Fluctuation of spastic location in patients with vasospastic angina: A quantitative angiographic study

Objectives.: This study sought to determine whether the location of coronary spastic activity may change over time in patients with persistent variant angina. Background.: Although electrocardiographic studies have provided indirect evidence to indicate that the location of ischemia may change in patients with variant angina, it has not been tested by quantitative angiography whether the location of vasospastic activity may change over time. Methods.: Paired ergonovine provocation tests and coronary angiography were performed at a mean (±SD) interval of 43 ± 13 months apart in patients with persistent symptoms of vasospastic angina in the absence of significant atherosclerosis. A total of 87 spastic and nonspastic segments of 87 major vessels in 29 patients were analyzed by quantitative angiography at baseline, after the administration of ergonovine and after isosorbide dinitrate at the initial and follow-up tests. Results.: In 13 patients (group 1), coronary spasm was observed in the same 16 coronary segments at both the initial and follow-up ergonovine provocation tests. In 16 patients (group 2), the following angiographic changes occurred between the initial and follow-up tests in 48 major vessels: Of the 23 segments that developed spasm at the initial test, 10 did not have spasm at the follow-up test; of the 25 vessels that did not demonstrate spasm on the initial test, 12 demonstrated spasm on the follow-up test (a new site of spasm). Thus, in 22 (46%) of 48 vessels, fluctuation of spastic location was observed at follow-up. Conclusions.: Quantitative coronary angiography and repeated ergonovine tests revealed that some patients with persistent vasospastic angina demonstrate fluctuation of vasospastic location, whereas others exhibit a fixed location of vasospasm. Vasospastic angina may not only be a transient disease restricted in location, but may also be a persistent and variable condition involving multiple vessels over many years

Normalization of coronary flow reserve by percutaneous transluminal coronary angioplasty

Fifteen patients undergoing routine follow-up angiography 5 months after successful percutaneous transluminal coronary angioplasty (PTCA) without angina and with normal exercise thallium scintigraphy were selected for analysis. The coronary flow reserves of these patients were compared with those of 24 patients with angiographically normal coronary arteries to establish whether PTCA can restore to normal the coronary flow reserve of patients with chronic coronary artery disease. The quantitative cineangiographic changes and the concomitant alterations in coronary flow reserve as an immediate result of the PTCA and the subsequent changes 5 months later are described. Coronary flow reserve was measured with digital subtraction cineangiography. PTCA resulted in an increase in minimal obstruction area (mean +/- standard deviation) from 0.8 +/- 0.3 to 3.4 +/- 0.7 mm2 and in coronary flow reserve from 1.0 +/- 0.3 to 2.5 +/- 0.6. Five months later a further substantial and significant (p less than 0.05) late increase in obstruction area (3.8 +/- 0.9 mm2) and flow reserve (3.6 +/- 0.5) had occurred. In 11 of 15 patients coronary flow reserve was restored to normal. Changes in stenosis geometry are likely to be 1 of the major determinants of this late normalization of coronary flow reserve

SYNTAX II and SYNTAX III trials: What is the take home message for surgeons?

Percutaneous coronary intervention (PCI) has evolved greatly in the last 40 years since its introduction by Andreas Grüntzig in 1977. Since then, we've observed an evolution in balloons, the development of stents, changes in stent structure, development of drug eluting stents, improvements in strut design, thickness and even their polymeric coating. Most recently we saw the rise and "fall" of bioabsorbable scaffolds for PCI. Trials with the most diverse devices for PCI and diagnostic techniques have been conducted. Two of the most recent trials were reported in the last year and deserve special attention-SYNTAX II and SYNTAX III. These trials are completely different in design but present valuable information for doctors managing coronary artery disease (CAD). Both trials take into account contemporary technology for assessing and treating CAD. The first uses so-called "state-of-the-art" PCI and compares the outcomes of that approach with the outcomes of the PCI arm of the pivotal SYNTAX trial. SYNTAX III Revolution on the other hand does not focus on clinical endpoints: it is a blinded trial that does not randomize patients but randomizes doctors ("the heart team") to make a decision on the best treatment for complex CAD. This decision was based either on multi-slice CT with physiological assessment using FFRCT or on conventional angiography. In this review we bring the most important aspects of those trials and the key messages for surgeons together; also, what the surgeon may expect in the future after the publication of these interesting concepts

Bioresorbable scaffolds: a new paradigm in percutaneous coronary intervention

Numerous advances and innovative therapies have been introduced in interventional cardiology over the recent years, since the first introduction of balloon angioplasty, but bioresorbable scaffold is certainly one of the most exciting and attracting one. Despite the fact that the metallic drug-eluting stents have significantly diminished the re-stenosis ratio, they have considerable limitations including the hypersensitivity reaction to the polymer that can cause local inflammation, the risk of neo-atherosclerotic lesion formation which can lead to late stent failure as well as the fact that they may preclude surgical revascularization and distort vessel physiology. Bioresorbable scaffolds overcome these limitations as they have the ability to dissolve after providing temporary scaffolding which safeguards vessel patency. In this article we review the recent developments in the field and provide an overview of the devices and the evidence that support their efficacy in the treatment of CAD. Currently 3 devices are CE marked and in clinical use. Additional 24 companies are developing these kind of coronary devices. Most frequently used material is PLLA followed by magnesium

Edge detection versus densitometry for assessing coronary stenting quantitatively

The optimal method used to analyze quantitatively the immediate angiographic results of coronary stenting in the coronary arteries has not been studied. Accordingly, minimal luminal cross-sectional area was determined by 2 methods, edge detection and densitometry, in 19 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) and then coronary stent implantation for symptomatic coronary stenoses. The correlation coefficient, 0.73 before angioplasty, decreased to 0.59 after coronary angioplasty and then increased to 0.83 after stent implantation. The mean differences between edge detection and densitometric determinations of minimal luminal cross-sectional area were 0.31 +/- 0.51 mm2 before PTCA, -0.38 +/- 1.22 mm2 after angioplasty and 0.35 +/- 0.79 mm2 after coronary stenting. It is concluded that, although the correlation and variability in the measurement of minimal luminal cross-sectional area between edge detection and densitometry deteriorate after PTCA, they are improved after stenting, probably because of smoothing of the vessel contours by the stent and remodeling of the stented segment into a more circular configuration. Therefore, in the stented coronary artery, edge detection and densitometry are equally acceptable methods of analysis

Strut protrusion and shape impact on endothelial shear stress: insights from pre-clinical study comparing Mirage and Absorb bioresorbable scaffolds

Protrusion of scaffold struts is related with local coronary flow dynamics that can promote scaffold restenosis and thrombosis. That fact has prompted us to investigate in vivo the protrusion status of different types of scaffolds and their relationship with endothelial shear stress (ESS) distributions. Six Absorb everolimus-eluting Bioresorbable Vascular Scaffolds (Absorb, Abbott Vascular) and 11 Mirage sirolimus-eluting Bioresorbable Microfiber Scaffolds (Mirage, Manli Cardiology) were implanted in coronaries of eight mini pigs. Optical coherence tomography (OCT) was performed post-scaffold implantation and obtained images were fused with angiographic data to reconstruct the three dimensional coronary anatomy. Blood flow simulation was performed and ESS distribution was estimated for each scaffold. Protrusion distance was estimated using a dedicated software. Correlation between OCT-derived protrusion and ESS distribution was assessed for both scaffold groups. A significant difference was observed in the protrusion distances (156 ± 137 µm for Absorb, 139 ± 153 µm for Mirage; p = 0.035), whereas difference remained after adjusting the protrusion distances according to the luminal areas. Strut protrusion of Absorb is inversely correlated with ESS (r = -0.369, p < 0.0001), whereas in Mirage protrusion was positively correlated with EES (r = 0.192, p < 0.0001). Protrusion distance was higher in Absorb than in Mirage. The protrusion of the thick quadratic struts of Absorb has a tendency to lower shear stress in the close vicinity of struts. However, circular shape of the less thick struts of Mirage didn't show this trend in creating zone of recirculation around the struts. Strut geometry has different effect on the relationship between protrusion and shear stress in Absorb and Mirage scaffolds

Coronary lumen at six-month follow-up of a new radiopaque Cordis tantalum stent using quantitative angiography and intracoronary ultrasound.

To determine the reliability of geometric (edge-detection) quantitative coronary angiographic analysis (QCA) of restenosis within a new Cordis tantalum stent, QCA and intracoronary ultrasound (ICUS) measurements were compared in both an experimental restenosis model and in the clinical follow-up of patients. In the experimental series, Plexiglas phantom vessels with concentric stenosis channels ranging from 0.75 to 3.0 mm in diameter and with a reference diameter of 3.0 mm were imaged both before and after their insertion in tantalum stents. In the clinical series, the agreement of QCA and ICUS measurements were studied in 23 patients who had undergone coronary implantation of the new tantalum stent and in 23 patients who had undergone balloon angioplasty 6 months previously. The reliability of QCA declined in the presence of the radiopaque stent (accuracy of QCA decreased from -0.07 to -0.12 mm), whereas the reliability of lumen measurements by ICUS was independent of the presence of the radiopaque stent (-0.12 and -0.13 mm). Without the stent, the average minimal luminal diameter (MLD) obtained by QCA of the 1.00 mm Plexiglas vessel was 1.00 +/- 0.01 mm, and the 3.00 mm reference vessel diameter was 2.81 +/- 0.05 mm, providing a 64 +/- 1% diameter stenosis. After introduction of the stent, the average MLD and reference vessel diameter were 0.99 +/- 0.06 and 3.36 +/- 0.17 mm, respectively, providing a diameter stenosis of 71 +/- 2%. ICUS measurements (2.77 mm) of the reference vessel diameter (3.00 mm) were unaffected by the presence of the stent. (ABSTRACT TRUNCATED AT 250 WORDS