Impact Of Coronary Revascularization Research Articles

Impact of coronary revascularization on coronary flow capacity measured by transthoracic Doppler echocardiography in patients with chronic coronary syndrome

Coronary flow capacity (CFC) integrates quantitative assessment of hyperemic myocardial blood flow and coronary flow reserve. We aimed to evaluate the effect of elective percutaneous coronary revascularization (PCI) on CFC using serial stress transthoracic Doppler echocardiography (STDE). Overall, 148 stable patients underwent STDE of the left anterior descending arteries (LAD), before and after elective PCI. Coronary flow velocity reserve (CFVR) was measured using basal and hyperemic diastolic peak velocity (hDPV). Vessels were classified into four CFC categories: severely, moderately, or mildly reduced CFC, and normal flow. Changes in hDPV and CFC status post-PCI, as well as predictors of hDPV increase, were assessed. Despite improvements in fractional flow reserve (FFR) in all cases, 31 cases (20.9%) showed a decrease in hDPV following PCI. Vessels with ischemic CFC, defined as moderately or severely reduced CFC, decreased from 46.6% (69/148) to 19.6% (29/148) post-PCI. Conversely, CFC worsened in 15.5% of patients. Multivariable analysis showed lower pre-PCI hDPV and ischemic CFC were independently predictive of higher-level (> 50%) hDPV increase after PCI. Approximately 20% of FFR-guided LAD PCI resulted in decreased hDPV. CFC deterioration was not uncommon despite FFR improvement. Preprocedural non-invasive STDE may help identify lesions that benefit from revascularization.

Impact of coronary revascularization on clinical outcomes of post-acute myocardial infarction patients with left ventricular thrombus

Abstract Background Left ventricular thrombus (LVT) is an uncommon, but dangerous complication seen in post-acute myocardial infarction (AMI). With advances in percutaneous coronary intervention (PCI) techniques, the incidence of post-AMI LVT has declined in the contemporary era. However, a minority of patients do not undergo coronary revascularisation due to medical contraindications or patient preference. This study aimed to evaluate the clinical characteristics and outcomes of post-AMI LVT patients treated with and without coronary revascularisation. Methods This was a retrospective study of 263 consecutive post-AMI patients diagnosed with LVT from November 2012 to January 2021, retrieved from a echocardiography database. Patients were stratified by the presence or absence of revascularisation treatment. Baseline clinical characteristics, treatment and outcomes data were collected and analysed. Results The median follow-up duration was 2.9 years (IQR: 0.9 – 4.7). A majority of post-AMI LVT patients underwent revascularisation via PCI (71.5%, n = 188), CABG (4.2%, n = 11) or thrombolysis (0.4%, n = 1). Unrevascularised patients (24.0%, n = 63) were older (p <0.001), more likely to be female (p <0.001), and had more co-morbidities such as previous stroke (p <0.001), heart failure (p = 0.001), chronic kidney disease (p = 0.020), and malignancy (p = 0.021). More unrevascularised patient had NSTEMI (p < 0.001), and significantly fewer were treated with triple therapy (p < 0.001). Incidence of LVT resolution was lower (p < 0.001) while all-cause mortality was higher (p < 0.001) for unrevascularised patients on univariate survival analyses. On multivariable Cox regression, revascularisation status was not an independent predictor of LVT resolution, bleeding, stroke, or all-cause mortality outcomes. Conclusion While unrevascularised post-AMI LVT patients had poorer outcomes compared to revascularised patients overall, revascularisation status itself was not independently associated with poorer clinical outcomes. Optimising medical therapy such as triple therapy remains a key treatment goal for post-AMI LVT patients.

C-45 | Impact of coronary revascularization on Mortality and Ventricular Tachyarrhythmia recurrence: A Meta-Analysis

C-45 | Impact of coronary revascularization on Mortality and Ventricular Tachyarrhythmia recurrence: A Meta-Analysis

The impact of coronary revascularization on coronary flow capacity assessed by serial transthoracic echocardiographic findings in patients with chronic coronary syndrome

Abstract Background Coronary flow capacity (CFC) integrates quantitative hyperaemic myocardial blood flow and coronary flow reserve (CFR) to comprehensively assess physiological severity of coronary artery disease. This study evaluated the effects of revascularization (PCI) on CFC assessed by serial transthoracic doppler echocardiography (TDE) examinations before and after elective PCI. Methods A total of 177 patients with chronic coronary syndrome underwent stress TDE examinations of left anterior descending arteries (LAD) before and after PCI to assess changes in CFC. Resting and hyperemic diastolic peak velocity (hDPV) was used to calculate CFR. Using previously reported thresholds for ischemia and normal perfusion, vessels were stratified in four CFC categories: severely reduced, moderately reduced, minimally reduced CFC, and normal flow. The association between CFC increase and pre-procedural TDE parameters was studied. Results After PCI, fractional flow reserve (FFR) values improved in all cases (0.70, (0.62 - 0.74), P < 0.001), although 74 cases (41.8%) showed CFC decrease. Pre-PCI lower FFR, lower resting Pd/Pa, lower CFR, and lower hDPV were significant predictors for CFC increase after PCI. Lower baseline CFC, particularly in ischemic CFC defined as a composite of moderately, and severely reduced CFC was a predictor of CFC increase (P < 0.01). On multivariable analysis, pre-PCI lower hDPV, and pre-PCI ischemic CFC were independent factors predicting CFC-improvement, while pre-PCI wire-based physiological data including FFR were not significantly associated with CFC improvement. Conclusions About a half of successful LAD PCI resulted in an increase in CFC. Preprocedural TDE-derived parameters including hDPV and CFC may help identification of lesions that benefit from revascularization with respect to an increase in coronary flow capacity. Further studies are needed to elucidate the effect of CFC improvement on prognosis.Effect of preprocedural CFC after PCI

The impact of coronary revascularization on vessel-specific coronary flow capacity and long-term outcomes: a serial [15O]H2O positron emission tomography perfusion imaging study.

AimsCoronary flow capacity (CFC) integrates quantitative hyperaemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) to comprehensively assess physiological severity of coronary artery disease (CAD). This study evaluated the effects of revascularization on CFC as assessed by serial [15O]H2O positron emission tomography (PET) perfusion imaging.Methods and resultsA total of 314 patients with stable CAD underwent [15O]H2O PET imaging at baseline and after myocardial revascularization to assess changes in hMBF, CFR, and CFC in 415 revascularized vessels. Using thresholds for ischaemia and normal perfusion, vessels were stratified in five CFC categories: myocardial steal, severely reduced CFC, moderately reduced CFC, minimally reduced CFC, and normal flow. Additionally, the association between CFC increase and the composite endpoint of death and non-fatal myocardial infarction (MI) was studied. Vessel-specific CFC improved after revascularization (P < 0.01). Furthermore, baseline CFC was an independent predictor of CFC increase (P < 0.01). The largest changes in ΔhMBF (0.90 ± 0.74, 0.93 ± 0.65, 0.79 ± 0.74, 0.48 ± 0.61, and 0.29 ± 0.66 mL/min/g) and ΔCFR (1.01 ± 0.88, 0.99 ± 0.69, 0.87 ± 0.88, 0.66 ± 0.91, and −0.01 ± 1.06) were observed in vessels with lower baseline CFC (P < 0.01 for both). During a median follow-up of 3.5 (95% CI 3.1–3.9) years, an increase in CFC was independently associated with lower rates of death and non-fatal MI (HR 0.43, 95% CI 0.19–0.98, P = 0.04).ConclusionSuccessful revascularization results in an increase in CFC. Furthermore, baseline CFC was an independent predictor of change in hMBF, CFR, and subsequently CFC. In addition, an increase in CFC was associated with a favourable outcome in terms of death and non-fatal MI.

Abstract 13895: Impact of Coronary Revascularization on Cardiopulmonary Performance in Patients With Coronary Chronic Total Occlusion

Background: —CTO PCI represents the tip of iceberg in interventional cardiology, however owing to lack of enough data, there is still debate about its benefit. CPET combines measurement of gas indices with standard exercise and ECG parameters giving a comprehensive way for patient evaluation also there is plenty of data about its use in many cardiovascular diseases and about its prognostic value in many occasions. So we thought of using CPET in evaluating value of CTO PCI on various CPET parameters. Hypothesis: CTO PCI improves cardiopulmonary performance evaluated by CPET. Methods: fifty nine patients underwent successful CTO PCI and CPET at baseline and at12 month follow up, of whom nine patients had suboptimal results in control angiography which is a higher than usual incidence of re-stenosis, we compared the results of the CPET pre and post-PCI in both groups. Results: In patent group, CPET at follow up revealed a significant increase of peak oxygen consumption (Peak VO 2 ) (13.47±1.53 ml/kg/min vs. 17.84±0.99 ml/kg/min p &lt;0.0001), VO 2 at anaerobic threshold (AT) (11.63 ± 1.14 ml/kg/min vs. 10.35 ±1.01ml/kg/min ( p &lt; 0.0001), peak oxygen pulse ( 16.02 ±1.34 vs. 11.15 ± 1.36, p &lt; 0.0001) and significant increase in peak cardiac index (3.78 ± 0.5 vs. 2.98 ±0.6, p &lt; 0.0001). Also there was significant decrease of Peak VE/VCO 2 (32.98 ± 3.2 vs. 42.98 ± 6.2, p &lt; 0.0001).In patients with re-stenosis, CPET at follow up revealed a significant decrease of peak oxygen consumption (Peak VO 2 ) (13.36±1.48 ml/kg/min vs. 12.41±0.97 ml/kg/min, p =0.02) and a significant increase of Peak VE/VCO 2 (42.73 ± 4.33 vs. 43.27 ± 3.29, p =0.01)also there was worse numerical values of other parameters despite not being statistically significant. Conclusions: CTO revascularization improves cardiopulmonary performance assessed by CPET in addition patients with re-occlusion after successful procedure had worse parameters even than their own baseline. CPET can provide a way for non-invasive follow-up of patients after PCI and earlier detection of in-stent re-stenosis that is more common in CTO.

Rate, causes, and predictors of 90-day readmissions and the association with index hospitalization coronary revascularization following non-ST elevation myocardial infarction in the United States.

To assess the causes and predictors of readmission after NSTEMI. Studies on readmissions following non-ST elevation myocardial infarction (NSTEMI) are limited. We investigated the rate and causes for readmission and the impact of coronary revascularization on 90-day readmissions following a hospitalization for NSTEMI in a large, nationally representative United States database. We queried the National Readmission Database for the year 2016 using appropriate ICD-10-CM/PCS codes to identify all adult admissions for NSTEMI. We determined the 90-day readmissions for major adverse cardiac events (MACE). All-cause readmission was a secondary endpoint. The association between coronary revascularization and the likelihood of readmission was analyzed using multivariate Cox regression analysis. A total of 296,965 adult discharges following an admission for NSTEMI were included in this study. The rate of readmissions for MACE was 5.2% (n=15,637) and for any cause was 18.0% (n=53,316). 38% of MACE readmissions and 40% of all-cause readmissions occurred between 30- and 90-days following the index hospitalization. During index hospitalization, 51.0% underwent coronary revascularization (40.8% with PCI and 10.2% with CABG). This was independently predictive of a lower risk of 90-day readmission for MACE (adjusted HR 0.59, 95% confidence interval (CI) 0.56-0.63, p < .001) and for any cause (adjusted HR 0.65, 95% CI 0.63-0.67, p < .001). In-hospital mortality for MACE readmissions was significantly higher compared to that of index hospitalization (3.8% vs. 2.6%, p < .001). Readmissions following NSTEMI carry higher mortality than the index hospitalization. Coronary revascularization for NSTEMI is associated with a lower readmission rate at 90 days.

P206 Immediate impact of coronary revascularization on global and regional myocardial function evaluated by speckle tracking echocardiography

Abstract Funding Acknowledgements No. OnBehalf No. Background The immediate effect on myocardial function and deformation after coronary revascularization is incompletely studied. Effective revascularization along with perioperative myocardial injury compromises improved regional and global left ventricular function and leads to the risks of adverse perioperative events following coronary artery bypass grafting (CABG) surgery. Global longitudinal strain (GLS) assessed by speckle-tracking echocardiography (STE) has been reported as a better predictor and a more sensitive marker for postoperative ventricular remodeling. Purpose This study aimed to evaluate changes of left ventricular (LV) systolic function and GLS in the perioperative period during CABG and to investigate the value of GLS using two-dimensional STE in predicting short-term outcome. Methods A total of 22 patients who underwent elective CABG surgery (EuroSCORE II 1.84 ± 1.2) were evaluated. Transesophageal echocardiography was performed, 2D and three-dimensional echocardiography (3DE) data was acquired before sternotomy, before cardiopulmonary bypass (CPB), after bypass and after chest closure. LV GLS and tissue motion annular displacements (TMAD) of the mitral valves were quantified by 2D STE using CMQ software. LV volumes and ejection fraction (EF) were evaluated by 3DE at the same timepoints. Short-term outcomes were defined as death, stroke, myocardial infarction, acute kidney dysfunction, rehospitalization and repeated revascularization in a one-month period after surgery. Results Both 2D and 3DE of all patients were analyzed. The cohort had a mean age of 68.2 ± 7.2 years and 9.1% was women. Before sternotomy, GLS was -15.7 ± 2.9%. Despite little change in 3D LVEF, GLS was immediately impaired after coronary artery bypass graft (before bypass vs after chest closure, -15.9 ± 3.6% vs -13.5 ± 4.0%, P = 0.001). There was strong correlation between GLS and 3D LVEF (r=-0.77, P &amp;lt; 0.001), moderate correlations between GLS and absolute value of TMAD (r=-0.61, P &amp;lt; 0.05), between GLS and percentage of TMAD (r=-0.64, P &amp;lt; 0.05). Patients with poor outcome (n = 6) had a lower longitudinal strain (LS) in the apical 2-chamber (A2C) views (-14.5 ± 4.6% vs -10.8 ± 1.3%, P = 0.007) but no statistical difference between A3C and A4C views. The ROC analysis demonstrated a cut­off value -11.8% for A2C-LS to predict adverse events (AUC 0.81, P = 0.027, 95% CI 0.632-0.993), with an 83.3% sensitivity and 81.2% specificity, followed by 3D LVEF (AUC = 0.29), absolute and percentage of TMAD (AUC = 0. 21, 0.23) as less sensitive predictors of poor postoperative outcome. Conclusion Direct effects of myocardial deformation related to revascularization can be characterized by STE during CABG surgery. GLS could be a more sensitive parameter in the perioperative environment, which correlates well with LV global function assessed by 3D LVEF and TMAD. Early impairment of anterior and inferior wall myocardial strain after CABG may contribute to short-term adverse clinical outcome. Abstract P206 Figure.

Impact of coronary revascularization vs medical therapy on ischemia among stable patients with or suspected coronary artery disease undergoing serial myocardial perfusion scintigraphy

BackgroundRandomized trials have challenged the role of revascularization in stable coronary artery disease. We aimed to appraise the impact of revascularization on ischemia in patients undergoing serial myocardial perfusion scintigraphy (MPS). MethodsWe queried our institutional database for stable subjects undergoing serial MPS and appraised the impact of revascularization on changes in ischemia. ResultsA total of 3631 patients were included: 967 (27%) undergoing revascularization and 2664 (73%) receiving medical therapy only. Patients treated with revascularization had a significantly lower burden of myocardial ischemia at follow-up (odds ratio = 0.577 [95% confidence interval 0.483-0.689] vs medical therapy, P < .001). Among all those having moderate or severe ischemia at baseline, revascularization was associated with a follow-up prevalence of 80% for no, minimal, or mild ischemia and 20% for moderate or severe ischemia, vs 43% and 57% for medical therapy (P < .001). Even at multivariable analysis and propensity-adjusted, and propensity-matched analyses, revascularization was associated with a significantly lower prevalence of moderate or severe ischemia at follow-up (respectively P < .001, P = .001, and P = .042). ConclusionsRevascularization appears superior to medical therapy in reducing ischemic burden and normalizing myocardial perfusion among subjects with moderate or severe ischemia at baseline.

Impact of coronary revascularization on the clinical and scintigraphic outlook of patients with myocardial ischemia.

The impact of coronary revascularization on outcomes and ischemic burden among patients with objective proof of ischemia is not yet established. We appraised the impact of revascularization on outcomes and residual ischemia in patients with objective evidence of ischemia at myocardial perfusion scintigraphy (MPS). We queried our database for stable patients with myocardial ischemia at MPS, excluding those with prior myocardial infarction, systolic dysfunction, or cardiomyopathy. The impact of revascularization (defined as revascularization as first follow-up event) on outcomes and changes in myocardial ischemia at repeat MPS was appraised with propensity-matched analyses. From 6195 patients, propensity matching yielded 1262 pairs of patients undergoing revascularization versus not undergoing revascularization. After 35.2 ± 23.9 months, revascularization was associated with lower risks of cardiac death [2 (0.2%) versus 10 (0.8%) in those not revascularized, P = 0.038] and of the composite of cardiac death or myocardial infarction [17 (1.3%) versus 37 (2.9%), P = 0.007]. In addition, revascularization was associated with a higher rate of improvement in ischemia degree after 28.1 ± 20.7 months of follow-up (P < 0.001), with 257 (69.3%) patients with moderate or severe ischemia at baseline MPS improving after revascularization versus 136 (42.0%) in the nonrevascularization group. Conversely, revascularization did not prove impactful on follow-up MPS in patients with only minimal or mild ischemia at baseline MPS (P < 0.001). In a large series of patients with objective evidence of myocardial ischemia at MPS, especially when moderate or severe, revascularization was associated with a better clinical prognosis and a lower ischemic burden at repeat MPS.

Impact of Chronic Kidney Insufficiency on Cardiovascular Outcomes in Patients that Undergo Coronary Revascularization: A Historical Review

Chronic kidney disease (CKD) is associated with poorer short and long-term cardiovascular morbidity and mortality. Even after the commencement of haemodialysis in end stage renal failure patients, mortality exceeds 20% in the first year1. More than 50% of these deaths are contributed by cardiovascular diseases (CVD), of which 20% are caused by acute myocardial infarction2. Consequent to these findings, the degree and impact of coronary revascularization on CKD patients represents a clinical challenge, especially in the setting of advanced stages of CKD.

Abstract 17855: Prognostic Impact of Coronary Revascularization in Acute Coronary Syndrome Patients With Cardiogenic Shock

Background: Randomized trials have shown that coronary revascularization benefits patients with acute coronary syndrome (ACS). Furthermore, recent studies reported that revascularization could improve the outcome even in high-risk patients. We investigated the prognostic impact of revascularization and the factors that abandon the invasive strategy in patients with ACS complicated with cardiogenic shock. Methods and results: The Japanese Circulation Society Cardiovascular Shock registry (JCS-Shock registry) was a prospective, observational, multi-center, cohort study. Between May, 2012 and June, 2014, a total of 980 patients with cardiovascular shock were enrolled from 82 centers in Japan. We assessed the prognostic impact of coronary revascularization in ACS patients in JCS-Shock registry. The primary endpoint was all cause mortality at 30 days after administration. Among 495 subjects with ACS (ST-segment elevation acute myocardial infarction (STEMI) 408, Non-ST-segment elevation ACS (NSTEACS) 87), emergent coronary angiography was carried out in 448 (90.9%) subjects and any revascularization (percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)) was performed in 411 (83.0%) subjects. Thirty-day mortality in subjects treated with PCI and/or CABG (Revasc group) was 29.8% and neither PCI nor CABG (Non-Revasc group) was 51.2% (n=84, 17.0%) (P=0.0015 by Chi-square test), suggesting a beneficial effect of revascularization. Baseline characteristics of subgroups in Revasc or Non-Revasc were significantly different in age (71.0 vs. 76.5, P&lt;0.0037), female gender (23.2% vs. 40.5%, P=0.0016), previous PCI (66.7% vs. 39.1%, P&lt;0.0276), STEACS (86.8% vs. 60.7%, P&lt;0.0001). Conclusions: In the JCS Shock registry that observed contemporary emergency cardiovascular care in Japan, 30-day mortality of ACS complicated with cardiogenic shock was lower in patients underwent coronary revascularization compared with patients without any revascularization. Revascularization was less performed in elderly, female, patients without previous PCI and NSTEACS patients, associated with unfavorable outcomes. We may reconsider the therapeutic strategy to benefit patients by coronary revascularization.

Abstract 132: The POWR Survey: Patient and Physician Perspectives on Outcomes Weighting in Revascularization.

Objective: To better understand and compare how patients and physicians weight adverse outcomes of coronary revascularization. Background: One in every twenty American adults is living with coronary heart disease. Given the high prevalence, approximately one million percutaneous coronary interventions (PCI) and half a million coronary artery bypass grafting (CABG) procedures are performed each year. The decision between PCI and CABG is based on studies that have looked at differences in major adverse cardiac events (MACE) in various populations. While the outcomes included in the MACE category are impactful, they are selected by physicians and do not include all possible adverse outcomes of coronary revascularization that affect patients. With so many Americans facing the clinical impact of coronary revascularization we wished to see if patients and physicians align in the weighting of twenty outcomes of coronary revascularization that have been identified. Methods: 1500 physicians (500 internists, 500 cardiologists and 500 cardiac surgeons) and 54 patients were invited to fill out a survey over a 12 month period. Patients were approached upstream of diagnostic catheterization. Physicians were invited through an AMA database licensee. All responders were asked to use a rating scale to weight twenty outcomes of coronary revascularization. Results: 54 patient and 57 physician (20 internists, 19 cardiologists and 18 cardiac surgeons) responses were received. Patients weighted stroke the highest (8.83/10), while physicians weighted death the highest (8.63/10). Patients and physicians differed (p&lt;0.01) on myocardial infarction (physicians 6.59, patients 8.13), atrial fibrillation (physicians 4.28, patients 6.67), acute respiratory distress syndrome (ARDS) (physicians 5.94, patients 7.44), pseudoaneurysm (physicians 4.45, patients 6.23), post-operative chronic pain (physicians 5.20, patients 6.38) and procedural cost (physicians 4.22, patients 3.18). Notably patients weighted ARDS, renal failure, major bleeding, atrial fibrillation, mediastinits, post-operative chronic pain, post-procedural angina, pseudoaneurysm, long term plavix and pneumonia heavier than repeat PCI, another commonly used outcome for MACE. Conclusions: Patients and physicians agree on which outcomes are most (death and stroke)and least impactful (incision scar), but there is a lot of variability in between supporting the reporting of more adverse outcomes and not just those included in MACE.

Abstract 225: Clinical Impact of Coronary Revascularization and Hospitalization for Unstable Angina in Acute Myocardial Infarction Patients

Background: While clinical trials often use the endpoint of major adverse cardiovascular events (MACE) that include unstable angina (UA) and coronary revascularization outcomes, to power the studies, the relationship of these components to mortality is not known. Methods: Using a 24-center observational cohort study of 3283 AMI patients, we identified those with an unplanned coronary revascularization or unstable angina (UA) admission and calculated the subsequent rates of 1-year cardiovascular hospitalizations and 2-year mortality. Staged revascularizations electively performed 30 demographic, clinical, and health status data and achieved good balance between the cohorts (standardized difference &lt;10% for all). Proportional hazards models of subsequent outcomes were compared for those who did and did not have an event after their AMI. Results: A total of 144 (4.39%) patients underwent unplanned revascularization and 140 (4.26%) were readmitted for UA after their AMI, of whom 9.6% and 30.2% died or were readmitted after an unplanned revascularization and 5.2% and 36.8% had these events after an UA admission. After propensity adjustment, the risk of mortality (HR=1.84) and cardiovascular rehospitalization (HR=5.13) were elevated among those who underwent revascularization vs. those who did not. The adjusted risk of 2-year mortality was not elevated after an UA event (HR=0.95) but the risk of cardiovascular rehospitalization was (HR=7.26; Table ). Conclusions: Patients undergoing coronary revascularization or those readmitted for UA following AMI have greater subsequent risks for cardiovascular rehospitalizations as compared with those who do not get readmitted for these reasons. Subsequent survival is also worse in those who underwent coronary revascularization following AMI. From a prognostic standpoint, the inclusion of revascularizations and UA admissions as a component of a MACE outcome in clinical trials may be reasonable from a prognostic standpoint.

Percutaneous Coronary Interventions and Bypass Surgery in Patients With Cardiac Allograft Vasculopathy: A Single-Center Experience

IntroductionCardiac allograft vasculopathy (CAV) remains a major impediment to long-term survival after heart transplantation (HT). Limited data exist regarding the impact of coronary revascularization in these patients. ObjectiveTo evaluate the outcomes of revascularization procedures in patients with CAV compared with patients who did not undergo revascularization. MethodsRetrospective analysis of 249 patients who underwent HT at our center between June 1998 and December 2009 and who were examined by coronary angiography after HT. We included patients with moderate or severe CAV according to the International Society for Heart and Lung Transplantation (ISHLT) nomenclature to evaluated outcomes after revascularization or diagnostic angiography. Major adverse cardiovascular events (MACE) comprised death, acute coronary syndrome, coronary revascularization, admission because of heart failure not due to an acute rejection episode, and cardiac retransplantation. ResultsModerate or severe CAV was detected in 43 patients. Twelve (27.9%) underwent coronary revascularization: eight percutaneous interventions and four bypass surgeries. Indications for revascularization were symptomatic ischemia or noninvasive evidence of ischemia (n = 6, 14.0%) or high-risk asymptomatic CAV (n = 6; 14.0%), namely, lesions located in the left main or proximal anterior descending arteries or multivessel disease with left ventricular dysfunction. The remaining 31 (72.1%), who did not undergo revascularization showed an absence of ischemia during exercise echocardiography (n = 11; 25.6%) or diffuse disease not amenable to revascularization (n = 20; 46.5%). During a mean follow-up of 3.0 ± 2.4 years, MACE occurred in three revascularized patients (25.0%), in one with absence of stress-induced ischemia (9.1%) and in 13 with nonrevascularizable disease (65%; P = .012). ConclusionsRevascularization procedures were effective in HT patients with evidence of ischemia or high-risk CAV. Patients with absence of stress-induced ischemia have a good prognosis without revascularization. On the other hand, diffuse nonrevascularizable CAV is associated with a poor prognosis.

Impact of coronary revascularization and transmural extent of scar on regional left ventricular remodelling

Transmural extent (TME) of myocardial scar, contractile reserve, and perfusion all predict improvement in regional myocardial function after coronary revascularization. We sought their association with regional remodelling after infarction. We studied 89 patients (age 62 +/- 10 years) with left ventricular (LV) dysfunction, at least 1 month post infarction. Viability was identified by TME < 75% on contrast-enhanced magnetic resonance imaging (ce-MRI), augmentation at low-dose dobutamine echocardiography (DbE), or >60% uptake on delayed redistribution on TI-201 SPECT (single photon emission computed tomography). Coronary revascularization was performed in 36 patients. Regional LV end-diastolic volume (EDV) and end-systolic volume, and ejection fraction were measured with MRI at baseline and after a median follow-up of 18 months. Of 357 segments identified with subendocardial infarction (TME 0-25%) on ce-MRI, 176 were revascularized. Subendocardial scar segments were associated with reverse regional remodeling during follow-up. Revascularization was an independent correlate of change in EDV, but TME and revascularization showed no interaction with respect to their influence on regional volumes. Contractile reserve was present on DbE in 228 segments, of which 129 were TME 0-25%; remodelling was associated with intervention in non-transmural infarcts showing viability by DbE. Viability was identified by TI-201 SPECT in 381 segments (233 with TME 0-25%), but viability by SPECT was not associated with reverse remodelling. No significant reverse remodelling occurred in segments with intermediate scar thickness (TME 26-75%) or transmural scar, independent of revascularization or viability by DbE or TI-SPECT. Reverse regional remodelling is associated with subendocardial infarction, especially in the setting of contractile reserve and revascularization.

Dependence of recovery of contractile function on maintenance of oxidative metabolism after myocardial infarction

This study was performed to define the importance of maintenance of oxidative metabolism as a descriptor and determinant of the potential for functional recovery after revascularization in patients with recent myocardial infarction. In 11 patients (mean interval after infarction 6 days; 5 patients given thrombolytic therapy), positron emission tomography (PET) was performed to characterize myocardial perfusion (with oxygen-15-labeled water), glucose utilization (with fluorine-18-fluorodeoxyglucose) and oxidative metabolism (with carbon-11-acetate). Dysfunctional but viable myocardium was differentiated from nonviable myocardium by assessments of regional function before and after coronary revascularization. The impact of coronary revascularization on regional myocardial perfusion and metabolism was assessed in nine patients in whom tomography was repeated after revascularization.Before revascularization, dysfunctional but viable myocardium (19 segments) and nonviable myocardium (10 segments) exhibited relative perfusion equivalent to 74% and 63% of that of normal myocardium (33 segments), respectively (p < 0.02). Dysfunctional but viable myocardium exhibited oxidative metabolism equivalent to 74% of that of normal myocardium (p < 0.02). In contrast, in nonviable myocardium, oxidative metabolism was only 45% of that seen in normal (p < 0.02) and 60% of that in reversibly dysfunctional myocardium (p < 0.003). Regional glucose utilization (normalized to regional perfusion) in dysfunctional but viable myocardium was higher than that in normal myocardium (p < 0.02). Nonviable myocardium exhibited lower levels of glucose utilization than did normal tissue (p < 0.02). However, in both reversibly and persistently dysfunctional myocardium utilization of glucose normalized to relative perfusion was markedly variable.The results indicate that preservation of oxidative metabolism is a necessary condition for recovery of function consequent to coronary recanalization after myocardial infarction. Therefore, approaches that measure myocardial oxygen consumption, such as dynamic PET imaging with carbon-11-acetate, should facilitate the identification of dysfunctional but still viable myocardium in patients with recent myocardial infarction who are most likely to benefit from coronary revascularization.