Standard Coronary Angiography Research Articles

AB10-3: High speed rotational coronary venous angiography improves delineation of coronary venous anatomy during cardiac resynchronization therapy

Standard 2-view coronary venous angiography (SCVA) provides a static, fixed projection of the coronary venous (CV) tree, often leading to a suboptimal delineation of the takeoff, angulations, or course of the venous tributaries. High-speed rotational CV angiography (RCVA) permits a dynamic, multi angle visualization of the CV anatomy.

Randomized study of the safety and clinical utility of rotational vs. standard coronary angiography using a flat-panel detector

The purpose of this study was to test the hypothesis that rotational angiography improves patient safety while maintaining diagnostic accuracy for patients undergoing coronary angiography. Despite advances in angiographic technique, patients remain at risk for complications of coronary angiography, including contrast-induced nephropathy and radiation exposure. Technology has been developed to perform coronary angiography with active rotation of the imaging system that may reduce the quantity of contrast and radiation to which the patient is exposed. Fifty patients undergoing diagnostic cardiac catheterization were randomized to either standard vs. rotational angiography of the coronary arteries using a prespecified protocol with a flat-panel single-plane imaging system. We measured the quantity of radiographic contrast utilized and radiation exposure. Using an intention-to-treat analysis, there was a 40% reduction (24 +/- 5 vs. 40 +/- 10 ml; P < 0.0001) in contrast utilization in the rotational group compared to the standard group. Neither radiation exposure (35 +/- 14 vs. 30 +/- 20 Gycm(2); P = 0.35), fluoroscopic time (44 +/- 33 vs. 44 +/- 40 sec; P = 0.99), nor procedure time (249 +/- 137 vs. 214 +/- 79 sec; P = 0.26) differed, although significant intraoperator variability was noted for both standard and rotational angiography. The radiation exposure using this flat-panel system is significantly lower than prior reports that used an image intensifier system. Rotational coronary angiography has the potential to improve patient safety by markedly reducing radiographic contrast exposure while maintaining comparable diagnostic accuracy, radiation exposure, and procedure time compared to standard coronary angiography.

Usefulness of Parametric Imaging-Based Quantitative Myocardial Contrast Echocardiography in Predicting the Functional Recovery of Akinetic Segments Following Primary Angioplasty in Acute Myocardial Infarction Patients

Myocardial contrast echocardiography (MCE) is useful for predicting the functional recovery of akinetic segments in patients undergoing primary angioplasty after acute myocardial infraction (AMI). Recently, parametric imaging-based quantitative MCE has been developed for measuring perfusion. Our aims were: a) to measure perfusion in akinetic myocardial segments in patients undergoing primary angioplasty using parametric imaging-based quantitative MCE; and b) to assess the usefulness of these measurements in predicting functional recovery of these segments. The study group comprised 49 consecutive patients undergoing primary angioplasty. Both MCE and standard echocardiography were performed between 2 and 5 days after AMI. Six months later, additional standard echocardiography and coronary angiography were performed. Perfusion was quantified independently off-line from parametric images. The patients' mean age was 62.3+/-14.5 years (39 men; 79.2%). Some 170 akinetic segments were detected. Of these, 105 (62.1%) recovered function. The quantitative MCE parameter that best predicted functional recovery was myocardial blood flow velocity (beta): the area under the receiver operating characteristic (ROC) curve was 0.96 (95% CI, 0.92-0.99). For a cut-off point of 31 dB/s, the sensitivity was 87.62%, the specificity was 95.31%, the positive predictive value was 96.8%, and the negative predictive value was 82.43%. These results were better than those obtained using qualitative methods for assessing myocardial perfusion. Perfusion measurement by parametric imaging-based quantitative MCE is useful for predicting the functional recovery of akinetic segments in patients undergoing primary angioplasty after AMI. The technique provides superior information to older qualitative methods.

Quantification of Coronary Artery Stenosis with 16-Slice MSCT in Patients before CABG Surgery: Comparison to Standard Invasive Coronary Angiography

Invasive, selective coronary angiography is the gold standard for evaluation of coronary artery disease (CAD) and degree of stenosis. The purpose of this study was to compare 3-dimensional (3D) reconstructed 16-slice multislice computed tomographic (MSCT) angiography and selective coronary angiography in patients before elective coronary artery bypass graft (CABG) procedure. Sixteen-slice MSCT scans (Philips Mx8000 IDT) were performed in 50 patients (42 male/8 female; mean age, 64.44 +/- 8.66 years) scheduled for elective CABG procedure. Scans were retrospectively electrocardiogram-gated 3D reconstructed. The images of the coronary arteries were evaluated for stenosis by 2 independent radiologists. The results were compared with the coronary angiography findings using the American Heart Association segmental classification for coronary arteries. Four patients (8%) were excluded for technical reasons. Thirty-eight patients (82.6%) had 3-vessel disease, 4 (8.7 %) had 2-vessel disease, and 4 (8.7%) had an isolated left anterior descending artery stenosis. In the proximal segments all stenoses >50% (56/56) were detected by MSCT; medial segment sensitivity was 97% (73/75), specificity 90.3%; distal segment sensitivity was 90.7% (59/65), specificity 77%. Accurate quantification of coronary stenosis greater than 50% in the proximal and medial segments is possible with high sensitivity and specificity using the new generation of 16-slice MSCTs. There is still a tendency to overestimate stenosis in the distal segments. MSCT seems to be an excellent diagnostic tool for screening patients with possible CAD.

Assessment of Myocardial Infarctions Using Multidetector-Row Computed Tomography

To evaluate the diagnostic power of contrast-enhanced multidetector-row computed tomography (MDCT) in assessing the presence, age, and size of myocardial infarctions. One hundred six patients underwent standard MDCT coronary angiography without additional changes in the protocol. In all patients, a complete patient history and left heart catheterization with biplane contrast ventriculography were available. The MDCT images were reviewed for the presence and age of myocardial infarctions in a blinded fashion. Infarct areas were detected as regions of reduced uptake of contrast in the early arterial phase and/or regional wall thinning. Reviewing the computed tomography (CT) images, CT density values (Hounsfield units [HU]) were measured at the site of infarcted and noninfarcted myocardium, and a volumetric assessment of the infarct size was performed. In 27 of 106 patients, myocardial infarctions were present. Multidetector-row computed tomography detected 23 of 27 infarctions (sensitivity of 85%, specificity of 91%, and accuracy of 90%). Comparing the HU of infarcted versus noninfarcted myocardium, the mean HU of infarcted areas was 54 +/- 19 HU versus 117 +/- 28 HU for noninfarcted myocardium (P < 0.01). Multidetector-row computed tomography was able to differentiate between recent and chronic infarctions. The infarct volumes of recent infarctions (6.3 +/- 3.6 cm) showed a negative correlation to the ejection fraction (EF) according to contrast ventriculography (ie, the larger the infarct volumes as measured using MDCT, the worse was the EF [r = -0.72, P < 0.01]). Performing standard MDCT coronary angiography, areas of infarcted myocardium can be identified with moderate to high sensitivity, without additional scanning or contrast administration. Infarct localization can be assessed accurately as compared with cineventriculography. To some degree, infarct age and infarct volume can be estimated.

Quantification of coronary artery stenosis in patients before CABG surgery with 16-slice MSCT – Comparison to the standard invasive coronary angiography

Objectives: Invasive, selective coronary angiography is up to now the gold standard for evaluation of coronary artery disease (CAD) and degree of stenosis. Purpose of this study was to compare 3D reconstructed 16-slice MSCT angiography and selective coronary angiography in patients before elective CABG procedure.

Simultaneous hemodialysis during coronary angiography fails to prevent radiocontrast- induced nephropathy in chronic renal failure

Radiocontrast medium- (RM) associated nephrotoxicity continues to be a common cause of acute renal failure and may lead in patients with pre-existing chronic renal insufficiency even to end-stage renal failure requiring chronic dialysis. Since extracorporeal removal of RM after RM administration has been shown to be effective but does not prevent radiocontrast-induced nephropathy, the effect of a simultaneous dialysis during RM administration on renal function is not clear. In a prospective, randomized and controlled trial, we studied the effect of a 4-hour online dialysis during RM (iomeprol) application in patients with advanced chronic renal failure (serum creatinine > or = 3 mg/dl) undergoing coronary angiography. All patients received hydration with saline before and after standardized coronary angiography and were randomized to receive a simultaneous high-flux hemodialysis (7 patients, HD group) or to control group (10 patients). 24-hour creatinine clearance (CrCl) was measured in all patients before, 1 week and 8 weeks after coronary angiography. The clinical follow-up comprised 8 weeks after RM application. RM plasma levels were measured in both groups 15, 30, 60 minutes, 2, 4, 12, 24, 48 and 72 hours after application by high-pressure liquid chromatography. At baseline, CrCl (19 +/- 10 vs 17 +/- 7 ml/min), percentage of diabetics (57 vs 70%) and dose of RM (77 +/- 27 vs 86 +/- 21 ml) were similar in both groups. Pharmacokinetics: Total clearance of iomeprol was significantly higher (54 +/- 15 vs 20 +/- 12 ml/min, p < 0.001) and the area under curve (AUC) was significantly lower (23 +/- 10 g x h/l vs 94 +/- 57 g x h/l, p < 0.001) in the HD group compared to control group. RM peak plasma levels 15 min after application were not different in both groups (3.0 +/- 1.1 vs 4.2 +/- 1.7 mmol/l, NS), however, significantly lower 60 min (1.6 +/- 0.4 vs 3.7 +/- 1.5 mmol/l, p < 0.01) and 240 min (0.7 +/- 0.3 vs 2.3 +/- 0.7 p < 0.001) after angiography. CrCl showed no difference 1 week (24 +/- 11 vs 19 +/- 9 ml/min, ns) and 8 weeks (24 +/- 5 vs 20 +/- 9 ml/min, NS) after angiography from baseline or between the groups. In each group, 2 patients developed end-stage renal disease and requested permanent dialysis during the 8-week follow-up. Simultaneous dialysis reduces AUC of iomeprol significantly, however, does not influence plasma peak concentration after angiography. Renal function and incidence of end-stage renal failure were not influenced by online-dialysis.

Improved visualization of coronary arteries using a new three-dimensional submillimeter MR coronary angiography sequence with balanced gradients.

The goal of our study was to evaluate a new three-dimensional real-time navigator MR coronary angiography sequence to noninvasively visualize the coronary arteries. Fifteen healthy volunteers underwent MR coronary angiography with a new balanced turbo field-echo sequence in comparison with the standard turbo field-echo sequence. Signal-to-noise, blood-to-myocardium, blood-to-fat, and blood-to-pericardial fluid contrast ratios of the left and right coronary artery systems were measured. Image quality was graded, the length and diameter of the coronary arteries were measured, and the number of visible side branches was assessed. The balanced turbo field-echo images yielded a higher blood-to-myocardium and blood-to-pericardial fluid contrast ratio, a similar blood-to-fat contrast ratio, and a lower signal-to-noise ratio than the turbo field-echo images. On a 5-point grading scale (1, nondiagnostic or unreadable; 2, poor; 3, moderate; 4, good; 5, excellent), image quality was rated significantly better for the balanced turbo field-echo sequence than for the turbo field-echo sequence (left coronary artery, 4.0 +/- 0.6 vs 3.6 +/- 0.5 [p = 0.015]; right coronary artery, 4.4 +/- 0.4 vs 3.6 +/- 0.4 [p < 0.0001], respectively), resulting in a significantly longer segment of the three major coronary arteries visualized (left anterior descending coronary artery, 92 +/- 21 mm vs 79 +/- 24 mm; left circumflex coronary artery, 70 +/- 7 mm vs 60 +/- 18 mm; right coronary artery, 112 +/- 28 mm vs 95 +/- 27 mm) and a significantly higher number of side branches visualized (left anterior descending coronary artery, 2.9 +/- 1.3 vs 1.5 +/- 1.3; left circumflex coronary artery, 2.1 +/- 1.7 vs 1.0 +/- 1.2; right coronary artery, 3.7 +/- 1.7 vs 2.6 +/- 1.5). Mean imaging time per coronary artery was significantly shorter for the balanced turbo field-echo sequence (5.7 +/- 1.0 min) than for the turbo field-echo sequence (8.4 +/- 1.4 min) (p < 0.0001). Compared with standard turbo field-echo MR coronary angiography, optimized balanced turbo field-echo MR coronary angiography improves the visualization of the coronary arteries and their side branches within a significantly shorter imaging time.

Usefulness of rotational spin for coronary angiography in patients with advanced renal insufficiency

Coronary angiography in patients with advanced renal insufficiency is typically restricted to cases of life-threatening circumstances such as acute myocardial infarction and unstable angina. To gather a large amount of visual information with a minimum number of cine runs, and consequently, with a minimum volume of contrast medium, we rotated the gantry at 40°/s throughout an angle of 120°, from the right toward the left anterior oblique positions. This technique of rotational spin during cinegraphic runs has not yet become established in invasive cardiology. Three experienced cardiologists independently evaluated all coronary segments in rotational versus standard coronary angiography modes for 15 patients, on the basis of an 11-point scale (0 = cardiac spin far better to 10 = standard mode far better). A score of 5 signified that there was no difference in quality between the 2 modes. The arithmetic mean of the assessment values was 4.9 ± 0.3 for coronary segments, 5.4 ± 1.3 for coronary lesions, 5.1 ± 1.4 for bifurcations, and 5.0 ± 0.1 for coronary flow. The arithmetic means for the volume of contrast medium (25 ± 4 ml), for the overall dose area product (8.6 ± 4.5 Gy × cm 2), and for the number of cine graphic frames (203 ± 65) for a diagnostic cardiac spin were significantly below published typical values in standard mode. Cardiac spin enables 3-dimensional coronary impression under conditions of adequate image quality and represents a new, useful, and beneficial method in invasive cardiology for applications involving the special indication of advanced renal insufficiency.

Outcome after myocardial revascularization and renal transplantation: a 25-year single-institution experience.

Cardiac disease is a common cause of death in renal transplant recipients. This study retrospectively analyzes the results of myocardial revascularization procedures in these patients and makes recommendations for managing coronary atherosclerosis in patients with renal disease who already have a transplanted kidney or who may receive a kidney transplant. Patients who had myocardial revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) and renal transplantation at the authors' institution between 1968 and 1994 were analyzed. Patient, procedural, and institutional variables were used for actuarial analyses of survival, as well as multivariate analyses of risk factors for death. Eighty-three of 2989 renal transplant patients required myocardial revascularization either before or after their transplant, and diabetes mellitus was the cause of renal failure in 42% of these patients. Standard coronary angiography, CABG, and PTCA techniques were used without periprocedural renal allograft loss. Actuarial patient survival was 89%, 77%, and 65% at 1, 3, and 5 years after the last procedure (transplantation or revascularization). Cardiac disease was the most common mode of death. Early-phase risk factors for death by multivariate analysis included hypertension and revascularization before 1989. Late-phase risk factors for death included diabetes mellitus, higher number of pre-CABG myocardial infarctions, renal transplantation before 1984, older age, and unstable angina before CABG. Myocardial revascularization can be performed with acceptable short- and long-term results in patients with renal disease who have renal transplantation either before or after the revascularization procedure. Diabetes mellitus was a highly prevalent condition among these patients, and cardiac disease was their most common mode of death. PTCA and CABG, as performed at this institution, posed little risk for renal allograft loss. Modification of risk factors for coronary atherosclerosis, rigorous cardiac evaluation of patients at risk for coronary artery disease before renal transplantation, and aggressive use of revascularization procedures to decrease the incidence of myocardial infarction are proposed as ways to prolong the survival of renal transplant patients with ischemic heart disease.

Determinants of exercise-induced ST-segment displacement in the aVL lead in patients with known or suspected coronary artery disease.

Although the aVL lead in exercise electrocardiography is reported to be helpful in identifying a significant narrowing of the left anterior descending coronary artery (LAD), its role in exercise testing has not been fully evaluated. Accordingly, 821 patients who underwent both standard exercise testing and coronary angiography were evaluated. In patients with aVL lead ST elevation, the incidence of a significant narrowing of the LAD (124/165 vs 348/656; p<0.001) was higher than in those without. Multiple logistic regression analysis revealed that the 2 most important variables that correlated with aVL lead ST elevation were a greater number of leads with ST depression in the inferior leads and a smaller amplitude of R wave in the aVL lead. In contrast, variables correlating with aVL lead ST depression in the majority of cases were a greater number of leads with ST depression in all leads and the presence of inferior lead ST elevation. The results of this study indicate that although aVL lead ST elevation could be a marker for LAD narrowing, more important factors such as inferior lead ST-segment depression and the R-wave amplitude of the aVL lead should be taken into consideration. In contrast, ST depression in the aVL lead mostly represents exercise-induced myocardial ischemia of greater extent and severity.

Management Strategy for Simultaneous Carotid Endarterectomy and Coronary Revascularization

Background. The occurrence of significant carotid artery disease in patients requiring coronary artery bypass grafting (CABG) results in a dilemma regarding the best surgical management. Our philosophy has been to perform simultaneous carotid endarterectomy and CABG. We reviewed the efficacy of this therapy in patients treated at a large community-based hospital. Methods. During a 6-year period, from 1990 to 1996, 88 patients underwent simultaneous carotid endarterectomy and CABG. All patients underwent preoperative four-vessel arch arteriography and standard coronary angiography. The principal indications for combined procedures were the need for CABG and (1) symptomatic carotid artery disease; (2) internal carotid artery stenosis of 80% or more, with or without contralateral disease; or (3) an ulcerated, unstable internal carotid artery lesion, regardless of degree of stenosis. The average patient age was 68 years, and there was a 3:1 male-to-female predominance. All procedures were performed with the patients under general anesthesia. The carotid endarterectomy was performed first, and an intraluminal shunt was used in all patients. Results. The average degree of stenosis on the operated side was 86.2%. An average of 3.6 coronary bypasses per patient were performed. Morbidity included four strokes (4.5%). There were no perioperative myocardial infarctions. There were three hospital deaths (3.4%). The combined permanent stroke and mortality rate was 6.8%. Univariate predictors of stroke were an elevated serum creatinine level, a pulmonary complication, and left main coronary artery disease. Univariate predictors of hospital death were stroke, an elevated serum creatinine level, peripheral vascular disease, and left main coronary artery disease. Multivariate predictors of a prolonged hospitalization were stroke, an elevated serum creatinine level, and a pulmonary complication. Eighty-five patients (96.6%) were discharged and alive at 30 days. Conclusions. In the context of the indications we used to select patients for simultaneous carotid endarterectomy and CABG, the combined permanent stroke and mortality rate was less than 7%. Our management strategy identified patients that were at increased surgical risk as a result of advanced carotid and coronary artery disease. In our practice, simultaneous carotid endarterectomy and CABG is the preferred surgical approach for these high-risk patients and results in a low in-hospital morbidity and mortality using a single anesthetic and hospitalization.

Genetic polymorphisms of the renin-angiotensin system and angiographic extent and severity of coronary artery disease: the CORGENE study.

Genetic polymorphisms of the renin-angiotensin system (RAS) have been associated with coronary artery disease (CAD) but no relation between these polymorphisms and coronary atherosclerosis has yet been systematically evaluated. The CORGENE study is a cross-sectional study involving 463 Caucasians who underwent standardized coronary angiography for established or suspected CAD [156 patients with a previous myocardial infarction (MI), 307 without MI]. Four angiographic scores assessing the extent and severity of the coronary lesions were obtained from a double visual analysis of each angiogram, arbitration being achieved by a quantitative measurement. Three different genotypes were analyzed: the angiotensin I-converting enzyme insertion/deletion (ACE I/D) polymorphism, the Met to Thr change at position 235 of the angiotensinogen gene (AGT M235T) and the A to C transition at position 1166 of the angiotensin II type-1 receptor gene (AT1R A1166C). No significant association was observed between these polymorphisms and the clinical characteristics of MI and non-MI subjects. While most classical risk factors were positively correlated with the angiographic scores, no significant relationship could be established with the three genotypes (r ranging from -0.08 to 0.05). Only one significant correlation was observed: between the presence of the AGT 235T allele and the extent of the coronary lesions (r = -0.19, P = 0.04) in patients with low-risk status. These overall results are not in favor of a role of these RAS genetic polymorphisms in the development of coronary atherosclerosis.

Synchrotron Transvenous Angiography Holds Promise in Coronary Studies

A NEW IMAGING TECHNIQUE may provide a less invasive alternative to coronary angiography. The technique, synchrotron radiation-based transvenous angiography, requires only an iodinated contrast agent administered intravenously and in lower concentrations than required for cardiac catheterization. It utilizes lower radiation doses and takes less time to perform than coronary angiography. Edward Rubenstein, MD, who described the procedure at the recent annual meeting of the American Association for the Advancement of Science in San Francisco, Calif, said that because the procedural risk is much lower than that of standard coronary angiography, the technique has potential utility in long-term studies of atherogenesis and may be suitable for clinical use as well. Rubenstein, a professor of Medicine at Stanford (Calif) University Medical Center, has been developing the technique with a team of cardiologists and physicists at Stanford, Lawrence Berkeley Laboratory, and the National Synchrotron Light Source, Brookhaven National Laboratory, Long Island, NY. The