Visual-functional mismatch and results of fractional flow reserve guided percutaneous coronary revascularization

OBJECTIVE

To identify mismatches in the significance ofcoronary artery stenosis determined by physician 's visual estimation (VE) vs. quantitative coronary angiography (QCA), by VE vs. fractional flow reserve (FFR), and independent predictors for mismatch between VE and FFR. Second objective was to evaluate the clinical outcomes ofpatients receiving FFR-guided percutaneous coronary intervention (PCI).

MATERIAL AND METHOD

Two hundreds eighty consecutive patients (338 coronary lesions including non-left main (non-LM) 316 lesions and left main (LM) 22 lesions) underwent coronary angiography, offline edge detection QCA, and FFR measurement between August 2011 and December 2013 were included in the present study. Baseline patient data, lesion characteristics, and clinical outcomes were recorded and analyzed. Coronary lesions were then divided into four groups according to FFR results and treatment (FFR <0.75 and PCI, FFR 0.75-0.80 and PCI, FFR 0.75-0.80 and defer PCI, FFR >0.80 and defer PCI). Mismatches in the significance of coronary artery stenosis determined by VE vs. QCA, VE vs. FFR, independent predictors of VE-FFR mismatch, and clinical outcomes after FFR-guided treatment were reported.

RESULTS

Lesions with VE-QCA mismatch were seen in 64% of non-LM lesions and in 87% of the LM lesions. Conversely, lesions with VE-QCA reverse mismatch were seen in 13% of non-LM lesions and in 0% of the LM lesions. Lesions with VE-FFR mismatch were seen in 42% of non-LM lesions and in 53% of the LM lesions. Lesions with VE-FFR reverse mismatch were seen in 15% of non-LM lesions and in 14% of the LM lesions. The independent predictors for VE-FFR mismatch in non-LM lesions were shorter lesion and greater minimal lumen diameter. After FFR guided-treatment and dividing coronary lesions into four groups, all patients were followed-up for a median period of 11.6 (IQR; 7.3, 17.6) months. Major adverse cardiovascular events (excluded one death) of 338 lesions were not significantly different in the four groups (1.7% vs. 5.1% vs. 5.3% vs. 2.7%, p = 0.717). The median cost ofprocedure of lesions undergone FFR plus additional PCI was significantly higher than lesions undergone FFR only (140,000 vs. 137,000 vs. 45,000 vs. 45,000 Baht, p<0.001).

CONCLUSION

Mismatches between visually-estimated significance of angiographic coronary stenosis and QCA or FFR are frequently encountered. Visual estimation of coronary angiography alone cannot entirely predict functional significance of coronary stenosis. FFR measurement provides a helpful strategy for decision making before further revascularization.

Percutaneous coronary intervention in patients with anomalous origin of coronary artery

Percutaneous coronary intervention in patients with anomalous origin of right coronary artery from left sinus of Valsalva was performed in Central Chest Institute during 2005-2009. The diagnosis of this type of congenital anomaly is always difficult, since it requires high operator's consideration and experience. Standard catheter curve desired for general coronary angiography is also not suitable for the abnormal origin of artery, especially when coronary intervention is to be performed. The authors report a series of these anomalous coronary patients with atherosclerotic disease who underwent transcatheter coronary intervention using Extra Backup left coronary guiding catheters, which help cannulation of the anomalous ostium and enhance the operation success.

Immediate, short and intermediate results of transcatheter closure of secondum-type atrial septal defect using Amplatzer septal occluder devices

OBJECTIVES

To study the immediate, short, and intermediate results of transcatheter closure of secondum-type atrial septal defect using Amplatzer septal occluder devices (TCAA) in terms of clinical symptoms and residual lesions and shunts determined by transthoracic two-dimensional (TTE) and three-dimensional echocardiography (TDE).

MATERIAL AND METHOD

Thirty-six patients, who underwent successful TCAA at the Chest Disease Institute between August 2002 and August 2007 and were followed up clinically, by TTE and TDE at day 1-3, 4-6 months, and 1-year post TCAA, were analyzed.

RESULTS

TCAA was performed in 75 patients during the study period. Of these, 36 patients were completely followed-up. There were 92% female with a mean age of 40 +/- 16 yrs (range 19 to 65) and the mean of maximal size of ASD secondum determined by TTE, transesophageal echocardiography (TTE) and balloon sizing or balloon stretched diameter (BSD)was 18.9 +/- 4.7 mm (range 10-30), 22.6 +/- 5.3 mm (rang 10-32), and 24.3 +/- 5.3 mm (range 12-34) respectively. The size of ASOD was 26.4 +/- 4.9 mm (range 12-34). Fluoroscopic time was 16.4 +/- 7.1 min (range 6.7-35.6). The success rate of TCAA was 84%. No major complications and deaths were found. All of those with successful TCAA apparently improved their functional class. All of them showed complete ASD closure and yet 12 (31%) had Qp/Qs > or = 1.5 at year one.

CONCLUSION

TCAA is safe and effective and had resulted in clinical improvement, complete closure of secondum ASD, and good immediate, short, and intermediate outcomes with fewer complications.

Feasibility and effectiveness of a novel vascular hemostatic device (Chula-clamp) after coronary angiography or percutaneous coronary intervention

BACKGROUND

Chula-clamp is a newly hydraulic vascular hemostatic device. The advantages of the device are convenience, reusability, and lessen patient discomfort and vascular complication. Furthermore, the device is assembled with a recycled balloon inflator and other locally made components, which make it less expensive than other commercially available hemostatic devices. The present study was conducted to compare the effectiveness of Chula-clamp with standard manual compression.

MATERIAL AND METHOD

This is a prospective, quasi-randomized controlled clinical trial comparing effectiveness of Chula-clamp to conventional manual compression for attaining femoral artery hemostasis after coronary angiography (CAG) or percutaneous coronary intervention (PCI). Effectiveness was determined by femoral vascular complications rate. The primary endpoint was severe femoral vascular complications (the formation of a groin hematoma, femoral artery thrombosis, pseudoaneurysm, and arteriovenous fistula).

RESULTS

One hundred and forty patients scheduled for percutaneous coronary intervention or coronary angiogram in King Chulalongkorn Memorial hospital were enrolled (70 patients for each group). The baseline characteristics were similar in both groups. There was no serious vascular complication detected in either group. In addition, there was no statistical difference in minor complications at the access site between the two groups. [e.g., swelling (1.4% in standard manual compression group vs. 2.9% in Chula-clamp, p = 0.56) and ecchymosis (8.57% in both groups)].

CONCLUSION

Chula-clamp, a novel hydraulic vascular hemostatic device, is feasible, safe, and effective for femoral artery hemostasis (after CA G or PCI via femoral artery). Its effectiveness is not different from standard manual compression.