BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated w...BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.展开更多
Introduction and Objectives: The natural history of patients with left main coronary artery disease (LMCAD) is largely unknown. Our objective was to analyse the predictors of long-term mortality in these patients, bot...Introduction and Objectives: The natural history of patients with left main coronary artery disease (LMCAD) is largely unknown. Our objective was to analyse the predictors of long-term mortality in these patients, both those that have had surgery and those that have not undergone surgery for various reasons, in a cohort treated at a university hospital. Methods: The study included patients with significant LMCAD diagnosed through consecutive coronary angiograms from 2001 to 2009. Clinical variables, the reasons for cardiac catheterisation, therapeutic decisions and clinical evolution in long-term follow-up were analysed. Results: Of the 163 patients included in the analysis, a total of 109 (66.9%) underwent revascularisation, while the remaining 54 (33.1%) received other medical treatment. We analysed the clinical events that took place with a mean follow-up period of 54 months (IQR: 25-95). The non-revascularised group had a lower survival rate than the revascularised group in unadjusted analysis (logrank test 0.005). Age (OR 1.04, CI 1.02-1.07, p = 0.001), ventricular dysfunction (OR 2.87, CI95% 1.71-4.81, p 0.0001), clinical instability (OR 2.11, CI95% 1.08 to 4.13, p = 0.028) and above 70% severity of LMCAD (OR 1.78, CI 1.09 to 2.91, p = 0.021) were independent predictors of mortality for the entire cohort, but revascularisation was not. Conclusions: Revascularisation is associated with improved survival in patients with LMCAD, but only age, ventricular dysfunction, clinical instability and the severity of the lesion are independent predictors of long-term mortality in the unselected population.展开更多
Renal artery stenosis is a common cause of secondary hypertension and chronic kidney disease. We present here a case of fibromuscular dysplasia that was treated with surgical revascularization, resulting in recovery o...Renal artery stenosis is a common cause of secondary hypertension and chronic kidney disease. We present here a case of fibromuscular dysplasia that was treated with surgical revascularization, resulting in recovery of kidney function with eventual cessation of chronic dialysis. The case involves a 25-year-old female with coincidentally discovered hypertension, who underwent further investigations revealing a diagnosis of renal artery stenosis due to fibromuscular dysplasia. She subsequently developed two episodes of malignant hypertension, with flash pulmonary oedema and worsening renal failure that resulted in dialysis dependence. After evidence was obtained that the right kidney was still viable, a revascularization procedure was performed, improving blood pressure control and restoring kidney function, thereby allowing dialysis to be stopped. This case highlights the importance of evaluating patients with renal artery stenosis for revascularization before committing them to a life of chronic dialysis.展开更多
文摘BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.
文摘Introduction and Objectives: The natural history of patients with left main coronary artery disease (LMCAD) is largely unknown. Our objective was to analyse the predictors of long-term mortality in these patients, both those that have had surgery and those that have not undergone surgery for various reasons, in a cohort treated at a university hospital. Methods: The study included patients with significant LMCAD diagnosed through consecutive coronary angiograms from 2001 to 2009. Clinical variables, the reasons for cardiac catheterisation, therapeutic decisions and clinical evolution in long-term follow-up were analysed. Results: Of the 163 patients included in the analysis, a total of 109 (66.9%) underwent revascularisation, while the remaining 54 (33.1%) received other medical treatment. We analysed the clinical events that took place with a mean follow-up period of 54 months (IQR: 25-95). The non-revascularised group had a lower survival rate than the revascularised group in unadjusted analysis (logrank test 0.005). Age (OR 1.04, CI 1.02-1.07, p = 0.001), ventricular dysfunction (OR 2.87, CI95% 1.71-4.81, p 0.0001), clinical instability (OR 2.11, CI95% 1.08 to 4.13, p = 0.028) and above 70% severity of LMCAD (OR 1.78, CI 1.09 to 2.91, p = 0.021) were independent predictors of mortality for the entire cohort, but revascularisation was not. Conclusions: Revascularisation is associated with improved survival in patients with LMCAD, but only age, ventricular dysfunction, clinical instability and the severity of the lesion are independent predictors of long-term mortality in the unselected population.
文摘Renal artery stenosis is a common cause of secondary hypertension and chronic kidney disease. We present here a case of fibromuscular dysplasia that was treated with surgical revascularization, resulting in recovery of kidney function with eventual cessation of chronic dialysis. The case involves a 25-year-old female with coincidentally discovered hypertension, who underwent further investigations revealing a diagnosis of renal artery stenosis due to fibromuscular dysplasia. She subsequently developed two episodes of malignant hypertension, with flash pulmonary oedema and worsening renal failure that resulted in dialysis dependence. After evidence was obtained that the right kidney was still viable, a revascularization procedure was performed, improving blood pressure control and restoring kidney function, thereby allowing dialysis to be stopped. This case highlights the importance of evaluating patients with renal artery stenosis for revascularization before committing them to a life of chronic dialysis.
