Faculty Bibliography

AIM: To evaluate safety and utility of coronary computed tomography angiography (CCTA) compared to invasive coronary angiography (ICA) in new cardiomyopathy. METHODS: Eighteen patients (mean age 56.5 years, 10 males) who presented for evaluation of new onset heart failure with evidence of systolic dysfunction (ejection fraction < 40%) on echocardiography and recent ICA were prospectively enrolled. Patients with known coronary artery disease, atrial fibrillation, creatinine > 1.5 g/dL, and contraindication to intravenous contrast administration were excluded. CCTA was performed using a dual source 64-slice scanner. Mean heart rate was 75 beats per minute. Stenosis was graded for each coronary segment as: none, mild (< 50%), moderate (50%-70%), severe (> 70%), or non-evaluable. Ischemic cardiomyopathy (ICM) was diagnosed if severe stenosis was present in the left main, proximal left anterior descending artery, or two or more major arteries. RESULTS: Two patients were diagnosed with ICM by ICA. CCTA correctly identified 2 patients with ICM and 16 patients as non-ICM. CCTA successfully evaluated 240/246 coronary segments with an accuracy of 97.5%, sensitivity 70%, specificity 98.7%, positive predictive value of 70%, and negative predictive value of 98.7% for identifying severe stenosis on a per-segment level. CONCLUSION: Dual source 64-slice multi-detector CCTA is a safe, accurate, and non-invasive technique for diagnosing ICM in patients presenting during the acute phase of newly diagnosed cardiomyopathy.

BACKGROUND: Drug-eluting stents (DES) have been in clinical use for nearly a decade; however, the relative short- and long-term efficacy and safety of DES compared with bare-metal stents (BMS) and among the DES types are less well defined. METHODS AND RESULTS: PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials, until March 2012, that compared any of the Food and Drug Administration-approved durable stent and polymer DES (sirolimus-eluting stent [SES], paclitaxel-eluting stent [PES], everolimus-eluting stent [EES], zotarolimus-eluting stent [ZES], and ZES-Resolute [ZES-R]) with each other or against BMS for de novo coronary lesions, enrolling at least 100 patients and with follow-up of at least 6 months. Short-term (PES approximately ZES>BMS), with a >42% probability that EES had the lowest target-vessel revascularization rate. There was no increase in the risk of any long-term safety outcomes, including stent thrombosis, with any DES (versus BMS). In addition, there was reduction in myocardial infarction (all DES except PES versus BMS) and stent thrombosis (with EES versus BMS: Rate ratio, 0.51; 95% credibility interval, 0.35-0.73). The safest DES appeared to be EES (>86% probability), with reduction in myocardial infarction and stent thrombosis compared with BMS. Short-term outcomes were similar to long-term outcomes, with SES, ZES-R, and everolimus-eluting stent being the most efficacious and EES being the safest stent. CONCLUSIONS: DES are highly efficacious at reducing the risk of target-vessel revascularization without an increase in any safety outcomes, including stent thrombosis. However, among the DES types, there were considerable differences, such that EES, SES, and ZES-R were the most efficacious and EES was the safest stent.

Aims: Previous studies have demonstrated an increase in the amount of radiation administered when utilising the radial artery versus the femoral artery for access. However, radiation exposure between experienced radial and femoral operators is not well defined. Methods and results: We retrospectively analysed 1,922 patients who underwent coronary angiography with or without percutaneous coronary intervention (PCI) and had radiation dose data available for analysis at a tertiary care center from October 2010 to June 2011. Experienced operators were defined as those that perform more than >75 PCIs a year with more 95% of cases performed using the transradial or transfemoral approach for at least 5 years. The outcomes of interest were fluoroscopy time (FT) and dose area product (DAP). Analysis was performed separately for diagnostic only procedures and procedures PCI. Data is presented as median [interquartile range], and statistical analysis was performed using the Mann-Whitney U test. Of the 1,922 patients, 1,565 (81.4%) cases were performed by experienced femoral operators and 357 (18.6%) cases were performed experienced radial operators. The majority of these cases (65.3%) underwent a diagnostic coronary angiogram only (989 femoral and 266 radial). For diagnostic coronary angiography, both total dose area product (DAP) and fluoroscopy time (FT) were significantly higher in transradial versus transfemoral approaches (6038 [3158-8884] vs. 5240 [3517-7429] Gym², p<0.001 and 6.2 [4.0-10.2] vs. 3.6 [2.7-5.4] min, p=0.02). For procedures involving PCI, DAP was not significantly different in transradial versus transfemoral approaches (16,842 [12,017-24,532] vs. 15,577 [10,089-22,203] Gym², p=0.06) although FT was significantly higher (20.4 [13.3-29.6] vs. 14.0 [9.9-20.71] min, p<0.001). Conclusions: In a contemporary cohort of patients undergoing coronary angiography with or without PCI, the transradial approach was associated with higher radiation exposure when compared with transfemoral approach, even in cases performed by experienced operators. While transradial procedures has other advantages (reduced access site complications/bleeding), the amount of radiation administered should be borne in mind while caring for such patients

BACKGROUND: . Unique identifier: NCT00798122

BACKGROUND: Catheter-based mitral valve clip repair (CBMCR) is feasible for selected patients with mitral regurgitation (MR). Two-dimensional (2D) transesophageal echocardiography (TEE) is the standard modality for evaluating MR and procedural guidance. Recently, real-time three-dimensional TEE became available. The aim of this study was to evaluate the value of combined 2D and three-dimensional TEE for CBMCR. In evaluating MR for CBMCR, the confidence of interpretation of 2D TEE was compared with that of combined imaging for the localization of major valve pathology. In patients who underwent CBMCR, the outcomes and the duration of CBMCR were compared. METHODS: In this retrospective study, MR evaluation was performed by 2D TEE alone and by combined imaging in 80 and 57 patients, respectively. CBMCR was guided by 2D TEE alone in 20 patients and by combined imaging in 39 patients. RESULTS: Examination by combined imaging allowed en face visualization of mitral valve anatomy and MR jet origin. The confidence of interpretation by combined imaging was higher than for 2D TEE (1.1 +/- 0.3 vs 1.8 +/- 0.7, P < .001).The guidance of CBMCR by combined imaging facilitated alignment of the catheter trajectory, clip positioning, and orientation of clip arms. The procedural success and final MR grade were not different between the two study groups. However, the procedural time of CBMCR using combined imaging compared with that using 2D TEE guidance alone was shorter (241 +/- 58 vs 201 +/- 68 min, P = .035). CONCLUSIONS: The use of combined imaging compared with 2D TEE alone appears to enhance the confidence of interpretation concerning mitral pathology and catheter-clip system location and may also reduce CBMCR time

BACKGROUND: In the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, an initial strategy of coronary revascularization and optimal medical treatment (REV) compared with an initial optimal medical treatment with the option of subsequent revascularization (MED) did not reduce all-cause mortality or the composite of cardiovascular death, myocardial infarction, and stroke in patients with type 2 diabetes mellitus and stable ischemic heart disease. In the same population, we tested whether the REV strategy was superior to the MED strategy in preventing worsening and new angina and subsequent coronary revascularizations. METHODS AND RESULTS: Among the 2364 men and women (mean age, 62.4 years) with type 2 diabetes mellitus, documented coronary artery disease, and myocardial ischemia, 1191 were randomized to the MED and 1173 to the REV strategy preselected in the percutaneous coronary intervention (796) and coronary artery bypass graft (377) strata. Compared with the MED strategy, the REV strategy at the 3-year follow-up had a lower rate of worsening angina (8% versus 13%; P<0.001), new angina (37% versus 51%; P=0.001), and subsequent coronary revascularizations (18% versus 33%; P<0.001) and a higher rate of angina-free status (66% versus 58%; P=0.003). The coronary artery bypass graft stratum patients were at higher risk than those in the percutaneous coronary intervention stratum, and had the greatest benefits from REV. CONCLUSIONS: In these patients, the REV strategy reduced the occurrence of worsening angina, new angina, and subsequent coronary revascularizations more than the MED strategy. The symptomatic benefits were observed particularly for high-risk patients. Clinical Trial Registration: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00006305

The effectiveness and safety of drug-eluting stents (DES) compared with bare-metal stents (BMS) in saphenous vein graft (SVG) disease remains unclear. In particular, there is a paucity of data on long-term outcomes. In this study, 395 patients enrolled in the National Heart, Lung, and Blood Institute Dynamic Registry who underwent stenting of SVG lesions with BMS (n = 192) from 1999 to 2006 or DES (n = 203) from 2004 to 2006 were analyzed. Patients were followed prospectively for the occurrence of cardiovascular events and death at 3 years. Patients treated with DES were more likely to have diabetes mellitus and other co-morbidities and previous percutaneous coronary intervention. Treated lesions in DES patients were more complex than those in BMS patients. At 3 years of follow-up, the adjusted risk for target vessel revascularization (hazard ratio 1.03, 95% confidence interval 0.65 to 1.62, p = 0.91) and death or myocardial infarction (hazard ratio 0.72, 95% confidence interval 0.49 to 1.04, p = 0.08) was similar in patients treated with DES and those treated with BMS. The combined outcome of death, myocardial infarction, or target vessel revascularization excluding periprocedural myocardial infarction was also similar (adjusted hazard ratio 0.82, 95% confidence interval 0.62 to 1.09, p = 0.16). In conclusion, this multicenter nonrandomized study of unselected patients showed no benefit of DES in SVG lesions, including no reduction in target vessel revascularization, compared with BMS at 3 years. An adequately powered randomized controlled trial is needed to determine the optimal stent type for SVG percutaneous coronary intervention

BACKGROUND: A substantial minority of patients with acute coronary syndromes (ACS) do not have a diameter stenosis of any major epicardial coronary artery on angiography ('no obstruction at angiography') of >/= 50%. We examined the frequency of this finding and its relationship to race and sex. HYPOTHESIS: Among patients with myocardial infarction, younger age, female sex and non-white race are associated with the absence of obstructive coronary artery disease at angiography. METHODS: We reviewed the results of all angiograms performed from May 19, 2006 to September 29, 2006 at 1 private (n = 793) and 1 public (n = 578) urban academic medical center. Charts were reviewed for indication and results of angiography, and for demographics. RESULTS: The cohort included 518 patients with ACS. There was no obstruction at angiography in 106 patients (21%), including 48 (18%) of 258 patients with myocardial infarction. Women were more likely to have no obstruction at angiography than men, both in the overall cohort (55/170 women [32%] vs 51/348 men [15%], P < 0.001) and in the subset with MI (29/90 women [32%] vs 19/168 men [11%], P < 0.001). Black patients were more likely to have no obstruction at angiography relative to any other subgroup (24/66 [36%] vs 41/229 [18%] Whites, 31/150 [21%] Hispanics, and 5/58 [9%] Asians, P = 0.001). Among women, Black patients more frequently had no obstruction at angiography compared with other ethnic groups (16/27 [59%] vs 17/59 [29%] Whites, 17/60 [28%] Hispanics, and 3/19 [6%] Asians, P = 0.001). CONCLUSIONS: A high proportion of a multiethnic sample of patients with ACS were found to have no stenosis >/= 50% in diameter at coronary angiography. This was particularly common among women and Black patients.