Objective Angiographic assessment of a left main coronary artery (LMCA) stenosis is often difficult and unreliable. Intravascular ultrasound (IVUS) assessment of absolute lumen dimensions has been shown to correlate w...Objective Angiographic assessment of a left main coronary artery (LMCA) stenosis is often difficult and unreliable. Intravascular ultrasound (IVUS) assessment of absolute lumen dimensions has been shown to correlate with fractional flow reserve (FFR) and to predict clinical outcome in patients with a LMCA stenosis. Methods During 21 months period (October, 2004 to July, 2006), 153 patients (Ostial lesions, n=47; Non-ostial lesion, n=106) underwent IVUS evaluation specifically to assess the severity of an angiographically inconclusive LMCA narrowing. IVUS analysis included plaque morphology; external elastic membrane (EEM), lumen, plaque cross-sectional areas (CSA), plaque burden (plaque CSA/ EEM) and remodeling index (lesion EEM CSA/reference EEM CSA). Results Overall, minimum lumen area (MLA) and diameter (MLD) and plaque burden measured 8.2 mm2, 2.6 mm, and 59.3 %, respectively. An MLA【6.0 mm2 (which has been shown to correlate with a FFR 【0.75) was seen 41.5% in ostial lesions and 44.5% in non-ostial lesions. In particular, ostial LMCA lesions had a larger MLA and a smaller plaque burden than non-ostial lesions (Table). Conclusions Patients referred for LMCA evaluation commonly have insignificant narrowing. Negative remodeling was prominent at the LMCA ostium. These patients deserve IVUS assessment before revascularization.展开更多
Objectives We compared intravascular ultrasound (IVUS) findings of drug-eluting stent (DES)-treated lesions that developed stent thrombosis versus in-stent restenosis (ISR) to identify underlying mechanical difference...Objectives We compared intravascular ultrasound (IVUS) findings of drug-eluting stent (DES)-treated lesions that developed stent thrombosis versus in-stent restenosis (ISR) to identify underlying mechanical differences. Methods IVUS findings in 15 post-DES thrombosis patients were compared with 45 matched ISR patients who had no evidence of stent thrombosis. Results Minimum stent area [MSA, (3.7±0.8) mm2 vs (4.9±1.8) mm2, P=0.01], minimum stent diameter [(1.9±0.3) mm vs (2.3±0.4) mm, P=0.005], mean stent area [(5.2±0.8) mm2 vs (7.2±2.1) mm2, P【0.01], and both focal [MSA/reference lumen area, (54.7±15.9)% vs (75.0±20.1)%, P=0.001] and diffuse stent expansion [mean stent area/reference lumen area, (76.6±23.0)% vs (110.3±23.3)%, P【0.01] were significantly smaller in the stent thrombosis group (vs the ISR group). An MSA 【4.0 mm2 (73.3% vs 35.6%, P=0.01) or 【5.0 mm2 (86.7% vs 53.3%, P=0.02) was more often found in the stent thrombosis group (vs the ISR group). The MSA site occurred more frequently in the proximal stent segment within the stent thrombosis group compared to the ISR group (60% vs 24.4%, P=0.01). There were no differences in edge dissection, stent fracture, or stent-vessel wall malapposition between the two groups. Independent predictors of stent thrombosis were diffuse stent expansion (OR=1.5, P=0.03) and proximal location of the MSA site (OR=12.7, P=0.04). Conclusion DES-treated lesions that develop thrombosis or restenosis are often underexpanded. Underexpansion appears to be more severe in DES-thrombosis lesions. Lesions with diffuse underexpansion and a proximal (vs distal) underexpanded MSA site are more predisposed to thrombus formation than ISR.展开更多
Objective We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections and intramural hematomas after drug-eluting stent (DES) implantation. Method...Objective We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections and intramural hematomas after drug-eluting stent (DES) implantation. Methods We studied 887 patients with 1 045 non-in-stent restenosis lesions in 977 native arteries undergoing DES implantation with IVUS imaging, and compared the dissected stent end to the non-dissected stent end. Results Eighty-two dissections were detected; 51.2% (42/82) involved the proximal and 48.8% (40/82) the distal stent edge. When compared to the non-dissected stent end, residual plaque area [(8.0±4.3) mm2 vs (5.2±3.0) mm2, P【0.01], plaque burden [(52±12)% vs (36±15)%, P【0.01], plaque eccentricity (8.4±5.5 vs 4.0±3.4, P【0.01), and stent edge symmetry (1.17±0.11 vs 1.14±0.08, P=0.02) were larger; plaque burden≥50% was more frequent (62% vs 17%, P【0.01) and calcium deposits (52.5% vs 35.6%, P=0.03) more common; and the lumen/stent area (0.86±0.16 vs 1.02±0.18, P【0.01) was smaller in the stent dissected end. Independent predictors of stent edge dissection were residual plaque eccentricity (OR=1.3, P【0.01) and residual plaque burden≥50% (OR=7.3, P【0.01). Intramural hematomas occurred in 34.1% (28/82) of dissections.Independent predictors of intramural hematomas were plaque eccentricity (OR=1.4, P=0.005), plaque burden≥50% (OR=7.1, P=0.02), and mean lumen diameter to stent diameter ratio (OR=0.37, P=0.04).Concluslon IVUS identified edge dissections after 9.4% of DES implantations. Residual plaque eccentricity and significant plaque burden predicted coronary stent edge dissections. Dissections in less diseased reference segments with an arc of normal vessel wall (greater plaque eccentricity) more often evolved into an intramural hematoma.展开更多
Intravenous anticoagulant therapy is critical to prevent ischemic recurrences and complications without increasing the risk of bleeding in patients with ST-segment elevation myocardial infarction (STEMI) undergoing pr...Intravenous anticoagulant therapy is critical to prevent ischemic recurrences and complications without increasing the risk of bleeding in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). It includes the indirect thrombin inhibitor heparins and the direct thrombin inhibitor bivalirudin. However, the ideal anticoagulant for patients undergoing PPCI remains controversial. In this review, we provide an overview of currently available anticoagulant therapies used in STEMI patients undergoing PPCI, including describing the rationale for their use, pivotal clinical trial data, and treatment recommendations of guidelines, providing much-needed clarity to guide the selection of the safest and most effective anticoagulant regimens for PPCI.展开更多
Intravenous anticoagulant therapy is critical to prevent ischemic events without increasing the risk of bleeding in patients with ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous corona...Intravenous anticoagulant therapy is critical to prevent ischemic events without increasing the risk of bleeding in patients with ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous coronary intervention(PPCI).Heparin and bivalirudin are the most commonly used adjunctive anticoagulant agents during PPCI.However,the superiority of the 2 most optimal regimens with these agents in patients undergoing PPCI remains controversial.The BivaliRudin with prolonged high-dose Infusion durinG PPCI versus Heparin Trial 4(BRIGHT-4)is a large-scale,prospective,multicenter,active-control,parallel-group,open-label,randomized trial designed to test whether bivalirudin with a post-PCI high-dose infusion is superior to heparin monotherapy in STEMI patients undergoing PPCI.A total of 6000 patients will be enrolled and randomly assigned to receive bivalirudin or heparin in a 1:1 ratio.Patients allocated to the bivalirudin group will be treated with a high-dose bivalirudin infusion(1.75 mg/(kg·h))after PCI for 2 to 4 hours.In the heparin group,the use of glycoprotein IIb/IIIa inhibitors will be reserved for the development of procedural thrombotic complications.The efficacy and safety of bivalirudin will be evaluated at 30 days,6 months,and 12 months after the randomization.The primary endpoint is a composite of all-cause death or Bleeding Academic Research Consortium(BARC)types 3 to 5 bleeding at 30 days after randomization.The BRIGHT-4 study protocol has received approval from the ethics committee of General Hospital of Northern Theater Command(Shenyang,China).The procedures set out in this protocol are in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines.The results will be published following the Consolidated Standards of Reporting Trials statement in a peer-reviewed scientific journal(Trial registration number:NCT03822975).展开更多
文摘Objective Angiographic assessment of a left main coronary artery (LMCA) stenosis is often difficult and unreliable. Intravascular ultrasound (IVUS) assessment of absolute lumen dimensions has been shown to correlate with fractional flow reserve (FFR) and to predict clinical outcome in patients with a LMCA stenosis. Methods During 21 months period (October, 2004 to July, 2006), 153 patients (Ostial lesions, n=47; Non-ostial lesion, n=106) underwent IVUS evaluation specifically to assess the severity of an angiographically inconclusive LMCA narrowing. IVUS analysis included plaque morphology; external elastic membrane (EEM), lumen, plaque cross-sectional areas (CSA), plaque burden (plaque CSA/ EEM) and remodeling index (lesion EEM CSA/reference EEM CSA). Results Overall, minimum lumen area (MLA) and diameter (MLD) and plaque burden measured 8.2 mm2, 2.6 mm, and 59.3 %, respectively. An MLA【6.0 mm2 (which has been shown to correlate with a FFR 【0.75) was seen 41.5% in ostial lesions and 44.5% in non-ostial lesions. In particular, ostial LMCA lesions had a larger MLA and a smaller plaque burden than non-ostial lesions (Table). Conclusions Patients referred for LMCA evaluation commonly have insignificant narrowing. Negative remodeling was prominent at the LMCA ostium. These patients deserve IVUS assessment before revascularization.
文摘Objectives We compared intravascular ultrasound (IVUS) findings of drug-eluting stent (DES)-treated lesions that developed stent thrombosis versus in-stent restenosis (ISR) to identify underlying mechanical differences. Methods IVUS findings in 15 post-DES thrombosis patients were compared with 45 matched ISR patients who had no evidence of stent thrombosis. Results Minimum stent area [MSA, (3.7±0.8) mm2 vs (4.9±1.8) mm2, P=0.01], minimum stent diameter [(1.9±0.3) mm vs (2.3±0.4) mm, P=0.005], mean stent area [(5.2±0.8) mm2 vs (7.2±2.1) mm2, P【0.01], and both focal [MSA/reference lumen area, (54.7±15.9)% vs (75.0±20.1)%, P=0.001] and diffuse stent expansion [mean stent area/reference lumen area, (76.6±23.0)% vs (110.3±23.3)%, P【0.01] were significantly smaller in the stent thrombosis group (vs the ISR group). An MSA 【4.0 mm2 (73.3% vs 35.6%, P=0.01) or 【5.0 mm2 (86.7% vs 53.3%, P=0.02) was more often found in the stent thrombosis group (vs the ISR group). The MSA site occurred more frequently in the proximal stent segment within the stent thrombosis group compared to the ISR group (60% vs 24.4%, P=0.01). There were no differences in edge dissection, stent fracture, or stent-vessel wall malapposition between the two groups. Independent predictors of stent thrombosis were diffuse stent expansion (OR=1.5, P=0.03) and proximal location of the MSA site (OR=12.7, P=0.04). Conclusion DES-treated lesions that develop thrombosis or restenosis are often underexpanded. Underexpansion appears to be more severe in DES-thrombosis lesions. Lesions with diffuse underexpansion and a proximal (vs distal) underexpanded MSA site are more predisposed to thrombus formation than ISR.
文摘Objective We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections and intramural hematomas after drug-eluting stent (DES) implantation. Methods We studied 887 patients with 1 045 non-in-stent restenosis lesions in 977 native arteries undergoing DES implantation with IVUS imaging, and compared the dissected stent end to the non-dissected stent end. Results Eighty-two dissections were detected; 51.2% (42/82) involved the proximal and 48.8% (40/82) the distal stent edge. When compared to the non-dissected stent end, residual plaque area [(8.0±4.3) mm2 vs (5.2±3.0) mm2, P【0.01], plaque burden [(52±12)% vs (36±15)%, P【0.01], plaque eccentricity (8.4±5.5 vs 4.0±3.4, P【0.01), and stent edge symmetry (1.17±0.11 vs 1.14±0.08, P=0.02) were larger; plaque burden≥50% was more frequent (62% vs 17%, P【0.01) and calcium deposits (52.5% vs 35.6%, P=0.03) more common; and the lumen/stent area (0.86±0.16 vs 1.02±0.18, P【0.01) was smaller in the stent dissected end. Independent predictors of stent edge dissection were residual plaque eccentricity (OR=1.3, P【0.01) and residual plaque burden≥50% (OR=7.3, P【0.01). Intramural hematomas occurred in 34.1% (28/82) of dissections.Independent predictors of intramural hematomas were plaque eccentricity (OR=1.4, P=0.005), plaque burden≥50% (OR=7.1, P=0.02), and mean lumen diameter to stent diameter ratio (OR=0.37, P=0.04).Concluslon IVUS identified edge dissections after 9.4% of DES implantations. Residual plaque eccentricity and significant plaque burden predicted coronary stent edge dissections. Dissections in less diseased reference segments with an arc of normal vessel wall (greater plaque eccentricity) more often evolved into an intramural hematoma.
基金supported by the Key Research and Development Program of Liaoning Province(2020JH 2/10300167)Project of Science and Technology Plan of Shenyang(19-112-4-051)Cardiacare Sponsored Optimizing Antithrombotic Research Fund(BJUHFCSOARF201901-06).
文摘Intravenous anticoagulant therapy is critical to prevent ischemic recurrences and complications without increasing the risk of bleeding in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). It includes the indirect thrombin inhibitor heparins and the direct thrombin inhibitor bivalirudin. However, the ideal anticoagulant for patients undergoing PPCI remains controversial. In this review, we provide an overview of currently available anticoagulant therapies used in STEMI patients undergoing PPCI, including describing the rationale for their use, pivotal clinical trial data, and treatment recommendations of guidelines, providing much-needed clarity to guide the selection of the safest and most effective anticoagulant regimens for PPCI.
基金supported by the Chinese Society of Cardiology’s Foundation.
文摘Intravenous anticoagulant therapy is critical to prevent ischemic events without increasing the risk of bleeding in patients with ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous coronary intervention(PPCI).Heparin and bivalirudin are the most commonly used adjunctive anticoagulant agents during PPCI.However,the superiority of the 2 most optimal regimens with these agents in patients undergoing PPCI remains controversial.The BivaliRudin with prolonged high-dose Infusion durinG PPCI versus Heparin Trial 4(BRIGHT-4)is a large-scale,prospective,multicenter,active-control,parallel-group,open-label,randomized trial designed to test whether bivalirudin with a post-PCI high-dose infusion is superior to heparin monotherapy in STEMI patients undergoing PPCI.A total of 6000 patients will be enrolled and randomly assigned to receive bivalirudin or heparin in a 1:1 ratio.Patients allocated to the bivalirudin group will be treated with a high-dose bivalirudin infusion(1.75 mg/(kg·h))after PCI for 2 to 4 hours.In the heparin group,the use of glycoprotein IIb/IIIa inhibitors will be reserved for the development of procedural thrombotic complications.The efficacy and safety of bivalirudin will be evaluated at 30 days,6 months,and 12 months after the randomization.The primary endpoint is a composite of all-cause death or Bleeding Academic Research Consortium(BARC)types 3 to 5 bleeding at 30 days after randomization.The BRIGHT-4 study protocol has received approval from the ethics committee of General Hospital of Northern Theater Command(Shenyang,China).The procedures set out in this protocol are in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines.The results will be published following the Consolidated Standards of Reporting Trials statement in a peer-reviewed scientific journal(Trial registration number:NCT03822975).