S Thackray

Hull and East Yorkshire Hospitals NHS Trust, Kingston upon Hull, England, United Kingdom

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Publications (52)148.94 Total impact

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    ABSTRACT: Fractional flow reserve (FFR) guided angioplasty has been shown to have a beneficial effect on clinical outcome in patients with multi-vessel coronary disease. However, multi-vessel disease is frequently accompanied by a chronic total occlusion (CTO). We have limited understanding of the effect of the donation of a collateral supply to collateral dependent myocardium on the FFR. Marked changes in non-target vessel FFR post recanalisation of CTOs have been reported, but the consistency of this phenomenon remains uncertain and changes in haemodynamic indices immediately post-angioplasty might be confounded by the effect of the vessel trauma of angioplasty on the microvasculature. If the phenomenon is consistent, we might expect haemodynamics in a vessel donating collaterals to a CTO to be dependent on the extent of angiographic collateral flow originating from it.
    Heart (British Cardiac Society) 06/2014; 100(Suppl 3):A42. · 5.01 Impact Factor
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    ABSTRACT: Aims: Marked changes in non-target vessel FFR post recanalisation of chronic total coronary occlusions have been reported, but the consistency of the phenomenon remains uncertain, if a large change in FFR were universal we might expect an association between non-target vessel haemodynamics and extent of collateral donation of the non-target vessels. We sought to compare microvascular resistance and coronary flow between each non-target vessel prior to PCI of a chronic total coronary occlusion. Methods and results: Prior to angioplasty of a chronic total coronary occlusion in 22 patients, simultaneous pressure and flow were measured at rest and during hyperaemia in the distal and proximal segment of each non-target vessel. Absolute coronary flow, coronary flow reserve, hyperaemic microvascular resistance and fractional flow reserve were calculated. Blinded to haemodynamic measurements, the predominant (or major) collateral donor vessel was selected and each vessel was graded by the size of the largest collateral branch which originated from it by collateral connection (CC) grade (0=no continuous connection, 1=threadlike connection, 2=side branch like connection). Haemodynamic measurements were compared between the major and minor collateral donor vessels. Continuous data is expressed as mean (standard deviation), mean differences are expressed as mean (confidence interval of the difference). Comparisons between groups were made using a paired t-test. All patients had right dominant coronary anatomy. The target vessel was the left anterior descending artery in 9 patients, circumflex artery in 2 and right coronary artery in 11. All target vessels were filled by a modified Rentrop grade of >2 (2 n=12, 3 n=10). Collateral connection grade for the major and minor collateral donor vessel were as follows: major: 2=11, 1=11, 0=0; minor 2=3, 1=8, 0=11. The Mean Duke Jeopardy Scores for the entirety of each non-target vessel were not significantly different between groups (major=3.27 (1.91), minor=4.09 (1.44)). Mean diameter stenosis and fractional flow reserve did not differ significantly between groups. There was no significant difference in any of the measured haemodynamic indices between groups: hyperaemic microvascular resistance (mmHg/cm/s): major=2.01 (0.95), minor=2.19 (0.87), mean difference -0.18 (-0.74-0.38, p=0.51); hyperaemic absolute flow (ml/min): major=168.8 (97.7), minor=189.4 (126.9), mean difference 20.6(-30.7-72.0, p=.41); resting absolute flow adjusted for rate pressure product: major=105.8 (61.3) minor=111.6 (58.7), mean difference (-21.0-32.6, p=0.66); coronary flow reserve: major=2.11(0.61), minor=2.13 (0.78), mean difference -0.03(-0.36-0.42, p=0.88). Conclusions: The mechanism for a large rise in non-target vessel FFR post CTO angioplasty must involve a fall in coronary flow, and therefore resistance to flow, across a coronary stenosis. These results would suggest that the expected change in haemodynamics as a result of recanalisation of a chronic total occlusion are likely to be relatively small. The relationship between pressure gradient and flow of a coronary stenosis may be the major determinant of the size in change in FFR.
    EuroPCR; 05/2014
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    ABSTRACT: Aims: Whilst it seems clear that the endothelium distal to a chronic total coronary occlusion is dysfunctional in the immediate aftermath of PCI, it is not clear whether microvascular resistance and function is restored immediately, or whether this is also impaired. We sought to investigate microvascular resistance at rest and hyperaemia prior to and shortly after PCI of a chronic total coronary occlusion. Methods and results: In 10 patients undergoing PCI to a chronic total coronary occlusion, simultaneous pressure and flow velocity were measured using a Volcano ComboWire distal to the point of occlusion pre and post recanalisation. Post-recanalisation measures were compared with an unobstructed reference vessel subtending viable myocardium in the same patient. Hyperaemic microvascular resistance and coronary flow reserve as well as resting and hyperaemic instantaneous minimal microvascular resistance during the ‘wave free period’ were compared. Continuous values are expressed as mean (standard deviation) or median (interquartile range) and comparisons made with a paired t-test or Wilcoxon signed rank sum test, depending on conformity to a Gaussian distribution. Pre-PCI microvascular resistance was assessed in the target (chronically occluded) vessel in 9/10 patients. There was a significant redunction in hyperaemic microvascular resistance after PCI: pre PCI median 5.26(3.50-5.51) mmHg/cm/s, post-PCI median 1.51(1.25-3.44) mmHg/cm/s, p=0.028. We did not detect a significant difference in the reference vessel: pre-PCI median 2.15 (1.53-2.63), post-PCI median 1.72(1.34-2.02) p=0.31. There was no significant difference between reference and target vessels in hyperaemic microvascular resistance post-PCI, hyperaemic microvascular resistance was within the normal physiological range of <2 mmHg/cm/s in 7/10 target vessels (median 1.42(0.98-3.44) mmHg/cm/s) and 9/10 reference vessels (median 1.81(1.40-2.60) mmHg/cm/s), p=0.65. Similarly, there was no difference in coronary flow reserve (target vessel mean 1.96(0.70), reference vessel 2.22(0.98), p=0.57. Minimal instantaneous microvascular resistance measured during the ‘wave free period’ did not differ between target and reference vessels either at rest: target vessel median 2.31(1.45-2.90) mmHg/cm/s, reference vessel median 3.75(1.89-4.32) mmHg/cm/s, p=0.28; or hyperaemia: target vessel median 0.90(0.56-1.80) mmHg/cm/s, reference vessel median 1.05(0.87-1.30), p=0.96. Conclusions: This small study suggests that target vessel microvascular resistance decreases rapidly after PCI of chronic total coronary occlusions and the vascodilatory capacity of the microcirculation in response to Adenosine rapidly returns to normal in a high proportion of cases. Although physiological lesion assessment for clinical decision making in this setting is limited by endothelial dysfunction in the epicardial vessel, and is probably best avoided; these results have implications for the interpretation of clinical studies, and support the validity of those that have measured recruitable collateral function after PCI of chronic total coronary occlusions.
    EUROPCR 2014; 05/2014
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    Verah Harper, Simon D Thackray, Andrew L Clark
    International journal of cardiology 12/2011; 153(2):236-7. · 6.18 Impact Factor
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    ABSTRACT: Aortic atherosclerosis reduces compliance in the systemic circulation and increases peripheral resistance, afterload and left ventricular wall stress. In patients with heart failure, these changes can impair left ventricular systolic function and energy efficiency, which could reduce exercise capacity. Though the interaction and the impact of aortic atherosclerosis on left ventricular function have been investigated, its prognostic implications in patients with heart failure are unclear. We used cardiac magnetic resonance imaging and gadolinium-enhanced abdominal aortography to investigate the prevalence and prognostic impact of atherosclerotic disease of the abdominal aorta and its side branches in 355 patients with heart failure. Sclerotic abdominal aortic disease was defined as a luminal narrowing >50% of the aorta and its side branches or the presence of abdominal aortic aneurysm. Patients with disease of the aorta and its branches were older (P < 0.0001), had overall longer stay in hospital (P = 0.006) and had more admissions (P = 0.001) and worse prognosis (hazard ratio: 1.97, 95% confidence interval: 1.29-3.00, P = 0.002) than those without. In a multivariable model, increasing age and pulse pressure, diabetes mellitus and increasing left ventricular end-diastolic volume were associated with a worse prognosis, but sclerotic abdominal aortic disease was not independently related to outcome (hazard ratio: 1.06; 95% confidence interval: 0.64-1.74; P = 0.823). These data demonstrate that atherosclerosis of the abdominal aorta and its side branches is common and associated with increased morbidity in patients with chronic heart failure. How such disease should be managed remains uncertain, but its recognition and characterisation are the first steps in finding out.
    Heart Failure Reviews 10/2011; 17(2):229-39. · 4.45 Impact Factor
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    ABSTRACT: BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1617-25. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1607-16. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1607-16. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1617-25. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1607-16. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1617-25. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1617-25. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1607-16. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1617-25. Epub 2011 Apr 4..
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    ABSTRACT: BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1607-16. Epub 2011 Apr 4..
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    ABSTRACT: IntroductionChronic total occlusion (CTO) of coronary vessels is a relatively common finding on diagnostic angiography. There has been increasing interest in this clinically important area with development of technologies resulting in improved recanalisation rates. However, long term survival data in this cohort is lacking. In this study we looked at survival of patients in whom complete, successful revascularisation was achieved.Methods We identified consecutive patients, found to have CTO of at least one vessel of more than 1-month duration, on angiography performed between January 1999 and August 2000 in a single tertiary centre. We used a dedicated database to record data on variables and used central National Health Service database to obtain survival data. Results were analysed using SPSS statistics version 17.ResultsWe included 331 patients in the analysis. Mean age was 56.8 ±19.8 years, 76.1% were male and 21.8% (n=71) were diabetic. Mean duration of CTO was 29.5±25.9 months and was only reliably estimated in 82.5% of cases. Median follow-up duration was 10.09±3.3 years. Complete revascularisation was successfully achieved in 53.5% (n=177) patients, while 46.5% (n=154) were either treated medically from the outset or had failed or incomplete revascularisation. Both groups were age matched. Overall 10-year survival was 66.5%; those with complete revascularisation had significantly improved survival over those with incomplete revascularisation or medical therapy (75.1% vs 56.5%, p
    Heart. 01/2011; 97(1).
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    ABSTRACT: BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1617-25. Epub 2011 Apr 4..
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).
    N Engl J Med. 01/2011; 364(17):1617-25. Epub 2011 Apr 4..
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    ABSTRACT: Intravascular ultrasound (IVUS) is a catheter-based imaging modality, which provides high resolution cross-sectional images of the coronary arteries. Unlike angiography, which displays only the opacified luminal silhouette, IVUS permits imaging of both the lumen and vessel wall and allows characterization of the type of the plaque. Although IVUS provides accurate quantitative and qualitative information regarding the lumen and outer vessel wall, it is not routinely used during coronary angiography or in angioplasty procedures because the risk to benefit ratio (additional expense, procedural time, certain degree of risk, and complication versus improvement in the outcome) does not justify routine utilization. Nevertheless, there are situations where IVUS is extremely useful tool both for diagnosis and management so the aim of this review is to summarize the indications for IVUS imaging in the contemporary clinical practice. (Echocardiography 2010;27:1282-1290)
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    ABSTRACT: Coronary stenting is an increasingly common procedure. Complications are rare. However, when they do occur, they often require urgent invasive treatment. Investigations that are critical for establishing a diagnosis as well as such guide treatment as a detailed assessment of myocardial morphology and function using transthoracic echocardiography may be overlooked in the haste to treat the patient. We present a case report of subacute drug-eluting stent thrombosis in which a meticulous echocardiographic examination allowed the identification of a ventricular septal rupture, which ultimately modified treatment.
    Journal of Clinical Ultrasound 10/2009; 38(4):218-21. · 0.70 Impact Factor