Bei einem älteren Patienten mit hochgradigen Stenosen des Ramus interventricularis anterior (RIVA... more Bei einem älteren Patienten mit hochgradigen Stenosen des Ramus interventricularis anterior (RIVA) und des Ramus circumflexus trat während der Koronarangiographie eine Hauptstammdissektion auf. Die Läsionen sowohl des Hauptstammes als auch des RIVA konnten in der gleichen Sitzung mittels Katheterintervention (Stenting) versorgt werden. Der Patient blieb beschwerdefrei, eine Kontrollangiographie nach 6 Monaten wies ein weiterhin gutes Interventionsergebnis an beiden Gefäßabschnitten auf. Die katheterinduzierte Hauptstammdissektion als seltene aber mit einem sehr hohen Risiko behaftete Komplikation der elektiven Koronarangiographie war hier durch eine konsekutive Katheterintervention beherrschbar. Der vorliegende Fall bietet Gelegenheit zu einer Literaturübersicht über Hauptstammdissektionen als Folge der invasiven Koronardiagnostik und deren Behandlung. An elderly gentleman had a dissection of the left main coronary artery (LMCA) during coronary angiography. There were critical lesions in the left anterior descending (LAD) and left circumflex arteries. Both the LMCA and the LAD lesions were successfully stented in the same sitting. Thereafter the patient remained symptom free and the six-month follow-up angiogram revealed good angioplasty results in both lesions. We report this case for two reasons – first, acute dissection of the LMCA is a rare but devastating complication of selective coronary angiography and the situation becomes graver if the branch vessels have critical stenosis; that this could be managed percutaneously needs to be highlighted, and second, the case offers an opportunity to review literature pertinent to this awesome occurrence in the catheterization laboratory.
Background: Reopening of the infarct-related coronary artery is the treatment of choice in the cl... more Background: Reopening of the infarct-related coronary artery is the treatment of choice in the clinical setting of acute myocardial infarction. Nevertheless the removal of the total occlusion obtained either by thrombolysis or by primary angioplasty is followed by the ischemia/reperfusion sequelae. One of many proposed mechanisms playing a role in ischemia/reperfusion damage is a persistent increase in vasoconstrictor tone, which reduces cardiac function and impairs myocardial blood flow during primary percutaneous coronary intervention in acute myocardial infarction (PAMI). Methods: To investigate early neurohumoral changes during PAMI we enrolled 18 patients, who were collated to 13 patients with stable angina undergoing elective PTCA. To evaluate angiotensin II (AngII), endothelin-1 (ET-1), vasopressin (AVP), norepinephrine (NE), troponin T (TNT), creatinephosphate kinase (CPKM) and isoenzyme MB (CPKMB), we collected blood from the pulmonary artery before and immediately after the infarct-related artery (IRA; TIMI 0 → 2–3) or culprit lesion revascularization. Hemodynamic and angiographic LV-function parameters were compared to biochemical data. Corrected TIMI-frame count (CTFC) was used as an index of coronary blood flow and correlated to the biochemical measurements. Results: CTFC in the IRA correlated inversely (p = 0.03; r = −0.51) with left ventricular ejection fraction measured after 10 days, and positively (p = 0.03; r = 0.54) with the maximal amount of LDH released after onset of AMI. There was an abrupt and long lasting rise in ET-1 (+65 %; p < 0.001) and an instant short lasting increase in AVP (+37 %; p < 0.05), whereas NE concentrations were elevated prior to PAMI and remained elevated during reperfusion. Correlations with CTFC were found for ET-1 (p = 0.01; r = 0.61) and NE (p = 0.01; r = 0.58) during reperfusion. The extent of left ventricular dysfunction correlated with the concentrations of AVP and NE during reperfusion. Conclusions: There is evidence for a distinct pattern of neurohumoral activation during early reperfusion in acute myocardial infarction. In particular, we documented substantial increases in AVP and ET-1. Left ventricular wall-stress appears to be involved in the release of AVP. Elevated levels of ET-1 and NE are associated with impaired angiographic reperfusion and increased myocardial damage after mechanical recanalization.
Treatment of coronary bifurcation lesions (CBL) remains challenging. This study sought to evaluat... more Treatment of coronary bifurcation lesions (CBL) remains challenging. This study sought to evaluate a novel dedicated stent system (Frontier™ stent) by angiographic and clinical comparison with the provisional T-stenting technique using drug-eluting (DES) and bare metal stents (BMS). The study group comprised 105 CBL in 105 patients. 35 consecutive CBL were treated with the Frontier™ system. The control group of 70 CBL (35 DES, 35 BMS) was pair matched with the former group stratified by the type of CBL (Medina classification) and the reference diameter of the main branch (MB). Clinical, procedural, and quantitative angiographic data (QCA) were obtained in all patients. A follow-up angiography 6 ± 2-month post-index intervention was performed in 84/105 (80%) patients, clinical 6-month follow-up was available in all patients (100%). All Frontier™ stent procedures were clinically and angiographically successful. Post-procedural QCA analysis of the MB and the side branches revealed comparable minimal lumen diameters (MLDs) between groups. Moreover, contrast use and radiation exposure were not different between groups. DES use, however, was associated with a significantly lower late lumen (LL) loss in the main and the side branch as compared to the Frontier™ stent and BMS group. Likewise, MACE rates were lowest in the DES group (6%, P < 0.05 vs. BMS) as compared to the Frontier™ stent (9%) and the BMS group (16%). The Frontier™ stent accomplishes treatment of CBL with excellent acute clinical, procedural, and angiographic results. Provisional T-stenting using DES provides superior clinical and angiographic long-term results as compared to BMS and Frontier™ stents. The results of next generation CBL systems combining a dedicated specific CBL design with DES surfaces are to be awaited.
Bei einem älteren Patienten mit hochgradigen Stenosen des Ramus interventricularis anterior (RIVA... more Bei einem älteren Patienten mit hochgradigen Stenosen des Ramus interventricularis anterior (RIVA) und des Ramus circumflexus trat während der Koronarangiographie eine Hauptstammdissektion auf. Die Läsionen sowohl des Hauptstammes als auch des RIVA konnten in der gleichen Sitzung mittels Katheterintervention (Stenting) versorgt werden. Der Patient blieb beschwerdefrei, eine Kontrollangiographie nach 6 Monaten wies ein weiterhin gutes Interventionsergebnis an beiden Gefäßabschnitten auf. Die katheterinduzierte Hauptstammdissektion als seltene aber mit einem sehr hohen Risiko behaftete Komplikation der elektiven Koronarangiographie war hier durch eine konsekutive Katheterintervention beherrschbar. Der vorliegende Fall bietet Gelegenheit zu einer Literaturübersicht über Hauptstammdissektionen als Folge der invasiven Koronardiagnostik und deren Behandlung. An elderly gentleman had a dissection of the left main coronary artery (LMCA) during coronary angiography. There were critical lesions in the left anterior descending (LAD) and left circumflex arteries. Both the LMCA and the LAD lesions were successfully stented in the same sitting. Thereafter the patient remained symptom free and the six-month follow-up angiogram revealed good angioplasty results in both lesions. We report this case for two reasons – first, acute dissection of the LMCA is a rare but devastating complication of selective coronary angiography and the situation becomes graver if the branch vessels have critical stenosis; that this could be managed percutaneously needs to be highlighted, and second, the case offers an opportunity to review literature pertinent to this awesome occurrence in the catheterization laboratory.
Background: Reopening of the infarct-related coronary artery is the treatment of choice in the cl... more Background: Reopening of the infarct-related coronary artery is the treatment of choice in the clinical setting of acute myocardial infarction. Nevertheless the removal of the total occlusion obtained either by thrombolysis or by primary angioplasty is followed by the ischemia/reperfusion sequelae. One of many proposed mechanisms playing a role in ischemia/reperfusion damage is a persistent increase in vasoconstrictor tone, which reduces cardiac function and impairs myocardial blood flow during primary percutaneous coronary intervention in acute myocardial infarction (PAMI). Methods: To investigate early neurohumoral changes during PAMI we enrolled 18 patients, who were collated to 13 patients with stable angina undergoing elective PTCA. To evaluate angiotensin II (AngII), endothelin-1 (ET-1), vasopressin (AVP), norepinephrine (NE), troponin T (TNT), creatinephosphate kinase (CPKM) and isoenzyme MB (CPKMB), we collected blood from the pulmonary artery before and immediately after the infarct-related artery (IRA; TIMI 0 → 2–3) or culprit lesion revascularization. Hemodynamic and angiographic LV-function parameters were compared to biochemical data. Corrected TIMI-frame count (CTFC) was used as an index of coronary blood flow and correlated to the biochemical measurements. Results: CTFC in the IRA correlated inversely (p = 0.03; r = −0.51) with left ventricular ejection fraction measured after 10 days, and positively (p = 0.03; r = 0.54) with the maximal amount of LDH released after onset of AMI. There was an abrupt and long lasting rise in ET-1 (+65 %; p < 0.001) and an instant short lasting increase in AVP (+37 %; p < 0.05), whereas NE concentrations were elevated prior to PAMI and remained elevated during reperfusion. Correlations with CTFC were found for ET-1 (p = 0.01; r = 0.61) and NE (p = 0.01; r = 0.58) during reperfusion. The extent of left ventricular dysfunction correlated with the concentrations of AVP and NE during reperfusion. Conclusions: There is evidence for a distinct pattern of neurohumoral activation during early reperfusion in acute myocardial infarction. In particular, we documented substantial increases in AVP and ET-1. Left ventricular wall-stress appears to be involved in the release of AVP. Elevated levels of ET-1 and NE are associated with impaired angiographic reperfusion and increased myocardial damage after mechanical recanalization.
Treatment of coronary bifurcation lesions (CBL) remains challenging. This study sought to evaluat... more Treatment of coronary bifurcation lesions (CBL) remains challenging. This study sought to evaluate a novel dedicated stent system (Frontier™ stent) by angiographic and clinical comparison with the provisional T-stenting technique using drug-eluting (DES) and bare metal stents (BMS). The study group comprised 105 CBL in 105 patients. 35 consecutive CBL were treated with the Frontier™ system. The control group of 70 CBL (35 DES, 35 BMS) was pair matched with the former group stratified by the type of CBL (Medina classification) and the reference diameter of the main branch (MB). Clinical, procedural, and quantitative angiographic data (QCA) were obtained in all patients. A follow-up angiography 6 ± 2-month post-index intervention was performed in 84/105 (80%) patients, clinical 6-month follow-up was available in all patients (100%). All Frontier™ stent procedures were clinically and angiographically successful. Post-procedural QCA analysis of the MB and the side branches revealed comparable minimal lumen diameters (MLDs) between groups. Moreover, contrast use and radiation exposure were not different between groups. DES use, however, was associated with a significantly lower late lumen (LL) loss in the main and the side branch as compared to the Frontier™ stent and BMS group. Likewise, MACE rates were lowest in the DES group (6%, P < 0.05 vs. BMS) as compared to the Frontier™ stent (9%) and the BMS group (16%). The Frontier™ stent accomplishes treatment of CBL with excellent acute clinical, procedural, and angiographic results. Provisional T-stenting using DES provides superior clinical and angiographic long-term results as compared to BMS and Frontier™ stents. The results of next generation CBL systems combining a dedicated specific CBL design with DES surfaces are to be awaited.
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Papers by Deepak Jain