Atherosclerotic plaques vulnerable for rupture are characterised by e.g., a large lipid pole, a high concentration of inflammatory cells and a thin fibrous cap. Recent research has showed that vuln ...
Eleven patients presenting with the clinical diagnosis of suspected aortic dissection underwent intravenous digital subtraction aortography. In nine patients digital subtraction angiography (DSA) was performed as the investigation of first choice. In five of these the diagnosis was confirmed with this technique alone and surgical repair was undertaken without further investigation. Direct cine aortography was also undertaken in the other four patients and confirmed the DSA findings, demonstrating aortic dissection in one case and no dissection in three others. In two of the eleven patients, direct cine aortography was performed as the initial investigation. The results of subsequent digital aortography concurred in both cases, aortic dissection being demonstrated in one patient. In two cases, despite normal cine and digital aortography, aortic dissection was confirmed by computed tomography. We have found DSA to be a valuable technique for diagnosing aortic dissection, with no false positive or false negative findings when compared to direct cine aortography. Since it is a less traumatic procedure than direct aortography it should be the investigation of choice if computed tomography is not immediately available.
Left ventricular performance during percutaneous transluminal coronary angioplasty was assessed in 52 patients by intravenous digital subtraction ventriculography. After injection of contrast into the right atrium ventriculograms were obtained before and during balloon inflation. In 37 patients they were also obtained after the procedure. A 12 lead electrocardiogram was monitored throughout. During balloon inflation the left ventricular ejection fraction fell (from 73% to 57%) in all but one patient; the decreases in patients with single vessel or multivessel disease were similar. The fall in left ventricular ejection fraction during percutaneous transluminal coronary angioplasty of the left anterior descending artery (19%) was significantly greater than that during balloon inflation in the right coronary (10%) or circumflex (8%) coronary arteries. It also reduced anterobasal, anterior, and apical segmental shortening while right coronary percutaneous transluminal coronary angioplasty affected inferior and apical segments. In 33 (63%) patients the ST segment was altered during balloon inflation. The fall in left ventricular ejection fraction correlated significantly with the magnitude of both ST segment elevation (r = 0.637) and ST depression (r = 0.396). Left ventricular ejection fraction and regional wall motion returned to baseline values after the procedure. Balloon inflation during percutaneous transluminal coronary angioplasty produces considerable abnormalities of global and regional left ventricular performance and this indicates the presence of myocardial ischaemia, which may not be apparent on electrocardiographic monitoring. Intravenous digital subtraction ventriculography is useful for monitoring left ventricular performance during controlled episodes of coronary occlusion produced by balloon inflation.
The decision-making process in the management of patients with ischaemic heart disease has historically been the responsibility of the cardiologist and encompasses medical management, percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). Currently, there is significant geographical variability in the PCI:CABG ratio. There are now emerging recommendations that this decision-making process should be carried out through a multidisciplinary approach, namely the Heart Team. This work was carried out on behalf of The British Cardiovascular Society (BCS), Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) and British Cardiovascular Intervention Society (BCIS). This manuscript sets out the principles for the functioning of the Heart Team. This work has been approved by the Executive Committees of BCS/BCIS/SCTS.
Contemporary national and international guidelines recommend that patients with stable angina and acute coronary syndromes (ACS) with multi-vessel disease are discussed by a multidisciplinary “Heart Team” (HT) to facilitate optimal evidence-based management. However, there is a paucity of data describing the workings of a HT, actioning of it9s recommendations and reproducibility of decisions.
Methods
We have utilised a HT approach since 2005, meeting twice weekly with our HT database managed by a dedicated co-ordinator. We analysed the data for 2010 and describe the HT process. A random sample of cases were scrutinised to identify whether the HT decision had been implemented. Additionally, cases were re-presented to the HT after 1 year to determine consistency and reproducibility of decision making. The HT panel for the review process did not include members involved in the original discussion.
Results
During 2010, 108 meetings were held, attended by a median of 3 interventional cardiologists, 1 non-interventional cardiologist and 2 cardiac surgeons. A total of 1454 cases were discussed (mean 13.5 cases per meeting). 854 cases (58.7%) were from our own unit and 600 (41.3%) from referring hospitals. 356 (24.5%) were current inpatients and 1098 (75.5%) were outpatients. 1340 (92.2%) were patients with stable coronary artery disease (CAD) or ACS. The HT recommendation was for coronary artery bypass grafting (CABG) ± valve surgery in 429 (32%) cases, percutaneous coronary intervention (PCI) in 303 (22.6%), and optimised medical therapy (OMT) in 264 (19.7%). In the remaining 344 cases (25.7%) further investigation was advised before a HT decision was made; the most frequent recommendation was for a pressure wire study, in 151 cases (43.9%). 117 randomly selected cases were analysed to determine whether the HT recommendation had been actioned. This occurred in 101 (86.3%) cases. In the remaining 16 cases, deviation from the initial plan was due to the patient declining revascularisation (CABG 3, PCI 1), development of new co-morbidity (2) or revascularisation of different vessels (6). The reason for deviation was unclear in four cases. 50 cases were re-presented after 1 year with the original HT recommendation being the same in 38 cases (76%). Different decisions in the remaining 12 (24%) included seven cases (14%) in which further investigation had initially been suggested, and re-vascularisation was recommended on re-presentation.
Conclusions
A well-structured HT allows a large number of cases to be evaluated while interdisciplinary discussion facilitates consensus with evidence-based and individualised advice. There is a prominent role for pressure wire assessment in the further evaluation of equivocal CAD. The HT approach appears robust and reproducible in the majority of cases. Variation in decision making reflects the equipoise between suitability of CABG, PCI and OMT in many cases.
To assess the potential protective role of collateral vessels 27 patients undergoing angioplasty of the left anterior descending coronary artery were studied by intravenous digital subtraction left ventriculography. Fifteen patients had no collateral vessels (group 1) and 12 had some degree of collateral supply (group 2). During balloon inflation ST segment elevation in group 1 (4.9 mm) was significantly greater than that in group 2 (0.9 mm). Similarly the reduction in left ventricular ejection fraction was significantly greater in group 1 (24%) than in group 2 (12%). Both the size of ST segment elevation and the fall in ejection fraction correlated inversely with the extent of the collateral supply (r = -0.680 and r = -0.446 respectively). During balloon occlusion of the anterior descending coronary artery the percentage shortening of the anterior and apical segments fell in both groups but apical shortening fell to a lesser extent in group 2. An additional reduction in anterobasal contraction was confined to group 1. Electrocardiographic and ventriculographic manifestations of ischaemia produced by balloon inflation during angioplasty are less pronounced when collateral vessels are present. This suggests that the collateral circulation can protect myocardium at risk of ischaemia after coronary occlusion.
Recent ESC/EACTS revascularization guidelines advocate a 'Heart Team' (HT) approach in the decision-making process when managing patients with coronary disease. We prospectively assessed HT decision-making in 150 patients analysing personnel attendance, data presented, the 'actioning' of the HT decision and, if not completed, then the reasons why. Additionally, 50 patients were specifically re-discussed after 1 year in order to assess consistency in decision-making. We have two HT meetings each week. At least one surgeon, interventional cardiologist and non-interventional cardiologist were present at all meetings. Data presented included patient demographics, symptoms, co-morbidities, coronary angiography, left ventricular function and other relevant investigations, e.g. echocardiograms. HT decisions included continued medical treatment (22%), percutaneous coronary intervention (PCI; 22%), coronary-artery bypass grafting (CABG; 34%) or further investigations such as pressure wire studies, dobutamine stress echo or cardiac magnetic resonance imaging (22%). These decisions were fully undertaken in 86% of patients. Reasons for aberration in the remaining 21 patients included patient refusal (CABG 29%, PCI 10%) and further co-morbidities (28%). On re-discussion of the same patient data (n = 50) a year later, 24% of decisions differed from the original HT recommendations reflecting the fact that, for certain coronary artery disease pattern, either CABG or PCI could be appropriate.
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