Coronary Pressure Measurement Based Decision Making for Percutaneous Coronary Intervention

The fractional flow reserve (FFR) is a simple, reliable, and reproducible physiologic index of lesion severity. In patients with intermediate stenosis, FFR≥0.75 can be used to safely defer percutaneous coronary intervention (PCI), and patients with FFR≥0.75 have a very low cardiac event rate. Coronary pressure measurement can determine which lesion should be treated with PCI in patients with tandem lesions, and PCI on the basis of FFR has been demonstrated to result in an acceptably low repeat PCI rate. FFR can identify patients with equivocal left main coronary artery disease who benefit from coronary bypass surgery. Coronary pressure measurement distinguishes patients with an abrupt pressure drop pattern from those with a gradual pressure drop pattern, and the former group of patients benefit from PCI. Coronary pressure measurement is clinically useful in evaluating sufficient recruitable coronary collateral blood flow for prevention of ischemia, which affects future cardiac events. FFR is useful for the prediction of restenosis after PCI. As an end-point of PCI, FFR ≥0.95 and ≥0.90 would be appropriate for coronary stenting and coronary angioplasty, respectively. In summary, if you encounter a coronary stenosis in doubt you should measure pressure rather than dilate it

Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography ST segment elevation in lead aVR with less ST segment elevation in lead V1

AbstractOBJECTIVESWe sought to determine the electrocardiographic (ECG) features associated with acute left main coronary artery (LMCA) obstruction.BACKGROUNDPrediction of LMCA obstruction is important with regard to selecting the appropriate treatment strategy, because acute LMCA obstruction usually causes severe hemodynamic deterioration, resulting in a less favorable prognosis.METHODSWe studied the admission 12-lead ECGs in 16 consecutive patients with acute LMCA obstruction (LMCA group), 46 patients with acute left anterior descending coronary artery (LAD) obstruction (LAD group) and 24 patients with acute right coronary artery (RCA) obstruction (RCA group).RESULTSLead aVR ST segment elevation (>0.05 mV) occurred with a significantly higher incidence in the LMCA group (88% [14/16]) than in the LAD (43% [20/46]) or RCA (8% [2/24]) groups. Lead aVR ST segment elevation was significantly higher in the LMCA group (0.16 ± 0.13 mV) than in the LAD group (0.04 ± 0.10 mV). Lead V1ST segment elevation was lower in the LMCA group (0.00 ± 0.21 mV) than in the LAD group (0.14 ± 0.11 mV). The finding of lead aVR ST segment elevation greater than or equal to lead V1ST segment elevation distinguished the LMCA group from the LAD group, with 81% sensitivity, 80% specificity and 81% accuracy. A ST segment shift in lead aVR and the inferior leads distinguished the LMCA group from the RCA group. In acute LMCA obstruction, death occurred more frequently in patients with higher ST segment elevation in lead aVR than in those with less severe elevation.CONCLUSIONSLead aVR ST segment elevation with less ST segment elevation in lead V1is an important predictor of acute LMCA obstruction. In acute LMCA obstruction, lead aVR ST segment elevation also contributes to predicting a patient’s clinical outcome

Echocardiography in congenital pericardial defect - Alterations of cardiac motion induced by posture changes -

The true incidence of congenital pericardial defects is unknown, but it is more common than generally supposed. Because of the variance of chest X-rays, ECG and symptoms according to the degree of the defect, it is still not easy to diagnose a pericardial defect. Recently, we experienced four patients with congenital pericardial defects. Three cases were absence of the left pericardium and one was an absence of the right. In these patients, the view with echocardiography was characteristically altered by posture changes. All three patients with left-sided defect showed an enlarged right ventricular cavity, paradoxycal motion of the interventricular septum and hyperkinetic motion of the posterior wall in the left lateral decubitus position. These findings were not present in the right decubitus position. On the other hand, in a case with a right-sided defect, the view was almost normal in the left decubitus position. In the right decubitus position, the right ventricular cavity enlarged and the interventricular septum moved hyperkineticaly. These alterations of echocardiographic findings by posture changes were specific to the side of the pericardial defect, and were caused by a change in cardiac restraint. Therefore, an echocardiogram recorded with posture changes is useful in the diagnosis of congenital pericardial defects