Multicentre short- and medium-term report on the device closure of a post-myocardial infarction ventricular septal rupture - In search of risk factors for early mortality

BACKGROUND

Post-myocardial infarction ventricular septal rupture (VSR) is a rare and severe complication of myocardial infarction. To find early mortality (<30 days) risk factors of device VSR closure and to evaluate its medium-term outcome.

METHODS

Multicenter retrospective analysis on all 46 consecutive patients with percutaneous (n = 43) or hybrid (n = 3) VSR closure in 2000-2020 with various nitinol wire mesh occluders. Medical records, hemodynamic data, procedure results, short- and mid-term follow-up were analyzed (4.8 ± 3.7 years, range: 0.1-15, available in 61.7% of patients). Of the patients, 34.8% underwent VSR closure in acute phase (<21 days after VSR occurrence), 17.4% underwent device closure due to significant residual shunt after previous VSR surgery.

RESULTS

Success rate was 78.3%. More than moderate residual shunt, major complications, and early surgical reintervention affected 18.9%, 15.2% (including 2 intra-procedural deaths), and 21.7% of patients, respectively. Early mortality was 26.1% (13.9% in successful vs. 70% in unsuccessful closure; p < 0.001). Older age, need for intra-aortic balloon counterpulsation, severe complications, and procedural failure were identified as risk factors for early mortality. Among patients who survived the early period, the 5-year survival rate was 57.1%. NYHA class improved in 88.2% patients at the latest follow-up.

CONCLUSIONS

Procedure of VSR device closure demonstrates an acceptable technical success rate; however, the incidence of severe complications and early mortality is notably high. Older patients in poor hemodynamic condition and those with unsuccessful occluder deployment are particularly at a higher risk of a fatal outcome. The prognosis after early survival is promising.

Multicenter registry of Impella-assisted high-risk percutaneous coronary interventions and cardiogenic shock in Poland (IMPELLA-PL)

BACKGROUND

Impella is a percutaneous mechanical circulatory support device for treatment of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (HR-PCIs). IMPELLA-PL is a national retrospective registry of Impella-treated CS and HR-PCI patients in 20 Polish interventional cardiological centers, conducted from January 2014 until December 2021.

AIMS

We aimed to determine the efficacy and safety of Impella using real-world data from IMPELLA-PL and compare these with other registries.

METHODS

IMPELLA-PL data were analyzed to determine primary endpoints: in-hospital mortality and rates of mortality and major adverse cardiovascular and cerebrovascular events (MACCE) at 12 months post-discharge.

RESULTS

Of 308 patients, 18% had CS and 82% underwent HR-PCI. In-hospital mortality rates were 76.4% and 8.3% in the CS and HR-PCI groups, respectively. The 12-month mortality rates were 80.0% and 18.2%, and post-discharge MACCE rates were 9.1% and 22.5%, respectively. Any access site bleeding occurred in 30.9% of CS patients and 14.6% of HR-PCI patients, limb ischemia in 12.7% and 2.4%, and hemolysis in 10.9% and 1.6%, respectively.

CONCLUSIONS

Impella is safe and effective during HR-PCIs, in accordance with previous registry analyses. The risk profile and mortality in CS patients were higher than in other registries, and the potential benefits of Impella in CS require investigation.

Safety and efficacy of self-apposing Stentys drug-eluting stent in left main coronary artery PCI: Multicentre LM-STENTYS registry

BACKGROUND

There is a paucity of data on left main (LM) percutaneous coronary intervention (PCI) therapy with dedicated DES platforms. The LM-STENTYS is a multicenter registry aimed at evaluating clinical outcome after PCI of LM performed with a self-apposing Stentys DES implantation.

METHODS

The registry consists of 175 consecutive patients treated with Stentys DES implanted to LM. The primary endpoint was the composite of major adverse cardiac and cerebral events (MACCE) defined as cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stroke assessed after 1 year. The secondary endpoint was stent thrombosis (ST) at 1 year.

RESULTS

The median age was 69 years (IQR, 62-78 years). Acute coronary syndrome (ACS) was the presenting diagnosis in 117 (66.9%) patients [74 (63.2%) unstable angina, 31 (26.5%) NSTEMI, 12 (10.3%) STEMI] and stable angina (SA) was present in 58 (33.1%) patients. The median SYNTAX score was 23.0 (IQR, 18.7-32.2) in the SA group and 25.0 (IQR, 20.0-30.7) in the ACS group. During 1-year follow-up in the SA group two (3.4%) MACCE occurred, both of them were cardiac deaths. In ACS patients there were 19 (16.2%) MACCE [9 (7.7%) cardiac deaths, 11 (9.4%) MIs, 11(9.4%) TLR, 1(0.9%) stroke]. Altogether, three (1.7%) cases of acute ST were noted, all of them in ACS subset.

CONCLUSION

LM PCI using self-apposing Stentys DES showed favorable clinical outcomes at 1-year in patients with SA. Events of ST in the ACS group warrant further research.

[Left atrial appendage occlusion: consensus document of Association of Cardiovascular Interventions and Heart Rhythm Section of Polish Cardiac Society]

Left atrial appendage (LAA) occlusion devices have the potential to influence the clinical approach to stroke prevention in patients with atrial fibrillation. A number of percutaneous techniques have been proposed, including various intracardiac plugs and also external ligation. Several devices have been already used in Poland. One of them has been evaluated in randomised controlled trials compared with the current standard of care. Others are less well studied but quite commonly used in Eu-rope. It is anticipated that the use of LAA occlusion technologies in clinical practice will expand. This Consensus Document prepared jointly by Association of Cardiovascular Interventions (AISN) and Heart Rhythm Section (HRS) of Polish Cardiac Society seeks to highlight the critical issues surrounding LAA occlusion therapies and to facilitate the alignment of multiple interests, including those of primary care physicians, general cardiologists and procedural specialists (electrophysiologists and interventional cardiologists) but also other medical professionals. The article summarises current evidence and provides spe-cific recommendations on organisation and conduct of LAA therapy in patients with atrial fibrillation in Poland and defines also operator and institutional requirements fundamental to the establishment of successful LAA occlusion programmme.

Associations between selected angiographic parameters and the number of CD34⁺ cells and plasma levels of vascular endothelial growth factor and angiogenin in patients with ST-segment elevation myocardial infarction

INTRODUCTION

Left ventricular (LV) function and prognosis in patients after myocardial infarction are associated with some angiographic parameters.

OBJECTIVES

The aim of the study was to assess the associations between the TIMI score in the infarct-related artery (IRA) before percutaneous coronary intervention (PCI), myocardial blush grade (MBG) following effective PCI, and the extent of collaterals measured using the Rentrop scale and plasma levels of vascular endothelial growth factor (VEGF) and angiogenin, number of CD34⁺ cells, as well as LV ejection fraction (LVEF) and wall motion score index (WMSI).

PATIENTS AND METHODS

In 62 patients with the first ST-segment elevation myocardial infarction (STEMI) treated with PCI and bare metal stent implantation, plasma VEGF and angiogenin levels as well as the number of CD34⁺ cells were assessed before PCI, 24 hours after PCI, at discharge, and at 30 days following STEMI. LVEF and WMSI were evaluated by echocardiography at discharge and at 1 and 6 months after STEMI.

RESULTS

Patients with TIMI 0-1 flow in the IRA before PCI (64.6% of the patients) had significantly higher troponin I and VEGF levels as well as a higher number of CD34⁺ cells than patients with TIMI 3 flow. Patients with TIMI 0-1 flow also had worse LV systolic function at 1 and 6 months following STEMI. Neither the MBG grade nor the Rentrop score showed associations with the mobilization of CD34⁺ cells, VEGF and angiogenin levels, and parameters of L V systolic function.

CONCLUSIONS

Early patency of the IRA and lower myocardial necrosis seem to be more important for LV function assessed in patients 6 months after STEMI than mobilization of CD34⁺ cells and levels of angiogenic factors.

Admission glucose and left ventricular systolic function in non-diabetic patients with acute myocardial infarction

Carbohydrate metabolism disorder in patients hospitalized due to acute ST-segment elevation myocardial infarction (STEMI) is associated with poor outcome. The association is even stronger in non-diabetic patients compared to the diabetics. Poor outcome of patients with elevated parameters of carbohydrate metabolism may be associated with negative impact of these disorders on left ventricular (LV) function. The aim of the study was to determine the impact of admission glycemia on LV systolic function in acute phase and 6 months after myocardial infarction in STEMI patients treated with primary angioplasty, without carbohydrate disorders. The study group consisted of 52 patients (9 female, 43 male) aged 35-74 years, admitted to the Department of Cardiology and Internal Medicine, Collegium Medicum in Bydgoszcz, due to the first STEMI treated with primary coronary angioplasty with stent implantation, without diabetes in anamnesis and carbohydrate metabolism disorders diagnosed during hospitalization. Echocardiography was performed in all patients in acute phase and 6 months after MI. Plasma glucose were measured at hospital admission. In the subgroup with glycemia ≥7.1 mmol/l, in comparison to patients with glycemia <7.1 mmol/l, significantly lower ejection fraction (EF) was observed in acute phase of MI (44.4 ± 5.4 vs. 47.8 ± 6.3 %, p = 0.04) and trend to lower EF 6 months after MI [47.2 ± 6.5 vs. 50.3 ± 6.3 %, p = 0.08 (ns)]. Higher admission glycemia in patients with STEMI and without carbohydrate metabolism disturbances, may be a marker of poorer prognosis resulting from lower LV ejection fraction in the acute phase and in the long-term follow-up.

A critical overview on ticagrelor in acute coronary syndromes

Until a few years ago, the mainstay of anti-platelet therapy in patients with acute coronary syndrome (ACS) was the combination of aspirin and clopidogrel, a P2Y12 receptor inhibitor. However, current clinical practice has now changed with the introduction of ticagrelor, a more potent cardiovascular drug than clopidogrel, without the limitations related to clopidogrel therapy. In this review, we provide a critical overview of ticagrelor in ACS, highlight the results with ticagrelor in several subgroups of patients and discuss the future trials.

Stress hyperglycaemia in patients with first myocardial infarction

OBJECTIVE

To investigate the incidence of stress hyperglycaemia at first acute myocardial infarction (MI) with ST-segment elevation, occurrence of stress hyperglycaemia as a manifestation of previously undiagnosed abnormal glucose tolerance (AGT), and its relation to stress hormone levels.

MATERIALS AND METHODS

  The population of this prospective cohort study consisted of 243 patients. On admission glucose, adrenaline, noradrenaline and cortisol levels were measured. Patients without previously diagnosed diabetes (n = 204) underwent an oral glucose tolerance test on day 3 of hospitalisation and 3 months after discharge.

RESULTS

Abnormal glucose tolerance at day 3 was observed in 92 (45.1%) patients without a previous diagnosis of diabetes mellitus and resolved after 3 months in 46 (50.0%) patients (p < 0.0001). Stress hyperglycaemia, defined as admission glycaemia ≥ 11.1 mmol/l, affected 34 (14.0%) study participants: 28 (54.9%) patients with diabetes vs. 3 (8.8%) subjects with newly detected impaired glucose intolerance (p < 0.00001) and 1 (2.2%) person with AGT at day 3 (p < 0.000001). Multivariable analysis identified elevated glycated haemoglobin (HbA(1c) ; p < 0.0000001), anterior MI (p < 0.05) and high admission cortisol concentration (p < 0.001), but not catecholamines, as independent predictors of stress hyperglycaemia. The receiver operating characteristic curve analysis revealed the optimal cut-off values of 8.2% for HbA(1c) and 47.7 μg/dl for admission cortisol with very good and sufficient diagnostic accuracies respectively.

CONCLUSIONS

  Newly detected AGT in patients with a first MI is transient in 50% of cases. Stress hyperglycaemia is a common finding in patients with a first MI with ST-segment elevation and diabetes mellitus, but is rarely observed in individuals with impaired glucose tolerance or transient AGT diagnosed during the acute phase of MI. The risk factors of stress hyperglycaemia occurrence include elevated HbA(1c) , anterior MI and high admission cortisol concentration.

Usefulness of C-reactive protein as a marker of early post-infarct left ventricular systolic dysfunction

Objective

To assess the usefulness of in-hospital measurement of C-reactive protein (CRP) concentration in comparison to well-established risk factors as a marker of post-infarct left ventricular systolic dysfunction (LVSD) at discharge.

Materials and methods

Two hundred and four consecutive patients with ST-segment-elevation myocardial infarction (STEMI) were prospectively enrolled into the study. CRP plasma concentrations were measured before reperfusion, 24 h after admission and at discharge with an ultra-sensitive latex immunoassay.

Results

CRP concentration increased significantly during the first 24 h of hospitalization (2.4 ± 1.9 vs. 15.7 ± 17.0 mg/L; p < 0.001) and persisted elevated at discharge (14.7 ± 14.7 mg/L), mainly in 57 patients with LVSD (2.4 ± 1.8 vs. 25.0 ± 23.4 mg/L; p < 0.001; CRP at discharge 21.9 ± 18.6 mg/L). The prevalence of LVSD was significantly increased across increasing tertiles of CRP concentration both at 24 h after admission (13.2 vs. 19.1 vs. 51.5 %; p < 0.0001) and at discharge (14.7 vs. 23.5 vs. 45.6 %; p < 0.0001). Multivariate analysis demonstrated CRP concentration at discharge to be an independent marker of early LVSD (odds ratio of 1.38 for a 10 mg/L increase, 95 % confidence interval 1.01–1.87; p < 0.04).

Conclusion

Measurement of CRP plasma concentration at discharge may be useful as a marker of early LVSD in patients after a first STEMI.

[Primary percutaneous coronary intervention facilitated with supersaturated oxygen therapy in a patient with anterior myocardial infarction: a case report and literature review]

Infarct size is regarded as the main factor determining short- and long-term prognosis after acute myocardial infarction. Effective reperfusion therapy reduces infarct size by half. Despite broad implementation of primary percutaneous coronary interventions, the prognosis in many patients with large infarcts remains serious. We present a case report on a patient with an anterior wall ST-segment elevation myocardial infarction successfully treated interventionally with the use of supersaturated oxygen delivery.

Coronary artery aneurysm after implantation of an endothelial progenitor cell capturing stent

The Genous™ stent coated with anti-CD34 antibodies has been designed to accelerate healing of the vessel by attracting circulating endothelial progenitor cells. Rapid restoration of a functional endothelial layer with a full coverage of the stent struts aims to minimise arterial injury after coronary stenting and to prevent thrombus formation and neointima proliferation. We report a case of a 56 year-old man who developed a coronary artery aneurysm after the implantation of a Genous™ stent due to an edge restenosis in sirolimus-eluting stent. We present diagnostics of our patient with the application of intravascular ultrasound and coronary computed tomography angiography, discuss his management, and hypothesise about the pathomechanism of aneurysm formation.

Occurrence and predictors of left ventricular systolic dysfunction at hospital discharge and in long-term follow-up after acute myocardial infarction treated with primary percutaneous coronary intervention

BACKGROUND

Post-ST-segment elevation myocardial infarction (STEMI) left ventricular systolic dysfunction (LVSD) has been identified as an important marker of poor prognosis.

AIM

To assess the prevalence and course of LVSD at hospital discharge and in long-term follow-up in STEMI patients treated with primary percutaneous coronary intervention (pPCI).

METHODS

We enrolled 205 patients (157 male, 48 female) with a first STEMI. Echocardiography was performed before hospital discharge and 12 months after STEMI. Left ventricular systolic function (LVSF) parameters were assessed: left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and average peak systolic mitral annular velocity (S') by tissue Doppler echocardiography (TDE). B-type natriuretic peptide plasma concentration was measured at admission (BNP(admission)) and at discharge (BNP(discharge)).

RESULTS

We found moderate LVSD, both at hospital discharge and after 12 months. Significant global LVSD (LVEF ≤ 40%) was observed in 34% of patients at discharge, and 21% after 12 months (p 〈 0.001). Significant regional LVSD (WMSI ≥ 1.7) after 12 months was less frequent than at discharge (21% vs 33%; p 〈 0.001). More patients had significant longitudinal LVSD (S' ≤ 6.0 cm/s) after 12 months compared to discharge (28% vs 23%; p 〈 0.001). Severe global LVSD (LVEF ≤ 30%) was rare. Univariate logistic regression analysis revealed the predictors of significant global LVSD at 12 months after STEMI to be: anterior location of STEMI; pre-discharge echocardiographic parameters of LVSF and left ventricle size and mass; prepPCI angiographic indices; ratio of the difference of BNP(discharge) and BNPa(dmission) to BNP(admission) expressed as % (BNP(delta) %); time from onset of pain to balloon, and the use of abciximab. Multivariate logistic regression analysis found independent predictors of significant global LVSD at 12 months to be: BNP(delta) % and LVEF at discharge with optimal cut-off values of 728.2% for BNP(delta) % and 37% for LVEF.

CONCLUSIONS

Patients with a first STEMI treated with pPCI present moderate LVSD, both at hospital discharge and after 12 months. In long-term follow-up, we found an improvement in global LVSF, and, albeit a smaller, improvement in regional LVSF. No improvement in longitudinal LVSF was observed. The increase of BNP during hospitalisation, and LVEF at discharge, are independent predictors of significant global LVSD at 12 months after a first STEMI treated with pPCI. Pre-discharge peak systolic mitral annular velocity obtained by TDE may be useful in predicting LVEF in long-term follow-up in this group of patients.

Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis

BACKGROUND

The aim of the current study was to perform two separate meta-analyses of available studies comparing low-molecular-weight heparins (LMWHs) vs. unfractionated heparin (UFH) in ST-elevation myocardial infarction (STEMI) patients treated (i) with primary percutaneous coronary intervention (pPCI) or (ii) with PCI after thrombolysis.

METHODS

All-cause mortality was the pre-specified primary endpoint and major bleeding complications were recorded as the secondary endpoints. Relative risk (RR) with a 95% confidence interval (CI) and absolute risk reduction (ARR) were chosen as the effect measure.

RESULTS

Ten studies comprising 16,286 patients were included. The median follow-up was 2 months for the primary endpoint. Among LMWHs, enoxaparin was the compound most frequently used. In the pPCI group, LMWHs were associated with a reduction in mortality [RR (95% CI) = 0.51 (0.41-0.64), P < 0.001, ARR = 3%] and major bleeding [RR (95% CI) = 0.68 (0.49-0.94), P = 0.02, ARR = 2.0%] as compared with UFH. Conversely, no clear evidence of benefits with LWMHs was observed in the PCI group after thrombolysis. Meta-regression showed that patients with a higher baseline risk had greater benefits from LMWHs (r = 0.72, P = 0.02).

CONCLUSIONS

LMWHs were associated with greater efficacy and safety than UFH in STEMI patients treated with pPCI, with a significant relationship between risk profile and clinical benefits. Based on this meta-analysis, LMWHs may be considered as a preferred anticoagulant among STEMI patients undergoing pPCI.

Value of oral glucose tolerance test in the acute phase of myocardial infarction

Background

Although European guidelines advise oral glucose tolerance test (OGTT) in patients with acute myocardial infarction (AMI) before or shortly after hospital discharge, data supporting this recommendation are inconclusive. We aimed to analyze whether disturbances in glucose metabolism diagnosed before hospital discharge in AMI patients represents a latent pre-existing condition or rather temporary finding. Additionally, we planned to investigate the value of pre-selected glycemic control parameters as predictors of long-term glucometabolic state.

Methods

We assessed admission glycemia, glycated hemoglobin, mean blood glucose concentration on days 1 and 2 in 200 patients with a first AMI but without overt disturbances of glucose metabolism. We also performed OGTT at discharge and 3 months after discharge.

Results

The prevalence of disturbances in glucose metabolism (as assessed by OGTT) at 3 months was significantly lower than at discharge (29% vs. 48%, p = 0.0001). Disturbances in glucose metabolism were not confirmed in 63% of patients with impaired glucose tolerance and in 36% of patients with diabetes mellitus diagnosed during the acute phase of AMI. Age >77 years, glucose ≥12.06 mmol/l at 120 minutes during OGTT before discharge and mean blood glucose level on day 2 >7.5 mmol/l were identified as independent predictors of disturbances in glucose metabolism at the 3-month follow-up.

Conclusions

Disturbances in glucose metabolism observed in patients with a first AMI are predominantly transient. Elderly age, high plasma glucose concentration at 120 minutes during OGTT at discharge and elevated mean blood glucose level on day 2 were associated with sustained disturbances in glucose metabolism.

[Percutaneous closure of the coronary artery fistula connecting left main coronary artery and the right atrium in a 61 year-old woman]

The case of 61 year-old woman with congenital coronary artery fistula connecting left main coronary artery and the right atrium is presented. The patient was admitted to the Cardiology Department because of the first atrial fibrillation episode. During hospitalisation the congenital heart defect was diagnosed thanks echocardiography and multi-slice computed tomography. Three months later the percutaneous closure of the fistula with Amplatzer Duct Occluder was performed. The direct and 6-months results were very good.

Circulating endothelial cells in coronary artery disease

BACKGROUND

endothelial damage and dysfunction play a crucial role in the pathophysiology of coronary artery disease (CAD). The quantification of circulating endothelial cells (CEC) in the peripheral blood is a novel method for assessing endothelial damage.

AIM

to evaluate the possible diagnostic use of single quantification of CEC in peripheral blood by flow cytometry in patients with CAD.

METHODS

we examined 48 patients with CAD, including 23 patients with acute myocardial infarction (AMI) and 25 patients with stable angina (SA). The control group consisted of 20 healthy subjects without symptoms of CAD. The CEC count was evaluated by flow cytometry using antibodies against CD31, CD146, and CD45. Plasma biochemical markers of endothelial damage (von Willebrand Factor [vWF], thrombomodulin [TM]) were measured by ELISA. Serum concentrations of troponin I (TnI) and lipid parameters were also included in the statistical analysis.

RESULTS

A significant increase in the CEC count was found in patients with AMI compared to the control group (p < 0.05) and SA patients (p < 0.05). However, no difference was found in the CEC count between patients with SA and the control group. Increased vWF activity was found in both groups of CAD patients compared to the control group (AMI: p < 0.001, SA: p , 0.01), and vWF activity was significantly higher in AMI patients compared to SA patients (p < 0.001). Thrombomodulin concentration did not differ significantly between any patient groups and the control group. The CEC count correlated positively with vWF activity (r = 0.3852, p < 0.05) and the atherogenic index TC/HDL-C (r = 0.3844, p < 0.05) in all patients with CAD (AMI + SA). The sensitivity of CEC count for the diagnosis of an acute coronary syndrome was lower than that of TnI level on admission (39% vs 69%).

CONCLUSIONS

we confirmed that CEC count in peripheral blood can be determined by flow cytometry in CAD patients with both AMI and SA. The CEC count in AMI was increased in comparison to healthy subjects and SA patients in one third of all cases. To determine whether CEC count could be used to improve the diagnosis of an acute coronary syndrome in patients with CAD, additional studies in larger patient groups would be required.

[Optical coherence tomography-guided stent implantation]

A case of 51-year-old woman who was admitted to Department of Cardiology and Internal Medicine in Bydgoszcz due to unstable angina pectoris with elevated level of troponin I is presented. The patient underwent optical coherence tomography-guided angioplasty of the proximal left anterior descending artery with an implantation of everolimus-eluting stent. Optical coherence tomography (OCT) visualized a plaque or thrombus prolaps between stent struts that was undetectable by intravascular ultrasound. A postdylatation with a bigger balloon was performed. Final OCT imaging revealed a well apposed and expanded coronary stent without any tissue prolaps between struts.

Gender differences and in-hospital mortality in patients undergoing percutaneous coronary interventions

BACKGROUND

Many observational and randomised studies have suggested that women are referred for invasive diagnostics and treatment of coronary artery disease (CAD) less frequently than men, and the effects of percutaneous coronary intervention (PCI) among women are worse than in men.

AIM

To compare direct results of PCI in men and women.

METHODS

The study was a retrospective assessment of case records of one thousand consecutive patients treated with PCI because of acute myocardial infarction (AMI) (344 patients), unstable angina (UA) (164 patients) and stable angina (SA) (492 patients). We examined the effects of demographic, angiographic and clinical variables on the duration of hospitalisation and in-hospital mortality separately in men and in women.

RESULTS

Women constituted 30.7% of patients treated with PCI because of AMI, 39.6% of those with UA and just 25.8% of those with SA. Women were significantly older than men, had a higher BMI, and more often suffered from hypertension and diabetes. The duration of hospitalisation was the same in men and women if the reason for PCI was SA or UA, however, in case of AMI women were hospitalised significantly longer than men. In the univariate analysis gender had no influence on in-hospital mortality regardless of the reason for PCI treatment. Among the variables subjected to multivariate analysis female gender, age, BMI, diabetes, hypercholesterolaemia, indication for PCI, final TIMI flow in the target vessel and cardiogenic shock as a complication of AMI were shown to affect mortality. Significant effects on in-hospital mortality for women were exhibited only by cardiogenic shock. Among men, indication for PCI, age, diabetes and final TIMI flow in the target vessel also had a significant influence on in-hospital mortality.

CONCLUSIONS

Stable angina is a reason for performing PCI more rarely in women than in men. Women with CAD are older than men and have more risk factors. The in-hospital mortality among patients treated with PCI because of SA is independent of gender. Cardiogenic shock appeared to be the only factor that influences in-hospital mortality in women. In the case of men such an influence is also observed for indication for PCI (AMI, UA or SA), diabetes and final TIMI flow in the target vessel.

[Drug-eluting stent-associated thrombosis: clinical relevance of impaired vessel-wall healing]

In-stent thrombosis remains to bo an uncommon but dreadful complication of coronary angioplasty manifesting as sudden death or acute coronary syndrome. Drug-eluting stents (DES) proved to be an effective approach in the prevention and treatment of restenosis across a broad spectrum of lesion and patient subsets. Considerable concerns over this technology were raised when a modest increase in the incidence of very late in-stent thrombosis was demonstrated in DES-treated patients which in some trials even translated into higher mortality and myocardial infarctions compared with bare metal stenting (BMS). Unfortunately, DES not only suppress neointimal formation, but also impair the vessel healing process. Delayed and incomplete endothelialization is frequently observed after DES application. Increased blood thrombogenicity due to the prothrombotic effects of eluting drugs and inadequate platelet inhibition along with altered blood flow through remodeled arteries with dysfunctional endothelium contribute to late DES thrombosis. However, a large amount of data from randomized trials suggest that DES when used on label are not associated with unfavourable clinical outcomes. In these patients DES are probably responsible for a slightly elevated risk of late thrombotic events and simultaneously decreased rates of restenosis-related myocardial infarctions and deaths compared with BMS. The potential benefits and risks of DES off-label stenting are yet to be assessed. Since insufficient platelet inhibition was reported as the strongest predictor of DES thrombosis, the necessity of prolonged dual antiplatelet therapy has constituted a major limitation of this device. Therefore, DES implantation should be particularly avoided in non-compliant patients, in those who are scheduled for major surgery requiring premature discontinuation of dual antiplatelet therapy, and in persons who are at high risk of bleeding. Elective operations in DES patients are suggested to be postponed until 12 months after stenting, while dental procedures, when needed, may be performed on dual antiplatelet treatment. Although recent European and American guidelines recommend dual antiplatelet therapy after DES placement for 6-12 and 12 months, respectively, its optimal duration is a matter of ongoing debate. Subsequent generations of DES developed for a better safety profile as well as novel technologies dedicated to facilitate endothelialization are currently under investigation. Finally, caution is advised in the choice of the particular device for each patient.

Usefulness of optical coherence tomography in the assessment of atherosclerotic culprit lesions in acute coronary syndromes. Comparison with intravascular ultrasound and virtual histology

In this paper, we present a case of a female patient with clinically unstable angina pectoris and a borderline stenosis in the proximal segment of the left anterior descending coronary artery as assessed by coronary angiography and intravascular ultrasound. Virtual histology revealed morphological criteria of a vulnerable plaque forming the culprit lesion. Optical coherence tomography visualized both fibrous cap fracture and a significant stenosis of a coronary artery caused by soft structures identified as mural thrombus covering the plaque surface. The image of atherosclerotic plaque obtained by optical coherence tomography enabled explanation of the cause of coronary instability and influenced subsequent management. The presented case illustrates usefulness of optical coherence tomography as an imaging method complementary to virtual histology and intravascular ultrasound in the diagnostic evaluation of selected patients with acute coronary syndromes. Application of optical coherence tomography in the assessment of vulnerable atherosclerotic plaques is discussed as related to the presented case.

Increased morning ADP-dependent platelet aggregation persists despite dual antiplatelet therapy in patients with first ST-segment elevation myocardial infarction: Preliminary report

BACKGROUND

Numerous trials have reported on the morning increase in the occurrence of myocardial infarction, stroke and sudden cardiac death. Similarly, enhanced morning platelet aggregation has been observed in healthy individuals and in subjects with coronary artery disease without adequate antiplatelet treatment. The purpose of the study was to assess circadian variation in platelet aggregation in patients with first ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary interventions (pPCI) and dual antiplatelet therapy.

METHODS

Fifteen consecutive patients (12 men and 3 women) were prospectively recruited into the study. Blood samples were collected at 6.00 a.m., 10.00 a.m., 2.00 p.m. and 7.00 p.m. on the third day of hospitalization. Aggregation in response to arachidonic acid and adenosine diphosphate (ADP) was assessed in the whole blood on a new generation impedance aggregometer.

RESULTS

A morning increase of 75% in ADP-dependent platelet aggregation was noted in the study population (p < 0.04). In contrast, we failed to show any significant diurnal variation in arachidonic acid-mediated platelet aggregation. The magnitude of the morning surge in platelet aggregation after ADP stimulation did not correlate with its baseline level.

CONCLUSIONS

Increased morning ADP-dependent platelet aggregation persists despite dual antiplatelet therapy in patients with first STEMI undergoing pPCI. The clinical significance of this finding remains to be demonstrated.

Predicted and observed in-hospital mortality after left main coronary artery stenting in 204 patients

BACKGROUND

The purpose of this study was to compare risk predicted using available risk scores and actual outcomes in patients with left main coronary artery disease undergoing percutaneous coronary intervention with stent implantation (PCI LM).

METHODS

We studied 204 patients treated with elective or emergent coronary angioplasty. We estimated in-hospital mortality using the EuroSCORE, Parsonnet and GRACE risk scores and compared this data with actual in-hospital mortality.

RESULTS

There were no deaths among 62 patients undergoing elective PCI LM regardless of the estimated risk. Acute coronary syndrome (ACS) was diagnosed in all 142 patients undergoing emergent PCI LM. Mortality in this group was 24% (34/142). Area under receiver operating characteristic curve (AUC) values for the EuroSCORE, Parsonnet and GRACE risk scores in patients with ACS were 0.812 (p = 0.0001), 0.857 (p = 0.0001), and 0.870 (p = 0.0001), respectively. No statistically significant differences were found when these AUC values for different evaluated risk scores were compared. Overall, the EuroSCORE and Parsonnet risk scores had no discriminative value, as all deaths occurred in the highest risk group. Only the GRACE risk score discriminated risk among intermediate- and high-risk patients with ACS.

CONCLUSIONS

The EuroSCORE and Parsonnet scoring systems are of no value in predicting periprocedural mortality risk in patients undergoing elective PCI LM. Overall, discriminative ability of the EuroSCORE, Parsonnet, and GRACE risk scores in unselected patients with ACS undergoing emergent PCI LM was good. In this group of patients, the EuroSCORE and Parsonnet scoring systems had no discriminative value in low and moderate risk patients. Only the GRACE risk score discriminated risk among intermediate and high risk patients.

The effect of trimetazidine added to maximal anti-ischemic therapy in patients with advanced coronary artery disease

BACKGROUND

The purpose of the study was to assess the effect of trimetazidine administered for 20 days in 56 patients with ischemic heart disease treated with maximal tolerated doses of anti-ischemic drugs who were not candidates for percutaneous or surgical revascularization.

METHODS

The efficacy of trimetazidine was evaluated by comparing exercise testing parameters before and after treatment, combined with the patient response to a questionnaire administered at baseline and following the treatment. We evaluated the duration of exercise, workload, double product, time to the occurrence of ischemic changes in ECG, the number of leads with diagnostic ST segment depression, and the magnitude of ST segment depression.

RESULTS

After 20 days of trimetazidine treatment, an improvement in exercise testing parameters was seen in about 50% of patients, and the differences of the mean values were statistically significant. The patient response to the questionnaire administered following the treatment indicated a decreased frequency of anginal episodes and an increased exercise duration to the occurrence of angina in two thirds of patients, less requirement for nitrates in 40% of patients, and increased exercise tolerance in 50% of patients. In patients with subjective response to treatment, comparison of exercise testing parameters before and after treatment showed significant increase in the duration of exercise, time to ischemic changes in ECG, and the degree of ST segment depression during peak exercise. In patients with no subjective response to treatment, a statistically significant difference was seen in the double product only.

CONCLUSIONS

After 20 days of treatment with trimetazidine added to maximal anti-ischemic treatment in patients with refractory angina, an improvement in exercise testing parameters and subjective response to treatment were seen in about 40% of patients. In patients with subjective response to treatment, exercise testing parameters improved significantly compared to the baseline values.

Transcatheter closure of iatrogenic perimembranous ventricular septal defect after aortic valve and ascending aorta replacement using an Amplatzer membranous ventricular septal occluder

Iatrogenic perimembranous ventricular septal defect is a rare complication after surgical replacement of the aortic valve, and so transcatheter closure of such a defect is not a routine procedure. We report the successful closure of an iatrogenic perimembranous ventricular septal defect which occurred after the replacement of the aortic valve and ascending aorta.

[Restenosis after coronary angioplasty: pathomechanism and potential targets for therapeutic intervention. Focus on inflammation]

Percutaneous transluminal coronary angioplasty has become the most widely implemented method of heart revascularization. Despite many advances, such as application of bare metal stents, high-pressure inflation, and the recent invention of drug-eluting stents, restenosis remains the major limitation of invasive cardiology and is associated with a significant number or target lesion re-interventions. This review highlights contemporary concepts of the pathogenesis of coronary restenosis and potential targets for therapeutic intervention, with a special emphasis on the role of inflammation and distinctions in vessel re-narrowing patterns after balloon angioplasty and both bare metal and drug-eluting stenting.

One-year outcomes of left main coronary artery stenting in patients with cardiogenic shock

BACKGROUND

The high in-hospital mortality of patients with cardiogenic shock is being reduced thanks to coronary interventions. The aim of the study was to evaluate the outcomes of angioplasty and stenting in patients with cardiogenic shock caused by left main coronary artery (LMCA) disease.

METHODS

A group of 71 consecutive patients managed for LMCA disease in an emergency setting (38 patients in cardiogenic shock and 33 without shock symptoms) were followed up clinically and angiographically for one year. Periprocedural and late mortality was assessed as well as the incidence of restenosis and coronary re-interventions.

RESULTS

There were 17 deaths in the study population (23.9%). One-year survival in the subgroup with cardiogenic shock was 57.9% (22 patients) with 15 periprocedural deaths and 1 death 3 months after the procedure. Restenosis and associated target lesion revascularization were documented in 5 patients (29.4%) with and 4 patients (16.0%) without cardiogenic shock. Multivariate analysis revealed the following independent predictors of cardiogenic shock in patients undergoing emergency LMCA angioplasty: STEMI as the reason for intervention (OR 14.1; 95% CI 3.71-53.7; p < 0.0002) and a small minimal lumen diameter before the procedure (OR 0.43; 95% CI 0.2-0.93; p < 0.04). The only independent predictor of the death in patients with cardiogenic shock was a small minimal lumen diameter after the procedure (OR 0.31; 95% CI 0.1-0.99, p < 0.05).

CONCLUSIONS

High mortality was observed in the study population, especially in the subgroup with cardiogenic shock. Most deaths were periprocedural. Because of the high rate of restenosis, periodical angiographic follow-up is necessary, preferably twice in the first 6 months after stent implantation. (Cardiol J 2007; 14: 67-75).

Periprocedural soluble P- and E-selectin levels fail as predictors of clinical restenosis in patients treated with elective coronary stenting

An increasing amount of basic scientific data indicates that adhesion molecules may be involved in the pathogenesis of vessel re-narrowing in patients undergoing coronary angioplasty. Furthermore, inflammation is suggested to be a pivotal mechanism linking atherosclerosis and restenosis. The aim of this study was to assess if periprocedural evaluation of soluble P-selectin (sP-selectin) and E-selectin (sE-selectin) possesses any additive value in the restenosis prediction to C-reactive protein (CRP) measurement. One hundred and nine stable angina patients were consecutively enrolled into the prospective cohort study. All participants were treated with single vessel coronary bare metal stenting. sP-selectin, sE-selectin and CRP were measured in peripheral venous blood samples collected before and 6, 24 h and 1 month after the procedure. Clinical follow-up visits were held 7 days(*), 1(*), 3, 6(*), and 12 months ((*)with an exercise test) after stenting. Any symptoms of restenosis were verified angiographically. Clinical restenosis occurred in 18 subjects. Concentrations of sP-selectin and sE-selectin did not differ between patients with and without clinical restenosis at any measuring point. In the latter group a decrease in sP-selectin and sE-selectin levels was observed 6 h after stenting. These findings when considered in all of the investigated subjects had no impact on the subsequent incidence of restenosis. An inflammatory response assessed as an increase in CRP level with the peak values at 24 h was noted in the whole population. However, it was significantly more pronounced in the restenosis group. Application of the Cox's proportional hazard model revealed a high CRP level 24 h after stenting and the history of coronary angioplasty concerning a nontarget lesion to be the only independent predictors of clinical restenosis. To conclude, the periprocedural evaluation of sP-selectin and sE-selectin in peripheral venous blood in patients undergoing elective coronary stenting provides no prognostic information in terms of clinical restenosis prediction, and the magnitude of the systemic inflammatory response triggered by coronary angioplasty assessed as an increase in CRP level and the history of coronary angioplasty concerning nontarget stenosis remain independent predictors of lesion re-narrowing.

Percutaneous coronary angioplasty in elderly patients: Assessment of in-hospital outcomes

BACKGROUND

We aimed to assess in-hospital outcomes of percutaneous transluminal coronary angioplasty (PTCA) in elderly subjects.

METHODS

A total of 1000 consecutive patients, who had all been admitted for interventional treatment of symptomatic coronary artery disease, were retrospectively analysed.

RESULTS

Elderly patients (>/= 70 years of age) were more likely to be diabetic, hypertensive and of female gender. They more frequently were diagnosed with chronic heart failure as well as prior stroke. Significantly higher proportions of the elderly population presented with cardiogenic shock and underwent PTCA as a result of acute coronary syndromes. Multivessel coronary disease affected a large majority of senior patients. Although stenting dominated in both age groups, balloon angioplasty was relatively more frequently applied in the elderly. Coronary angioplasty in elderly patients was associated with fewer direct stenting procedures, longer exposure to X-rays and a higher volume of the contrast medium. The efficacy of intervention, assessed according to clinical and angiographic criteria, was high in both groups, although revascularisation was significantly less complete while crude in-hospital mortality higher in the elderly group. Advanced age remained an independent predictor of both increased in-hospital mortality and longer exposure to X-rays after an adjustment for the baseline characteristics in multivariable analyses.

CONCLUSIONS

Despite frequent comorbidities and more extensive coronary athersoclerosis, a high rate of procedural success was achieved in the elderly population who underwent PTCA. However, after an adjustment for the baseline characteristics advanced age was still associated with a less favourable in-hospital outcome and a higher degree of procedural complexity. (Cardiol J 2007; 14: 143-154).

Smokers versus non-smokers undergoing percutaneous transluminal coronary angioplasty: The impact of clinical and procedural characteristics on in-hospital mortality

BACKGROUND

We aimed to compare clinical and procedural characteristics of unselected smokers and non-smokers undergoing percutaneous transluminal coronary angioplasty (PTCA) and to assess their impact on in-hospital mortality.

METHODS

One thousand consecutive patients treated interventionally were retrospectively enrolled into a single academic centre registry.

RESULTS

Smokers (n = 631), in comparison to non-smokers (n = 369), were younger and less likely to be hypertensive, diabetic and female gender. History of myocardial infarction and pre-existing heart failure were also less frequent in the group of smokers. Furthermore, univariate analysis revealed more frequent presentation with acute coronary syndromes (ACS), shorter overall duration of PTCA, shorter exposure to X-rays and lower volume of contrast medium administered in smokers than in non-smokers. Conversely, non-smokers were characterized by considerably higher prevalence of multivessel disease, lower completeness of revascularization and worse final epicardial flow in primary PTCA procedures. Moreover, non-smokers experienced higher crude in-hospital mortality than smokers in the setting of unstable angina/non-ST-segment elevation myocardial infarction (0.0% vs. 6.0%, p = 0.0544) and ST-segment elevation myocardial infarction (6.0% vs. 14.0%, p < 0.02). Smoking status, when adjusted for the baseline characteristics, did not possess any predictive value in terms of in-hospital mortality and surrogates of intervention complexity.

CONCLUSIONS

A strong trend towards decreased mortality among smokers undergoing PTCA was observed when compared to non-smokers. However, the survival advantage might be fully explained by the younger age of the smokers, their more favourable clinical characteristics and less extensive coronary atherosclerosis. (Cardiol J 2007; 14: 482-492).

[NT-proBNP and echocardiography for long-term left ventricular function assessment after acute myocardial infarction treated with primary angioplasty]

At present, primary angioplasty (PTCA) is preferred reperfusion treatment for acute ST elevation myocardial infarction (STEMI). Risk stratification after STEMI includes the evaluation of left ventricular (LV) function. B-type natriuretic peptide testing emerged as a potential marker of LV function and prognosis after STEMI.

AIM

The objective was long-term echocardiographic assessment of LV systolic and diastolic function in patients with STEMI who underwent PTCA and to evaluation of the relationship between NT-proBNP plasma levels and LV function. We assessed the value of NT-proBNP in prediction of LV dysfunction after STEMI treated with PTCA.

MATERIAL AND METHODS

A series of 98 patients (pts) (75 males, 23 females age from 50.0 to 63.0, mean age 55.0), treated successfully with PTCA in acute phase of STEMI were included in this study. NT-proBNP plasma levels were assessed just before PTCA (BNP-bsl) and at 6 month follow-up (BNP-6m). Transthoracic echocardiography (TTE) was performed at discharge(dc) and at 6 months follow-up (6m). The indices of LV systolic function (LVSF) (LV ejection fraction-EF, wall motion score index-WMSI), LV diastolic function (LVDF) (peak velocity of early (E) and late (A) transmitral flow, E-wave deceleration time (DT), isovolumic relaxation time (IVRT)) and global LV function (Tei index- calculated as a sum of isovolumetric contraction time and IVRT divided by the ejection time) were estimated.

RESULTS

At 6 month echocardiographic follow-up we observed the significant improvement of LVSF (the increase of EF (p < 0.0027), the decrease of WMSI (p < 0.0005)) and the deterioration of LVDF (the decrease of E/A (p < 0015), the increase of IVRT (p < 0085)). A negative correlation between BNP-bsl and EF-6m (Rs = -0.2877, p < 0.0072) and BNP-6m and EF-6m (Rs = 0.4125, p < 0.0001) were observed. Multivariate analysis identified BNP-bsl and CPK max during acute phase of STEMI as negative and EF-dc as positive significant, independent predictors of EF-6m.

CONCLUSIONS

The significant improvement of LV systolic function and LV abnormal relaxation were observed at 6 month follow-up in patients with acute STEMI treated with primary angioplasty. Baseline NT-proBNP plasma level, CPK max plasma level during acute phase of STEMI and echocardiographic LV systolic function indices at discharge are significant and independent predictors of LV systolic function in long-term follow up. Increasing NT-proBNP plasma level at 6 month after STEMI treated with PTCA has a good performance in detecting of LV systolic function deterioration in long-term follow-up.

[Recurrent restenosis in patient with single vessel coronary artery disease]

We present a patient with a single-vessel coronary artery disease, who during 5.5 years underwent 6 coronary intervention procedures -- 3 stent implantations including one drug eluting stent -- TAXUS, 2 balloon coronary angioplasty procedures and CABG. The choice of the optimal therapeutic method in patients with single-vessel coronary artery disease is discussed.

Percutaneous coronary intervention triggers a systemic inflammatory response in patients treated for in-stent restenosis -- comparison with stable and unstable angina

OBJECTIVE AND DESIGN

It is believed that the magnitude of the systemic inflammatory response induced by percutaneous coronary intervention (PCI) impacts on the long-term outcomes in patients with stable angina (SA) and unstable angina (UA). We aimed to determine whether an inflammatory response appears in in-stent restenosis (ISR) patients undergoing balloon angioplasty and to assess its pattern and magnitude in relation to SA and UA subjects.

SUBJECTS

80 patients (59 with SA, 10 with UA, 11 with ISR) were enrolled into the prospective study.

TREATMENT

SA and UA patients undergoing single vessel coronary balloon angioplasty followed by stenting versus ISR subjects in whom only balloon angioplasty was performed.

METHODS

C-reactive protein (CRP), serum amyloid A (SAA), tumor necrosis factor alpha (TNF-alpha) and interleukin 10 (IL-10) were measured in blood samples collected before and 6, 24 h and 1 month after the procedure.

RESULTS

A comparable pattern of inflammatory response in terms of CRP and SAA concentrations in subjects undergoing PCI due to ISR and SA was discovered while in unstable patients its magnitude was substantially higher. CRP and SAA levels increased significantly in each group with the peak value at 24 h and the baseline levels remarkably correlated with the highest markers' concentrations. In contrast, preprocedural TNF-alpha concentrations were higher in ISR group when compared with SA and UA patients. Additionally, in ISR group a twofold increase in their values of borderline significance at 6 h was noted. SA and UA subjects were found to have significantly lower TNF-alpha levels at 6 and 24 h after the intervention though the marker concentrations markedly increased with peak values at 1 month. The levels of IL-10 did not differ at any time point between the groups.

CONCLUSIONS

We suggest that PCI triggers a systemic inflammatory response in patients with ISR and considerable differences in its pattern when compared with SA and UA patients were demonstrated. Moreover, a high preprocedural TNF-alpha level and its increase provoked by PCI in the ISR group warrant the need for further investigation of its possible involvement in the restenosis process.

Combined periprocedural evaluation of CRP and TNF-alpha enhances the prediction of clinical restenosis and major adverse cardiac events in patients undergoing percutaneous coronary interventions

To assess the value of serial C-reactive protein (CRP), serum amyloid A (SAA), tumor necrosis factor-alpha (TNF-alpha) and interleukin-10 (IL-10) evaluation in the risk stratification in patients undergoing percutaneous coronary intervention. The study was designed as a prospective cohort trial with a 1-year follow-up. Eighty patients (70 with stable angina, 10 with unstable angina) were enrolled. Blood samples were collected before the procedure and after 6 and 24 h, and 1 month. Clinical follow-up visits were performed (*with exercise test) 7 days* and 1*, 3, 6* and 12 months after the procedure. Any symptoms of restenosis were verified angiographically. Multivariate logistic regression analysis identified increased preprocedural TNF-alpha and CRP levels and elevated CRP concentrations evaluated 24 h after the procedure as significant predictors of both clinical restenosis and major adverse cardiac events (MACE), while high SAA values at 24 h accurately predicted clinical restenosis. Patients, who were in the highest tertile of, either, baseline TNF-alpha and/or baseline CRP/CRP at 24 h, were more prone to develop restenosis and MACE than stratified only on the basis of a single marker. Our data indicate that combined analysis of CRP and TNF-alpha might be an effective approach to the clinical restenosis and MACE prediction. Additionally, long-term outcome is markedly influenced by the periprocedural activation of inflammation.

[Cardiac revascularisation in a high-risk patient--case report]

A case of a patient with left main stem stenosis and significant stenosis in the other coronary arteries is presented. The patient was disqualified from coronary artery bypass grafting (CABG) because of many surgical risk factors and underwent successful coronary angioplasty. Three months later the patient returned to the hospital because of unstable angina. Control coronary angiography revealed in-stent restenosis. The patient underwent CABG and drug-eluting stent implantation with good clinical result.

[Acute myocardial infarction in a patient with normal coronary arteries--a case report]

A case of a 72-year-old female who was admitted for elective dual-chamber pacemaker implantation, is presented. A few hours after the procedure the patient developed chest pain with ST-segment elevation in ECG and a significant increase in the troponin I level. An acute myocardial infarction was diagnosed. Urgent coronary angiography revealed normal coronary arteries without spasm. Possible causes of acute myocardial infarction following pacemaker implantation are discussed.

Analysis of the relationship between the inner structure and the magnitude of atherosclerotic plaques

The aim of this study was ultrasound evaluation of atherosclerotic plaque morphology in relation to the degree of coronary artery lumen narrowing in patients with ischaemic heart disease. Intravascular ultrasound was performed on 38 patients (30 men and 8 women) aged 35 to 77 (average age 60 +/- 11 years old) with symptoms of ischaemic heart disease. The structure of atherosclerotic plaques with a degree of lumen narrowing of < 50% (1st group) was distinctly different from the structure of plaques with a degree of lumen narrowing of 50-75% (2nd group, p = 0.0045) and the structure of plaques with a degree of lumen narrowing of >/= 75% (3rd group, p < 0.001). The incidence of soft plaques decreased, whereas the percentage of mixed and hard plaques increased gradually with the increase in the degree of artery lumen narrowing. Significant differences in the incidence of plaque calcification were observed between the groups evaluated with crosssections of different degrees of lumen narrowing (p = 0.0032). The smallest number of calcifications was discovered in the 1st group as compared to the 2nd (p = 0.0027) and the 3rd group (p = 0.0026). With a higher degree of lumen narrowing, a lower percentage of eccentric plaques and a higher percentage of concentric plaques were observed. There were more eccentric plaques and fewer concentric plaques in cross-sections of the 1 st group as compared to the 2nd group (p = 0.0056) and the 3rd group (p = 0.0018). A comparison between the 2nd and 3rd groups showed no significant difference in the incidence of eccentric or concentric plaques (p = 0.5). In conclusion, intravascular ultrasound evaluation revealed significant relationships between the structure, presence of calcifications and location of atherosclerotic plaques and the degree of artery lumen narrowing. The incidence of mixed, hard, calcified and concentric plaques increased, whereas the percentage of soft, non-calcified and eccentric plaques decreased gradually with the increase in the degree of artery lumen narrowing.

[Remodeling of coronary arteries examined by arteries intravascular ultrasonography]

In most papers atherosclerotic remodelling was assessed in one segment of each studied artery. Such mode of study makes impossible to investigate the homogeneity of the remodelling. The aim of the study was intravital assessment by means of intravascular ultrasonography (IVUS) of the incidence of positive and negative remodelling in coronary artery segments and verification of the hypothesis that remodelling is inhomogeneous within the same artery.

METHOD

Remodelling was assessed quantitatively by IVUS (3.5 F; 20 MHz Visions Five-64 F/X catheters, Oracle In-Vision Imaging System, Endosonics Corp. USA) in 48 segments of 27 coronary arteries. On the base of the difference between total vessel area (TA) at lesion site and reference cross-section (plaque area < 35%) remodelling was classified as negative, positive or absent. In 13 arteries out of 27 studied arteries more than 1 segment was assessed, containing both cross-section with > 50% stenosis and reference cross-section.

RESULTS

Positive, negative and absent remodelling was observed in 54%, 29% and 17% of segments, respectively. The analysis revealed two different types of remodelling in 7 out of 13 arteries with several analysed segments. This finding demonstrates that remodelling is inhomogenous within the artery (p < 0.006).

CONCLUSIONS

Compensatory enlargement is the most common response of coronary arteries to atherosclerotic plaque development followed by negative remodelling and absence of remodelling. Not homogenous remodelling within the same artery suggests a prominent role of local factors in determining the type of response of the artery to plaque accumulation.