIMI) grade 0 flow. We hypothesized that a minimalist immediate mechanical intervention (MIMI) based on the use of very small size balloons to avoid both large dissection and distal embolization may be sufficient to restore flow in emergency and that recanalization may be sustained by maximized antithrombotic regimen (abcximab, clopidogrel, aspirin and heparin) allowing one to postpone stenting in better conditions. Methods MIMI was performed in 93 patients for ST elevation myocardial infarction with initial TIMI grade 0 flow. Results MIMI resulted in a TIMI grade 3 flow in 77/93 patients (83%). Immediate stenting was performed in the 16 patients with failed MIMI and resulted in a TIMI grade 3 flow in nine (56%). The residual stenosis after MIMI was 81±11% and ST segment resolution (≥50%) at 1 h after reperfusion was obtained in 84%. Stenting was performed the following days in 52 patients with a post-stenting TIMI grade 3 flow in 50 (96%; 100% when stenting done beyond 24 h). No reocclusion occurred between MIMI and stenting. Among the 25 patients without stenting, six had mild stenosis at control angiogram and underwent medical treatment whereas 19 had multiple vessel disease and underwent bypass surgery. Conclusions MIMI combined with maximized antithrombotic therapy results in immediate and sustained recanalization with a high rate of ST resolution in a majority of patients with ST elevation myocardial infarction. This approach allows one to postpone stenting in more stable conditions with a low rate of TIMI flow deterioration or to schedule more appropriate medical or surgical alternative management.

Experimental investigations and invasive studies conducted in small series of patients using specially designed high-fidelity micromanometer tip catheters have suggested that downstream pressure recovery (PR) within the aorta may significantly affect transvalvular pressure gradient (PG) measurement. The study aims were to evaluate in a large cohort of patients the extent of PR when transvalvular PGs are routinely measured by fluid-filled pigtail side-hole catheters (FPC) using pullback from the left ventricle to the ascending aorta (AO), and to analyze factors influencing PR. The influence of PR on the correlation between catheter and Doppler PG measurements was also assessed in a subset of patients.Transvalvular PG were measured in 91 patients with aortic stenosis using FPC pullback with the catheter positioned at different sites within the ascending aorta. In 71 patients, Doppler echocardiography was obtained within 24 h of catheterization.Mean PR ranged from 0 to 20 mmHg, corresponding to a PR index (percent of maximal PG) ranging from 0 to 31%. PG was50 mmHg in nine of 61 patients (15%) with a PG50 mmHg at the origin of the aorta when further measurements were conducted with the catheter positioned more distally in the ascending aorta. PR index better correlated with the ratio of valve area to ascending AO cross-sectional area (r = 0.61, p = 0.001) than with valve area (r = 0.37, p = 0.001) and ascending AO cross-sectional area (0.27, p = 0.02) alone. Differences between Doppler- and catheter-predicted PG were minimized when correcting Doppler by non-invasively calculated PR (p0.0001).The magnitude of PR recorded in aortic stenosis by FPC, as used in most clinical catheterization laboratories, is low in the vast majority of patients. As predicted from fluid mechanics theory, the ratio of valve area to ascending AO cross-sectional area is the central determinant of PR. PR may affect the Doppler-catheter correlation in some patients.

Previous experimental studies have demonstrated that aortic valve disease is associated with significant downstream turbulence (T). In this study, we developed a noninvasive method on the basis of Doppler velocity recording for quantitating aortic blood flow T in patients with aortic valve disease. The instantaneous blood velocity at a point in the aorta is equal to the sum of a mean periodic velocity component with a random or turbulent velocity component. According to the ensemble average method, time mean absolute T intensity is the root-mean-square value of turbulent velocity averaged over time and T is better quantitated by the relative T intensity (TIr), which is the ratio of absolute T intensity to the ensemble average velocity averaged over time. We computed TIr in 18 patients with mild to severe aortic stenosis and in 13 healthy volunteers from instantaneous modal velocities of 70 cycle length–matched heart beats recorded in the proximal part of the descending aorta by pulsed Doppler using an ultrasound system with an output port for online digital data transfer into a microcomputer. TIr was greater in patients with aortic valve disease (18.4 ± 5.1%, range 11.2%-28.9%) than in control patients (7.9 ± 1.9%, range 4.8%-9.8%; P = .0001). In patients with aortic valve disease, TIr was better linearly related to the ratio of postvalvular aorta to valvular orifice cross-sectional areas ( r = 0.89, P = .0001) than to other parameters of valve restriction: transvalvular pressure gradient ( r = 0.78, P = .0001); valve area ( r = −0.56, P = .01); and valve resistance ( r = 0.72, P = .0002). Thus, T that can be computed noninvasively from direct digital transfer of Doppler velocity data appears to be linearly related to indices of aortic valve restriction. Our data support the concept of the postvalvular aorta to valvular orifice cross-sectional areas ratio as a new important hemodynamic parameter in patients with aortic valve disease.

Objectives. We tested the value of transesophageal Doppler echocardiography (TEDE) for quantitating proximal left coronary artery (LCA) stenosis by using the continuity equation. Background. The continuity equation applied to a stenosis states that the ratio of the time–velocity integral (TVI) of prestenotic to stenotic flow velocities is equal to the ratio of stenotic to prestenotic cross-sectional areas. TEDE allows the measurement of coronary blood flow velocities within the proximal part of the LCA. Methods. Forty-one patients with a stenosis of the proximal or mid left anterior descending coronary artery or with a nonostial stenosis of the left main coronary artery were studied. Coronary flow velocities were recorded by TEDE guided by color flow imaging. Prestenotic velocities were recorded by pulsed Doppler echocardiography and transstenotic velocities were recorded by pulsed or high pulse repetition frequency or continuous wave Doppler echocardiography. The prestenotic and transstenotic diastolic TVIs were calculated and the TEDE-derived percent area stenosis was calculated as (1 − TVI ratio) × 100. Quantitative angiography lesion analysis was performed using a computer-assisted automated edge-detection system. Results. TEDE recordings were successful in 35 of the 41 patients. A good linear correlation was found between TEDE and quantitative angiographically derived percent area stenosis (r = 0.89, p = 0.0001, SEE 5.7). However, TEDE measurements underestimated the actual percent area stenosis (slope of regression 0.54). A better agreement (slope 1.08) was obtained after dividing prestenotic velocity by 2 in the continuity equation, based on the assumption of a parabolic cross-sectional velocity profile in the prestenotic segment. Conclusions. TEDE may be used for quantitating stenosis of the proximal part of the LCA with the use of a modified continuity equation that takes into account the parabolic velocity profile in the normal prestenotic segment.

The prognosis of patients with myocardial infarction (MI) and normal coronary arteries (NCA) in the presence of an inherit-ed coagulation disorder is unknown.The purpose of this study was to compare the clinical thrombosis outcome of patients with (GpI) or without (GpII), inherited coagulation disorders, who suffered from an acute MI with NCA. Eighty two consec-utive patients (mean age 49 ± 15 years; 29 females) with MI, but NCA, were recruited. Twelve patients (15%) had an inherited coagulation disorder. GpI and GpII were statistically similar regarding age (45 ± 11 vs 50 ± 16 years-old), gender (33 vs. 36% female), tobacco consumption (50 vs. 53%), diabetes mellitus (8 vs. 10%), hypertension (25 vs. 17%), obesity (8.3 vs. 14%), fam-ily history of coronary heart disease (33 vs. 19%), hypercholes-terolemia (50 vs. 21%; p = . 08), left ventricular ejection fraction (58 ± 13 vs. 61 ± 13%) and spasm (8.3% vs. 17%). All patients were initially treated with antiplatelet agents with the excep-tion of one (8%) in GpI, and 6 (9%) in GpII who were taking oral anticoagulant therapy (ns). The mean follow-up was 57 ± 26 (range from 2-91 months). During the outcome, 12/78 (15.4%) thrombosis events occurred, including venous thrombosis or pulmonary embolism (1/12 vs. 1/66), reinfarction (2/12 vs. 4/66), and stroke (2/12 vs. 2/66), with two events in one patient (GpI). Kaplan-Meier event-free survival, with combined end-point, defined as venous thrombo-embolic event, reinfarction, or stroke differed between the two groups: 4/12 (33.3%) in GpI and 7/66 (10.6%) in Gp II (p

A 66 year old man presented with multiple episodes of tachycardia. Some had QRS complexes with a right bundle branch block configuration identical to those of sinus beats. The onset of the tachycardia was preceded by premature His bundle depolarizations. There was a His potential before each QRS complex of the tachycardia. Atrial activity was dissociated. Occasionally the appearance of sinus beats with a left bundle branch block pattern announced a tachycardia with an identical configuration and atrioventricular dissociation. His bundle activity occurred before the QRS complex and was followed by a right bundle branch deflection. A reentrant mechanism within the bundle branch system was invoked. One 200 J shock was delivered through an electrode catheter to the site of the right bundle branch. The postprocedure course was uneventful (follow-up 10 months).

The electrophysiologic changes produced by the intravenous administration of 0.6 mg/kg of sotalol were studied in 12 patients aged 45 to 85 years (mean 68 years). Effects upon atrioventricular (AV) nodal conduction time (AH interval) and His-Purkinje conduction time (HV interval) were assessed at identical rates. The Wenckebach cycle length was determined by rapid atrial stimulation. Refractory periods before and after the drug were compared at the same cycle length. Retrograde conduction was studied, with special reference to reentry phenomena within the His-Purkinje system. Sinoatrial function was evaluated using sinus node recovery time and sinoatrial conduction time. The following changes were noted: (1) decrease in sinus rate, (2) prolongation of QT interval, (3) depression of AV nodal conduction (prolonged AH interval) and increase in effective and functional refractory periods of the AV node, (4) increase in relative refractory period of the His-Purkinje system with no associated change in HV interval, (5) prolongation of effective refractory period in the atrium and ventricle, and (6) increase in retrograde refractory period of specialized ventricular tissue and depressed conduction of premature ventricular responses. Reentry phenomena in the His-Purkinje system were not significantly affected by the drug. Thus certain of the electrophysiologic effects of sotalol in humans were found to be in favor of a class III antiarrhythmic mechanism of action. These results justify further studies to evaluate the usefulness of this drug as an antiarrhythmic agent.