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ABSTRACT: There is no widely accepted classification to guide therapy in patients with symptomatic myocardial bridging (MB).
A retrospective analysis of 157 patients with chest pain, angiographic MB of the left anterior descending artery without obstructive coronary artery disease (CAD) was performed. Patients were evaluated for clinical symptoms, objective signs of ischemia by stress test, intracoronary Doppler flow measurement and coronary flow reserve. 100 patients without CAD or MB served as controls.
There was no difference in clinical symptoms and objective signs of ischemia between controls and patients with MB. The length of MB was 22.6 +/- 7.8 mm, maximal systolic luminal diameter reduction 71 +/- 16%, and maximal mid-diastolic luminal reduction 34.7 +/- 13% as demonstrated by quantitative coronary angiography (QCA). Intracoronary Doppler showed significantly increased average peak flow velocity (APV), average systolic peak velocity (ASPV), average diastolic peak flow velocity (ADPV), and maximal peak velocity (MPV) in MB versus proximal and distal segments at rest and after maximal vasodilatation (p < 0.001 for all parameters). Coronary flow reserve was significantly higher proximally (2.9 +/- 0.9) compared with segments distal to the MB (2.0 +/- 0.6, p < 0.01). We propose a new MB classification for symptomatic patients with MB:Type A:incidental finding on angiography, no objective signs of ischemia; Type B: objective signs of ischemia, and Type C: with or without objective signs of ischemia and altered intracoronary hemodynamics (by QCA/CFR/intracoronary Doppler). 5-Year follow-up data based on this classification showed that types B and C responded well to beta-blockers or calcium channel antagonists. Patients with type C refractory to medical therapy were treated with stenting of the MB.
Patients with MB without CAD did not have a higher prevalence of chest pain or abnormal non-invasive stress tests compared to patients without CAD or MB. Intracoronary hemodynamic measurement is a novel approach that may be valuable in defining the functional significance of MB. We propose a classification of symptomatic patients with MB without CAD using non-invasive and invasive parameters to guide therapeutic choices.
Cardiology 07/2008; 112(1):13-21. · 1.71 Impact Factor
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Peter W Radke,
Hans R Figulla,
Helmut Drexler, Heinrich G Klues,
Andreas Mügge,
Sigmund Silber,
Werner Daniel,
Alexander Schmeisser,
Nicolaus Reifart,
Wolfgang Motz,
Hans-Joachim Büttner,
Dieter Fischer,
Jan R Ortlepp,
Kerstin Schaefers,
Rainer Hoffmann,
Peter Hanrath
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ABSTRACT: Preclinical data suggest beneficial effects of angiotensin II receptor blockers (ARBs) on neointima formation after vascular injury. Preliminary clinical data, however, revealed conflicting results. The AACHEN trial was a double-blind, randomized, placebo-controlled clinical multicenter trial to evaluate the effects of candesartan cilexetil on intimal hyperplasia after coronary stent implantation.
A total of 120 patients (61 +/- 9 years, 83% male) were randomized to receive either 32 mg candesartan cilexetil (active) or placebo starting 7 to 14 days before elective coronary stent implantation. A follow-up angiography including intravascular ultrasound assessment of the target lesion was performed 24 +/- 2 weeks after stent implantation. The primary end point was defined as the difference in neointimal area between groups as assessed by intravascular ultrasound. Secondary end points included differences in angiographic parameters (ie, restenosis rate) and incidence of major cardiac events.
The mean stent length measured 15.0 +/- 4.9 mm in the active and 14.6 +/- 5.7 mm in the placebo group (P = .81). There was no significant difference in neointimal area between groups (2.1 +/- 1.0 vs 2.1 +/- 1.5 mm2, P = 1.00), nor were there differences in angiographic end point parameters. Major cardiac event rates were not significantly different between treatment groups (8% vs 11%, P = .75).
High-dose candesartan cilexetil therapy in patients with symptomatic coronary artery disease undergoing coronary stent implantation does not reduce clinical event rates, restenosis rates, or neointimal proliferation after elective stent implantation.
American heart journal 11/2006; 152(4):761.e1-6. · 4.65 Impact Factor
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Medizinische Klinik 07/2004; 99(6):332-3. · 0.34 Impact Factor
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Philipp K Haager,
François Schiele,
Heinz J Buettner,
Eulogio Garcia,
Marc Bedossa,
Harald Mudra,
Ulrich Dietz,
Carlo di Mario,
Thorsten Reineke,
Birger Horn,
Rainer Hoffmann,
Peter W Radke, Heinrich G Klues,
Juergen vom Dahl
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ABSTRACT: The ARTIST trial demonstrated a worse outcome for patients with in-stent restenosis (ISR) treated with rotational atherectomy (RA) and adjunctive balloon angioplasty (PTCA) as compared to PTCA alone. This intravascular ultrasound (IVUS) substudy compares effects of lumen enlargement and examines reasons for failure of RA in this setting. IVUS (n = 56) was performed after each interventional step and at follow-up. Volumetric lumen gain measured 79 +/- 68 mm(3) after PTCA (13 +/- 4 atm) as compared to 44 +/- 26 mm(3) after RA and adjunctive PTCA (7 +/- 3 atm; P < 0.0001). RA itself enlarged lumen by only 19 +/- 17 mm(3) and stent volume was 47% smaller as compared to high-pressure PTCA. Low-pressure strategy after RA did not prevent tissue growth during follow-up (19 +/- 25 vs. 36 +/- 38 mm(3); RA vs. PTCA; P = 0.09). Consequently, net lumen gain after PTCA was 82% higher compared to RA (46 +/- 54 vs. 25 +/- 24 mm(3); P = 0.09). Further stent expansion is the key mechanism to achieve luminal gain by PTCA of ISR. Neointimal ablation by RA has only minor effects. Low-pressure PTCA does not prevent recurrent tissue growth and failed for treatment of ISR due to insufficient stent expansion.
Catheterization and Cardiovascular Interventions 09/2003; 60(1):25-31. · 2.29 Impact Factor
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ABSTRACT: Summary. Hypertrophic cardiomyopathy (HCM) is a relatively common disease of the cardiac sarcomere with broad heterogeneity in terms of the disease-causing gene mutation, phenotypic expression, therapy and prognosis. Besides the standard drug treatment, there are several therapeutic options available for severe refractory symptomatic HCM with obstruction. Dual-chamber pacing and transcoronary ablation of septal hypertrophy (TASH) have recently emerged as alternatives to myectomy. However, myectomy remains the current gold standard of therapy for HCM until the promising initial follow-up data for TASH can be transferred into a long-term follow-up period, or prospective randomized comparative trials between these therapies are available. However, even now, TASH represents an important therapeutic alternative in patients with relevant co-morbidities and a high operative risk. Despite significant gradient reduction and amelioration of clinical symptoms, none of these treatment strategies has a proven influence on the natural history of HCM. Hence, regarding the long-term prognosis of the disease, risk stratification of sudden cardiac death using non-invasive risk assessment has become of paramount importance, while genotyping might become the determinant and stratifying marker in the near future. At present, according to secondary prevention, treatment with an implanted cardioverter-defibrillator - amiodarone therapy is mandatory, while according to primary prevention treatment should particularly depend on the individual risk profile. Zusammenfassung. Die hypertrophe Kardiomyopathie (HCM) ist eine relativ hufige genetisch bedingte Erkrankung des kardialen Sarkomers mit einer ausgeprgten Heterogenitt in Bezug auf die urschliche Genmutation, die phnotypische Expression, die Therapie und die Prognose. Neben der medikamentsen Basistherapie stehen vor allem fr die obstruktive Variante der HCM mehrere Therapieoptionen zur Verfgung. Die Zweikammerschrittmachertherapie mit einem DDD-System und die transkoronare Ablation der Septumhypertrophie (TASH) haben sich zuletzt zu therapeutischen Alternativen entwickelt. Dennoch muss die operative Myektomie derzeit weiterhin als der therapeutische Goldstandard angesehen werden, zumindest solange bis die erfolgversprechenden initialen Follow-up-Daten der TASH-Behandlung in Langzeitnachuntersuchungen besttigt werden knnen, oder randomisierte prospektive Vergleichsstudien zu den Therapien vorliegen. Bei Patienten mit relevanten Ko-Morbiditten und einem dementsprechend hohen operativen Risiko stellt TASH aber bereits jetzt die bevorzugte therapeutische Alternative dar. Obwohl alle hier beschriebenen Therapiestrategien die Obstruktion reduzieren und die Symptomatik lindern, teilweise sogar eine komplette Beschwerdefreiheit erzielen, hat keine dieser Behandlungsformen einen bislang nachgewiesenen Effekt auf den natrlichen Verlauf der HCM. Daher hat die Risikostratifizierung des pltzlichen Herztodes, vor allem in Bezug auf die Langzeitprognose der Erkrankung, eine wesentliche Bedeutung erlangt. Neben den nicht-invasiven Verfahren werden in Zukunft vor allem die Mglichkeiten der Genotypisierung bei der Entscheidungsfindung einer prophylaktischen Therapie zunehmend an Bedeutung gewinnen. Zum jetzigen Zeitpunkt muss die Therapie mit einem implantierten Cardioverter-Defibrillator - Amiodaron im Rahmen der Sekundrprvention als verpflichtend und im Rahmen der Primrprvention in Abhngigkeit vom Risikoprofil beurteilt werden.
Zeitschrift für Kardiologie 03/2003; 92(4):283-293. · 0.97 Impact Factor
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ABSTRACT: Patients with diffuse in-stent restenoses (ISRs) are at high risk for recurrent restenosis after percutaneous transluminal balloon angioplasty (PTCA). Percutaneous transluminal rotational ablation (PTCR) has proved effective in removing neointimal burden in ISRs. This study compares the acute and long-term results of PTCA and PTCR for the treatment of diffuse ISR in a randomized, multicenter investigation. The primary end point was the comparison of the minimum luminal diameter (MLD) between both groups at 6-month follow-up. Patients with symptomatic, diffuse, or high-grade ISRs were included; 146 patients were randomized to PTCA and 152 patients to PTCR. Diameter stenosis was reduced from 80 +/- 12% to 29 +/- 10% and from 80 +/- 11% to 28 +/- 12%, respectively, and MLD increased from 0.55 +/- 0.3 to 1.9 +/- 0.3 mm in the PTCA group and from 0.54 +/- 0.3 mm to 1.9 +/- 0.4 mm in the PTCR group. Spasm in the treated vessel and an intermittent slow flow phenomenon occurred more often after rotational ablation (17.7% vs 8.6%, p = 0.001; 5.3% vs 0%, p = 0.007). Minimum stenosis diameter at 6-month follow-up was smaller in the PTCR group than in the PTCA group (1.0 +/- 0.6 vs 1.2 +/- 0.6 mm, p = 0.008) and the restenosis rate was higher (64.9% vs 51.2%, p = 0.027). Procedural factors did not influence long-term outcome. In the PTCR group, the restenosis rate increased with decreasing vessel size, whereas this was not seen in the PTCA group. The lesion length and the baseline diameter stenosis were found to be predictive of restenosis with both treatment strategies; however, a residual diameter stenosis of <30% predicted absence of a restenosis only in the PTCR group. Thus, PTCA and PTCR of diffuse ISRs yield comparable acute angiographic results. The recurrence of a restenosis is higher after PTCR than after PTCA.
The American Journal of Cardiology 10/2002; 90(8):843-7. · 3.37 Impact Factor
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Jürgen vom Dahl,
Philipp K Haager,
Eberhard Grube,
Michael Gross,
Christian Beythien,
Eckhard P Kromer,
Norbert Cattelaens,
Christian W Hamm,
Rainer Hoffmann,
Thorsten Reineke, Heinrich G Klues
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ABSTRACT: Experimental studies suggest a reduced neointimal tissue proliferation in vascular stainless steel stents coated with gold. This prospective multicenter trial evaluated the impact of gold coating on neointimal tissue proliferation in patients undergoing elective stent implantation. The primary end point was the in-stent tissue proliferation measured by intravascular ultrasound at 6 months comparing stents of identical design with or without gold coating (Inflow). Two hundred four patients were randomized to receive uncoated (group A, n = 101) or coated (group B, n = 103) stents. Baseline parameters did not differ between the groups. Stent length and balloon size were comparable, whereas inflation pressure was slightly higher in group A (14 +/- 3 vs 13 +/- 3 atm, p = 0.013). Procedural success was similar (A, 97%; B, 96%). The acute angiographic result was better for group B (remaining stenosis 4 +/- 12% vs 10 +/- 11%, p = 0.002). Six-month examinations revealed more neointimal proliferation in group B. By ultrasound, the neointimal volume within the stent was 47 +/- 25 versus 41 +/- 23 mm(3) (p = 0.04), with a ratio of neointimal volume-to-stent volume of 0.45 +/- 0.12 versus 0.40 +/- 0.12 (p = 0.003). The angiographic minimal luminal diameter was smaller in group B (1.47 +/- 0.57 vs 1.69 +/- 0.70 mm, p = 0.04), with a higher late luminal loss of 1.17 +/- 0.51 versus 0.82 +/- 0.56 mm (p = 0.001). Thus, gold coating of the tested stent type resulted in more neointimal tissue proliferation.
The American Journal of Cardiology 05/2002; 89(7):801-5. · 3.37 Impact Factor
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Juergen vom Dahl,
Ulrich Dietz,
Philipp K Haager,
Sigmund Silber,
Luigi Niccoli,
Hans Juergen Buettner,
Francois Schiele,
Martyn Thomas,
Philippe Commeau,
David R Ramsdale,
Eulogio Garcia,
Christian W Hamm,
Rainer Hoffmann,
Thorsten Reineke, Heinrich G Klues
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ABSTRACT: Aim of this trial was to compare rotational atherectomy followed by balloon angioplasty (rotablation [ROTA] group) with balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA] group) alone in patients with diffuse in-stent restenosis.
The ARTIST study is a multicenter, randomized, prospective European trial with 298 patients with in-stent restenosis>70% (mean lesion length, 14 +/- 8 mm) in stents, implanted in coronary arteries for >/= 3 months. In the PTCA group, angioplasty was performed at the discretion of the local investigator, and rotablation was performed by using a stepped-burr approach followed by adjunctive PTCA with low (</= 6 atm) inflation pressure. Intravascular ultrasound during the intervention and at follow-up was used in a substudy in 86 patients (45 PTCA, 41 ROTA). Angiography demonstrated no difference regarding the short-term outcome, with equivalent procedural success rates defined as remaining stenosis <30% (89% PTCA, 88% ROTA). However, the results showed that, in the long term, PTCA was a significantly better strategy than ROTA. Mean net gain in minimal lumen diameter was 0.67 mm and 0.45 mm for PTCA and ROTA, respectively (P=0.0019). Mean gain in diameter stenosis was 25% and 17% (P=0.002), resulting in restenosis (>/= 50%) rates of 51% (PTCA) and 65% (ROTA) (P=0.039). By intravascular ultrasound, the major difference was the missing stent over-expansion during PTCA after ROTA. Six-month event-free survival was significantly higher after PTCA (91.3%) compared with ROTA (79.6%, P=0.0052).
In terms of the primary objective of the study, PTCA produced a significantly better long-term outcome than ROTA followed by adjunctive low-pressure PTCA.
Circulation 02/2002; 105(5):583-8. · 14.74 Impact Factor
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ABSTRACT: □ HintergrundDie Stent-Restenose hat sich zu einem relevanten Problem in der interventionellen Kardiologie entwickelt. Aufgrund pathogenetischer
Unterschiede ist unklar, ob ein einheitliches Schema zur Therapie dieser Erkrankung sinnvoll erscheint.
□ TherapieIn den meisten Fällen wird die Stent-Restenose mit einer erneuten Ballondilatation therapiert, doch weist diese Methode äußerst
ungünstige Langzeitergebnisse bei diffusen und langstreckigen Läsionen auf. Daher erscheinen gewebeabladierende Verfahren
bei komplexen Stent-Restenosen vorteilhaft. Der Stellenwert der intrakoronaren Strahlentherapie sowie der lokalen Medikamentenapplikation
oder des lokalen Gentransfers ist trotz des großen Potentials derzeit unklar.
□ PräventionDer Prävention der „iatrogenen” Erkrankung Stent-Restenose durch eine sorgfältige Indikationsstellung und Therapieplanung
kommt somit besondere Bedeutung zu.
□ BackgroundIn-stent restenosis has become a significant problem for interventional cardiologists. Due to different pathogenic causes
it remains unclear whether a uniform therapeutic regimen is appropriate.
□ TreatmentRedilatation has predominantly been used for the treatment of instent restenosis, however, in long and diffuse restenotic
stents, long-term results are reported to be poor. Therefore, tissue-debulking techniques may have beneficial effects in complex
cases of in-stent restenosis. The therapeutic benefit of intracoronary radiation, local drug delivery or gene transfer has
not been evaluated so far.
□ PreventionTherefore, prevention of the iatrogenic entity in-stent restenosis has become more important.
04/1999; 94(2):88-92.
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ABSTRACT: Anomalous origin of the right coronary artery from the main pulmonary artery is a rare congenital cardiac malformation. Most patients remain asymptomatic. However, there are cases of sudden cardiac death described in the literature, indicating a potentially malign course of the disease. To establish a double-ostium coronary system, correction of the aberrant vessel is recommended. Despite surgical reconstitution of normal coronary anatomy, the postoperative clinical presentation of some patients does not improve substantially, raising the question of the functional outcome of reinserted coronary vessels. This report of a patient with anomalous origin of the right coronary artery from the pulmonary trunk, in whom a complete hemodynamic assessment including intracoronary Doppler flow measurements was performed before and after reimplantation, very strongly supports the concept of an anatomically corrective operation.
The Annals of Thoracic Surgery 11/1998; · 3.74 Impact Factor
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ABSTRACT: Rotational atherectomy (rotablation) frequently results in transient myocardial hypoperfusion due to peripheral vessel obstruction. This study compares the incidence, extent, and severity of perfusion defects induced by rotablation of de novo coronary lesions with rotablation of in-stent restenosis.
Twenty-five patients undergoing rotablation for restenosed stents (group A) were studied by technetium 99m sestamibi single photon emission computed scintigraphy at rest before rotablation, during rotablation, and 2 days after the procedure. For semiquantitative analysis, perfusion in 24 left ventricular regions was expressed as percentage of maximal sestamibi uptake. The results were compared with those of 25 patients treated for de novo coronary lesions (group B). Transient perfusion defects were observed in 22 (88%) of 25 patients in group A and, similarly, in 23 (92%) of 25 in group B. Perfusion was significantly reduced during rotablation in 3.1 +/- 2.6 (mean +/- SD) regions in group A and in 3.3 +/- 2.5 regions in group B. Perfusion in the region with maximal reduction during rotablation in groups A and B was 77% +/- 13% and 76% +/- 15% at baseline. Technetium uptake decreased to 59% +/- 19% and 54% +/- 14% during rotablation (P <.001 vs baseline, P = not significant for A vs B) and returned to 76% +/- 16% and 76% +/- 15% after rotablation. Intravascular ultrasonography indicated no correlation between the volume of ablated plaque and the extent and severity of perfusion defects in in-stent restenosis.
Incidence, extent, and severity of rotablation-related transient hypoperfusion are influenced by neither the type nor the quantity of ablated plaque material. Thus embolization of ablated plaque may be less important compared with other factors such as microcavitation or platelet aggregation.
Journal of Nuclear Cardiology 9(3):304-11. · 2.67 Impact Factor
