Journal of Geriatric Cardiology (2013)10:2172252013JGC All rights rerved;
www. m; m |J o u rn al o f Ger iatric Card io lo g
y
Symposium:Rotational atherectomy updating Open Access
Guest Editor:Prof.Wei-HsianYin
Rotablation in the tr eatment of high-r isk patients with heavily calcified left-main cor onar y lesions
Meng-Hsiu Chiang 1,Hung-Tao Yi 2,Cheng-Rong Tsao 2,3,Wei-Chun Chang 2,3,Chieh-Shou Su 2,3,Tsun-Jui Liu 2,3,Kae-Woei Liang 2,3,Chih-Tai Ting 2,3,Wen-Lieng Lee 2,3
1Division o f Car d io logy,Saint Mary ’s Hospital,160Zhongzheng Sou th Road,Lu odong,Y ilan 26546,Taiwan,China 2Cardio vascular Center,Taichung V eterans General Hospital,160,Sec.3,Chung-Kan g Road,Taichung 407,Taiwan,China
3
Institute of Clinical Medicin e,National Y an g Ming University S cho o lof M edicine,155,Sec.2,Lin ong Street,Taipei 112,Taiwan,China
Abstract
Objective Heavily calcified left-main coronary dias (LMCA)remain a formidable challenge for percutaneous interventions (PCI).This study was to investigate the safety and efficacy of using rotational atherectomy (RA)in treating such lesions in actual practice.Methods From February 2004to March 2012,all concutive patients who received RA for heavily-calcified LMCA lesions in our cath lab were en-rolled.The relevant clinical and angiographic characteristics at the time of index PCI,as well as the clinical follow-up outcomes,were re-trieved and analyzed.Results A total of 34concutive patients were recruited with a mean age 77.2±10.2years.There were 82.4%pre-nted with acute coronary syndrome and 11.8%with cardiogenic shock.Chronic renal dia and diabetes were en
in 64.7%and 52.9%,respectively.Triple-vesl coronary dia was found in 76.5%of them.The mean SYNTAX score was 50±15and EuroSC ORE II scale 5.6±4.8.The angiographic success rate was 100%with a procedural success rate of 91.2%.The mean num ber of burrs per patient was 1.7±0.5.Crossing-over stenting was ud in 64.7%.Most stents were drug-eluting (67.6%).Intra-aortic ballon pump was ud in 20.6%of the procedures.Three patients died during hospitalization,all due to prenting cardiogenic shock.No major complication occurred.Among 31hospital survivors,the major adver cardiac events (MAC E)rate was 16.1%,all due to target lesion revascularization or target vesl revas-cularization.Conclusions In high-surgical-risk elderly patients,plaque modification with RA in PCI of heavily-calcified LMCA could be safely accomplished with a minimal com plication rate and low out-of-hospital MACE.J Geriatr Cardiol 2013;10:217225.doi:10.3969/j.issn.1671-5411.2013.03.009Keywords:Heavily calcified;Left main coronary;Rotational atherectomy
1Introduction
Coronary artery bypass surgery (CABG)has been con-sidered the gold standard for treatment of unprotected left-main coronary dia (LMCA)bad on the results of veral trials w hich have shown reductions in mortality.[1-3]The current guidelines also e CABG as a class I indication for significant unprotected LMCA dia in patients which are eligible for surgery.[4,5]However,a lot of t
he elderly patients are associated with multiple co-morbidities and at high surgical risk.Though in the study of Yanagawa et al.[6],
Correspon dence to :Wen-Lien g
Lee,MD,
Cardiovascular Center,
Taich ung Veterans General Hospital,160,Sec.3,Chung-Kang Road,Taich ung 407,Taiwan,China.E-mail:wenlieng. Telephone:+886-9-28310103Fax:+886-4-23741312Received:March 25,2013Revid :June 6,2013
Accep ted:July 9,2013
Pub lished online:September 25,2013
the overall mortality of CABG declined from 6.0%(49/817)in the earliest era (1990–1996)to 1.9%(22/1132)in the most recent era (2003–2010;P <0.001),the mortality rate could be as high as 9.1%with an appreciable morbidity rate of 16.4%.[7]Elderly patients who had prior CABG are also in
unfavorable anatomical conditions for repeated bypass surgery.Furthermore,in some countries,religion and tradi-tional thinking usually preclude the patients from open heart surgery.Over the past 10years,advances in percutaneous intervention (PCI)techniques,devices and operator skills all contributed to the incread numbers of and studies on LMCA PCI.[8]However,limited information is available for clinical outcomes of LMCA PCI in high-risk elderly pa-tients.Furthermore,coronary artery calcification,especially in the LMCA,impos a big challenge for PCI,in terms of vesl rigidity and device delivery difficulties.Rotational atherectomy (RA),with the ability to differentially ablate
calcif ied and fibrotic plaques,is particularly uful in the lesions.[9,10]RA has been advocated in the bare metal stent (BMS)era,but is often under-ud due to technical diffi-culty,cumbersome tup and no additional benefit in the reported literature.[11,12]In recent years,revival of RA u in the drug eluting stent(DES)era in the treatment of complex lesion treatment has been witnesd.However,there have been very limited reports on using RA for LMCA PCI in the literature.The aim of this study was to investigate the safety and clinical efficacy of incorporating RA for plaque de-bulking during PCI for heavily-calcified LMCA lesions in actual practice.
2Methods
2.1Patient population
From February2004to March2012,all concutive pa-tients w ho received RA treatment for heavily-calcified LMCA lesions were queried from the cath lab databa for all-inclusive recruitment.The relevant clinical and an-giographic characteristics at the time of index PCI,as well as the clinical follow-up outcomes,were retrieved from the databa,and collected after a thorough review of the medical chart records.This study protocol was approved by the Institutional Review Board for Human Rearch of our hospital.
2.2Angiographic characterization and measur ements
The angiographic measurements were made on a viewing workstation w ith softw are for quantitative analysis of an-giograms(Medcon/Horizon/TCS,Israel).The angiographic characterization of target lesions in the index coronary an-giogram was made by reviewing the ssion cine thoroughly. The LMCA was def ined as any gment of the left main 50%diameter stenosis.The coronary artery dia(CAD) vesl numbers were defined as the number of each of the three major coronary vesls70%diameter stenosis. Severe coronary artery calcification was defined as readily apparent radio-opacities within the vascular walls in more than one projection on the cine before contrast medium in-jection.Exact definition of vere calcification w as de-scribed in the SYNTAX classification.[13]
Patients w ith left main lesions and high Syntax scores were indications for bypass surgery.This was the principle strictly followed at our cath lab.In all of our patients,the merits and demerits of both PCI and CABG were fully ex-plained to both the patients themlves and their families after diagnostic angiograms were completed.The final deci-sion to undertake PCI was made after taking into account the multiple factors and personal preference.Patients w ho signed the informed connt and subquently completed PCI w ith rotablation were retrospectively recruited into this study.
All PCIs were performed by experienced,credentialed operators using standard practice in our cath lab.Patients were pretreated with aspirin and clopidogrel,or a minimum of300mg loading do of clopidogrel was administered if, in rare cas,patients were not pretreated.Calcium channel blocker and nitrate were also prescribed for prevention of coronary artery spasm.Heparin w as administered to main-tain an activated clotting time(ACT)of>300s.The deci-sion to do RA was made at the discretion at the operator if device delivery or full lesion dilatation was deemed impos-sible by the heavy coronary artery calcification at the begin-ning of the procedure.A0.009-inch floppy RotaWire TM was advanced by the wire exchanging technique through a mi-crocatheter or over-the-wire balloon.RA was carried out using the Rotablator TM RA system(Boston Scientific Cor-poration),starting with a1.25mm or1.5mm burr at a speed of180,000–200,000r/min and mostly suppl
女超人受难
emented by another burr one size larger(Figure1).Each advance time was not longer than30s.Normal saline with heparin and isosorbide dinitrate w as infud during the atherectomy.RA of one or both major branches of LM was made at the dis-cretion of the operators.If RA of both major branches was needed,usually the vesl w ith more critical lesions was treated first.After the blood flow in the first treated vesl was cured,rotaw iring of the another branch w as made and no regular w ire was lef t in the treated vesl.After the ro-tablation,both major branches were rewired with usual wires and the procedure then proceeded with balloon dilata-tion with,or without,stent implantation to achieve optimal angiographic results with minimal residual stenosis.The u of DES or BMS was determined by patient option(afforda-bility),physician discretion or other co-morbidities(im-pending non-cardiac surgery,drug compliance to dual anti-platelets or drug allergy).U of glycoprotein2b3a antago-nist,intra-aortic ballon pump(IABP)or intravascular ultra-sound(IVUS)were at the discretion of the operator as indi-cated by the clinical requirements.Patients with cardiogenic shock were managed w ith standard practice,including IABP support,intravenous inotropes and pulmonary capil-lary wedge pressure monitoring.Emergent coronary an-giography and revascularization were intended for every patient to achieve re-opening of the culprit vesl with grade III Thrombolysis In Myocardial Infarction(TIMI3)flow as fast as possible.
Angiographic success was defined as achievement of a residual stenosis<20%in the prence of TIMI3flow. Procedural success was defined as achieving angiographic
J o u rn a l o f Ge riatric Card io log y|jgc@j g c301.c om;www.j m
www. m;jgc@mail.s |J o u rn al o f Geriatric Ca rd io lo g y
success without in-hospital major adver cardiac events (MACE),including all-cau death,myocardial inf arction (MI),and repeat revascularization.Clinical success was defined as successfully discharged without in-hospital com-plications.MI was defined according to current guide-lines.[14]Target lesion revascularization (TLR)was defined as a repeat revascularization for a restenosis >50%in the target gment.Target vesl revascularization (TVR)was defined as any repeat revascularization within the treated vesl.Indication for repeat revascularization w as bad on the clinical criteria.
Cardiac biomarkers including creatine kina (CK),creatine kina-MB (CK-MB),and Troponin-I were rou-tinely measured in patients af ter the procedure.Myonecrosis was defined as exceeding three times the level of CK-MB or Troponin-I compared to the baline value.Clinical fol-low-up was carried out through reviews of medical records,or telephone contact.
2.3Statistical analysis
Descriptive analys were ud and made in this study.Continuous variables were reported as mean ±SD.Cate-gorical variables were prented as frequencies with per-centage.
3Results
During the study period,a total of 34patients met the all-inclusion criterion and were recruited into this study for retrospective analysis.The baline patient characteristics are prented in Table 1.The mean age was 77.2±10.2years.Eighteen (52.9%)patients had diabetes mellitus and twenty-two (64.7%)chronic kidney dia.Ten (29.4%)had prior CABG,fourteen (41.2%)prior PCI,and nine (26.5%)recent (within four weeks)MI.Regarding clinical prentation,ten (29.4%)patients prented with
unstable
Figure 1.A 90-year-old woman with unstable angina was admitted for PCI.The SYNTAX score was 48,the EuroSCORE II scale was 3.54.(A):Severely-calcified LMCA,LAD and LCX could be found readily by apparent radio-opacities within the vascular walls before contrast medium injection (as indicated by black arrows);(B):Coronary angiography revealed LM shaft and distal true bifurcation lesions,both LAD and LCX showed diffu atherosclerosis change with heavy calcification;(C ):Rotaburr could successfully advance to the LAD;(D):The final flow was good without residual stenosis.LAD:left anterior descending artery;LCX:left circumflex artery;LMCA:LMCA:left main coronary artery;PCI:percutaneous coronary intervention.
Table1.The baline patient characteristics(n=34). Char acteristics
Age(yrs)77.2±10.2
Gen der
Males,n(%)22(64.7%)
Female,n(%)12(35.3%) DM,n(%)18(52.9%) Hypertension94.1%(32/34) Smoking 2.9%(1/34) Hypercholesterolemia
(≥200mg/dL)
23.5%(8/34) Clinical prentation
Stable ang in a,n(%)17.6%(6/34)
Un stable angina29.4%(10/34)
NSTEMI44.1%(15/34)
鞋子磨脚小妙招STEMI8.8%(3/34)
Card iogenic sh ock11.8%(4/34) eGFR(mL/min)37.8±22.2 CKD,n(%)64.7%(22/34) PAD44.1%(15/34) Prio r PCI41.2%(14/34) Prio r CABG29.4%(10/34) Recent MI<4weeks26.5%(9/34)
LVEF(%)
Total cholestero l(mg/dL) LDL-ch olesterol(mg/dL) Triglyceride(md/dL)
Fastin g plasma sug ar(mg/dL) Serum creatinine(mg/d L)39.68±11.80 172.7±51.6 103.6±36.5 113.9±55.8 126.8±46.7
1.9±1.7
Coronary d is eas
Left main,n(%)0%(0/34)
Sin gle vesl 5.9%(2/34)
Double vesls17.6%(6/34)
Triple vesls76.5%(26/34)
Con comitant RCA dia
(>70%s tenosis),n(%)
73.5%(25/34)
SYNTAX Score50±15
EuroScore II(%) 5.6±4.8
CABG:co ronary artery bypass graft;CKD:chronic kid ney d is ea;DM: diabetes mellitus;eGFR:estimated Glomerular Filtration Rate;LDL:low density lipopro tein;LVEF:left v entricular ejection fraction;MI:myocardial infarction;NSTEMI:non-ST gmental elevation myocardial infarction; PAD:peripheral artery d is ea;PCI:p ercu t aneous interven tion;RCA:righ t coronary artery;SBP:systolic blood press u re;STEM I:ST gmental elev a-tion myocardial infarction.
angina,fifteen(44.1%)with non-ST-elevation MI (NSTEMI)and three(8.8%)with ST-elevation MI(STEMI). Furthermore,the estimated glomerular filtration rate(eGFR) was37.8±22.1mL/min.No patient had isolated LMCA. Twenty-six(76.5%)patients had triple-vesl dia.The mean SYNTAX score was50±15,and the surgical mortality Table2.Angiographic characteristics of LMCA lesions Angiogr aphic char acteristics
Les io n type
Type B220(58.8%)
Type C14(41.2%)
Les io n locatio n
Ostium
Shaft
3(8.8%)
20(52.8%)
Distal with in volvement of
LAD13(38.2%)
LCX4(11.8%)
LAD+LCX12(35.3%)
None5(14.7%)
Eccentricity31(91.2%)
Mild to v ere calcification34(100%)
LMCA lesion len gth>10mm19(55.9%)
Thromb us-containing3(8.8%)
Data are prented as n(%),n=34.LAD:left anterio r descend in g artery; LCX:left circumflex artery;LMCA:left main coronary artery;
rate of the cohort according to the EuroSCORE II scale was 5.6±4.8%.
The LMCA lesion characteristics are prented in Table2. The LMCA bifurcation lesions involved the ostia of both left anterior descending(LAD)and left cirrumflex(LCX) coronary artery in twelve(35.3%)patients.Thirty-one (91.2%)lesions were eccentric,and three(8.8%)had thrombus.The angiographic success rate w as100%with rota burrs delivered to the target lesions in all of the pa-tients,and there was no major procedural complication.The overall procedural characteristics of our patients are pre-nted in Table3.The average number of burrs ud per patient was1.7±0.5and the final burr size1.6±0.2mm. Three(8.8%)patients underwent RA PCI without stenting. Regarding the L
燃烧脂肪的食物M stenting strategy,twenty-two(64.7%) were crossing-over,four(11.8%)simultaneous kissing or V, two(5.9%)culotte and one(2.9%)crushing.T-/Y-stenting technique was done in2(5.9%).Final kissing balloon dila-tation was done in ten(29.4%).DES was ud in twenty-three(67.6%)of the patients and BMS in eight (23.5%).Seven patients(20.6%)underwent intra-aortic balloon pump(IABP)-assisted procedures due to cardio-genic shock,or intractable ventricular tachycardia.
The angiographic data are prented in Table4.The baline and post-PCI diameter stenos of LMCA rate were70%±7%and18%±5%,respectively.The post-PCI coronary flow was TIMI3flow in all patients.
J o u rn a l o f Ge riatric Card io log y|jgc@j g c301.c om;www.j m
Table3.Procedural characteristics(n=34).
Pr ocedure ch ar acter istics
Maximum ro ta b urr s ize(mm) 1.6±0.2
Number of rota burrs ud/patient 1.7±0.5
Stenting strategy,n(%)
No s tenting3(8.8%)
Crossing-over64.7%(22/34)
T/Y-sten ting2(5.8%)
Simultaneo us kissing/V11.8%(4/34)
Culo tte 5.9%(2/34)
Crushing 2.9%(1/34)
Final kissing ballooning,n(%)29.4%(10/34)
Number of sten ts ud,n(%) 1.2±0.6
No stent3(8.8%)
One stent64.7%(22/34)
Two stents26.5%(9/34)
Type of Stents ud,n(%)
秋天的祝福No s tent3(8.8)
DES67.6%(23/34)
BMS23.5%(8/34)
Main-ves l stent diameter(mm) 3.03±0.40
Main-ves l stent length(mm)24.2±6.4
Side-bran ch s tent diameter(mm) 2.8±0.2
Side-bran ch s tent length(mm)19.2±4.9
IABP u,n(%)20.6%(7/34)
GP IIb/IIIa u,n(%) 2.9%(1/34)
IVUS u,n(%) 2.9%(1/34)
BMS:bare-metal s tent;DES:drug-elu ting stent;IABP:Intra-aortic b alloon pump;GP IIb/IIIa:glycoprotein IIb/IIIa inh ib ito r;IVUS:Intravascular ultrasound.
Table4.Quantitative coronary analysis of LMCA.
Angiogr aphic data
Pre-procedure
Reference(mm) 2.9±0.9
M LD(mm)0.9±0.4
Diameter stenos is(%)70±7
Lesion length(mm)113±3.6
细微的近义词
TIMI flow 2.4±0.7
Post-procedure
Reference(mm) 3.3±0.9
M LD(mm) 2.5±0.8
Diameter stenos is(%)17.7±5.2
Lesion length(mm)10.3±3.9
TIMI flow 3.0±0
LMCA:left main coron ary artery;MLD:minimal lumen diameter;TIMI: thromb olysis in myocardial infarction.作文最难忘的一件事
The in-hospital and out-of-hospital follow-up outcomes are show n in Table5.The interventional procedure success rate was91.2%as three patients died during hospitalization, whom all prenting with cardiogenic shock complicating extensive anterior w all STEMI on hospitalization.The av-erage age for the succumbed patients was82±1years (range81–83years)and all had triple vesl dia.One of them received RA plus BMS for LM-LAD,one RA plus DES for LM-LAD and the other culotte DES for LM bifur-cation lesion.Besides the three cardiac deaths,there was one asymptomatic myonecrosis and one acute limb ische-mia w hich may be ascribed to IABP u.There was no Q-w ave MI,emergent CABG,repeated PCI,or cardiac tamponade during hospitalization.The i
ncidence of out-of-hospital MACE at a mean follow-up of30.4months(range 2–99months)was16.1%.Among thirty-one out-of-hospital follow-up patients,12patients(38.7%)received coronary angiographic follow-up.TLR w as needed in three(9.7%) and TVR in two(6.4%)patients.A ll were successfully re-opened by PCI and no CABG was needed.No coronary aneurysm w as found in the stented gment.
Table5.Clinical outcomes(n=34).
Procedural success,n(%)31(91.2%)
Clinical success,n(%)30(88.2%)
In-hospital complication,n(%)4(11.7%)
Card iac death3(8.8%)
Q wave MI0
Emergent CABG0
TLR/TVR0
Non-Q wave MI2(5.8%)
As y mp to matic my onecro sis1(2.9%)
Acute limb ischemia1(2.9%)
Out-o f-hospital follow-up(n=31)*5(16.1%)
Card iac death0
non-fatal STEMI0
non-fatal NSTEM I1(3.2%)
CABG0
TLR/TVR5(16.1%)
烧饼做法
*Excluded th ree in-h ospital d eaths;mean fo llow-up30.4months.CABG: coronary artery byp ass g raft;MACE:m ajor adv er cardiac event;MI: myocardial infarctio n;NSTEMI:non-ST gmental elevation myo cardial infarction;STEMI:ST gmental elev ation my ocardial infarction;TLR: targ et le
sion revascu l arizat io n;TVR:target ves l revascu larization.
兔子尾巴的歇后语4Discussion
In summary,we found in this study that PCI incorporat-ing RA for heavily calcified LMCA lesions could be safely
www. m;jgc@mail.s J o u rn al o f Geriatric Ca rd io lo g y
