Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 129-135).

OBJECTIVES The aim of this study was to test the hypothesis that hypothermia and early reperfusion are synergistic for limiting infarct size when an acutely occluded coronary is associated with cardiac arrest. BACKGROUND Cohort studies have shown that 1 in 4 post-cardiac arrest patients without ST-segment elevation has an acutely occluded coronary artery. However, many interventional cardiologists remain unconvinced that immediate coronary angiography is needed in these patients. METHODS Thirty-two swine (mean weight 35 +/- 5 kg) were randomly assigned to 1 of the following 4 treatment groups: group A, hypothermia and reperfusion; group B, hypothermia and no reperfusion; group C, no hypothermia and reperfusion; and group D, no hypothermia and no reperfusion. The left anterior descending coronary artery was occluded with an intracoronary balloon, and ventricular fibrillation was electrically induced. Cardiopulmonary resuscitation was begun after 4 min of cardiac arrest. Defibrillation was attempted after 2 min of cardiopulmonary resuscitation. Resuscitated animals randomized to hypothermia were rapidly cooled to 34 degrees C, whereas those randomized to reperfusion had such after 45 min of left anterior descending coronary artery occlusion. RESULTS At 4 h, myocardial infarct size was calculated. Group A had the smallest infarct size at 16.1 +/- 19.6% (p < 0.05). Group C had an intermediate infarct size at 29.5 +/- 20.2%, whereas groups B and D had the largest infarct sizes at 41.5 +/- 15.5% and 41.1 +/- 15.0%, respectively. CONCLUSIONS Acute coronary occlusion is often associated with cardiac arrest, so treatment of resuscitated patients should include early coronary angiography for potential emergent reperfusion, while providing hypothermia for both brain and myocardial protection. Providing only early hypothermia, while delaying coronary angiography, is not optimal. (J Am Coll Cardiol Intv 2016; 9: 2403-12)

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20283号 / 医博第4242号 / 新制||医||1021(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 湊谷 謙司, 教授 福原 俊一, 教授 横出 正之 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background: Coronary artery disease (CAD) is a frequent comorbidity in patients undergoing transcatheter aortic valve implantation (TAVI). If significant CAD can be excluded on coronary CT-angiography (cCTA), invasive coronary angiography (ICA) may be avoided. However, a high plaque burden may make the exclusion of CAD challenging, particularly for less experienced readers. The objective was to analyze the ability of machine learning (ML)-based CT-derived fractional flow reserve (CT-FFR) to correctly categorize cCTA studies without obstructive CAD acquired during pre-TAVI evaluation and to correlate recategorization to image quality and coronary artery calcium score (CAC). Methods: In total, 116 patients without significant stenosis (≥50% diameter) on cCTA as part of pre-TAVI CT were included. Patients were examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the torso. Patients were re-evaluated with ML-based CT-FFR (threshold = 0.80). The standard of reference was ICA. Image quality was assessed quantitatively and qualitatively. Results: ML-based CT-FFR was successfully performed in 94.0% (109/116) of patients, including 436 vessels. With CT-FFR, 76/109 patients and 126/436 vessels were falsely categorized as having significant CAD. With CT-FFR 2/2 patients but no vessels initially falsely classified by cCTA were correctly recategorized as having significant CAD. Reclassification occurred predominantly in distal segments. Virtually no correlation was found between image quality or CAC. Conclusions: Unselectively applied, CT-FFR may vastly increase the number of false positive ratings of CAD compared to morphological scoring. Recategorization was virtually independently from image quality or CAC and occurred predominantly in distal segments. It is unclear whether or not the reduced CT-FFR represent true pressure ratios and potentially signifies pathophysiology in patients with severe aortic stenosis.

Background: Significant coronary artery disease (CAD) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). Assessment of CAD prior to TAVI is recommended by current guidelines and is mainly performed via invasive coronary angiography (ICA). In this study we analyzed the ability of coronary CT-angiography (cCTA) to rule out significant CAD (stenosis ≥ 50%) during routine pre-TAVI evaluation in patients with high pre-test probability for CAD. Methods: In total, 460 consecutive patients undergoing pre-TAVI CT (mean age 79.6 ± 7.4 years) were included. All patients were examined with a retrospectively ECG-gated CT-scan of the heart, followed by a high-pitch-scan of the vascular access route utilizing a single intravenous bolus of 70 mL iodinated contrast medium. Images were evaluated for image quality, calcifications, and significant CAD; CT-examinations in which CAD could not be ruled out were defined as positive (CAD+). Routinely, patients received ICA (388/460; 84.3%; Group A), which was omitted if renal function was impaired and CAD was ruled out on cCTA (Group B). Following TAVI, clinical events were documented during the hospital stay. Results: cCTA was negative for CAD in 40.2% (188/460). Sensitivity, specificity, PPV, and NPV in Group A were 97.8%, 45.2%, 49.6%, and 97.4%, respectively. Median coronary artery calcium score (CAC) was higher in CAD+-patients but did not have predictive value for correct classification of patients with cCTA. There were no significant differences in clinical events between Group A and B. Conclusion: cCTA can be incorporated into pre-TAVI CT-evaluation with no need for additional contrast medium. cCTA may exclude significant CAD in a relatively high percentage of these high-risk patients. Thereby, cCTA may have the potential to reduce the need for ICA and total amount of contrast medium applied, possibly making pre-procedural evaluation for TAVI safer and faster.

No description available.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / To analyze the roles of CCTA, MPI, and CC to formulate a sequential clinical algorithm to use in patients with chest pain, risk factors for CAD, and an abnormal EKG. The goals of the study are to streamline and refine workup, to decrease radiation exposure to patients, and to contain costs. 39 patients underwent CCTA, MPI, and CC within 30 months of each other. CCTA was used to categorize mild, moderate, or severe CAD. MPI used SSS, SDS, TID, and formal reading to define mild, moderate, or severe physiologic ischemia. CC and coronary intervention cine films were analyzed to define and treat anatomical CAD medically or by intervention. Results: There was strong correlation between CCTA, CC, and treatment type (p<0.0001). CCTA was able to stratify all patients with mild or severe ischemia to appropriate treatment groups, and to reduce the need for MPI. With moderate ischemia from CCTA, the additional use of MPI could have reduced the need for 16/18 (89%) patients who underwent CC to undergo further testing. No patients with mild or moderate CAD by CCTA, followed by mild to moderate physiologic ischemia by MPI, needed CC or intervention. 37/39 patients (95%) could have avoided one or more tests using our algorithm. CCTA followed by MPI may be used in symptomatic patients with risk factors for CAD and an abnormal EKG to stratify mild and moderate CAD, and to thereby avoid cardiac catheterization. Our algorithm could lead to savings in healthcare expenditures, save patients from unnecessary invasive procedures, decrease radiation exposure, and total cost.

Os vasos de fino calibre apresentam maior risco para reestenose e revascularização da lesão alvo. Limitações relacionadas com a navegabilidade dos sistemas de dilatação por balão e menor capacidade de acomodação da neoíntima podem contribuir para isto. O stent autoexpansível de nitinol Sparrow® dedicado a vaso de calibre < 2,75 mm, resultou num conjunto com perfil de um fio-guia 0,014\". Testado na forma de stent de metal puro no estudo CARE I, revelou-se seguro e eficaz em vasos de fino calibre. Este estudo avaliou, de forma pioneira, o despenho de um stent autoexpansível farmacológico neste cenário. O objetivo primário foi comparar a perda luminal tardia no vaso-alvo pela angiografia coronária quantitativa ao final de oito meses, entre os stents Sparrow® farmacológico e não farmacológico, em coronárias com diâmetro de referência < 2,75 mm. Casuística e métodos: Os pacientes foram randomizados de forma prospectiva em dois grupos para procedimento de angioplastia: um grupo com o emprego o stent Sparrow® farmacológico (sirolimus), e ou outro grupo com o stent Sparrow® na versão não farmacológica. Análise pela angiografia coronária quantitativa foi realizada imediatamente antes e após o procedimento e aos oito meses, com seguimento clínico de 24 meses. Foi utilizado o programa IBM SPSS Statistics® para análise estatística e foi considerado nível de significância de 5% e poder de 80% para o cálculo do tamanho da amostra. Resultados: 24 pacientes foram randomizados, 12 no grupo com stent farmacológico Sparrow® e 12 no grupo com a versão não farmacológica. Na avaliação angiográfica aos oito meses verificou-se significativa redução de perda luminal tardia no grupo com o stent farmacológico Sparrow® em comparação com grupo com a versão não farmacológica (0,25 + 0,16 mm versus 0,97 + 0,76 mm, p = 0,008, IC 95% de -1,19 ; -0,22). No seguimento clínico de 12 meses, não foram observados eventos cardíacos adversos maiores (morte, infarto ou necessidade de revascularização do vaso alvo) no grupo com stent farmacológico. Não ocorreu trombose intrastent. Conclusão: Em pacientes submetidos à angioplastia transluminal percutânea em artérias coronárias com diâmetro de referência < 2,75 mm, o emprego do stent farmacológico autoexpansível Sparrow®, em comparação com a versão não farmacológica do mesmo stent, resultou em significativa redução de perda luminal tardia, sem ocorrência de eventos clínicos que deponham contra a segurança do dispositivo pesquisado. / Small vessels represent a group with high risk for restenosis and target lesion revascularization. Limitations associated with navigability of balloon dilation systems and less accommodating of the neointima may contribute to this. The self-expanding Sparrow® stent system dedicated to the vessel size <2.75 mm resulted in a profile similar to a 0.014\" guide wire angioplasty. Tested as bare metal stent in the CARE trial I, the Sparrow® stent system has proved to be safe and effective in small vessels. This study evaluated, for the first time, the performance of a self-expanding drug eluting stent in this scenario. The primary objective was to compare the in-stent late lumen loss by quantitative coronary angiography at the end of eight months between the Sparrow® drug-elutig stent and Sparrow® bare metal stent in coronary arteries with reference diameter <=2.75 mm. Materials and methods: Patients were prospectively randomized (1:1) Analysis by quantitative coronary angiography was performed immediately before and after the procedure and at eight months with clinical follow-up to 12 months. We used the IBM® SPSS for statistical analysis and was considered a significance level of 5% and 80% power for the calculation of sample size. Results: 24 patients were randomized, 12 in each group. At Eight months follow-up there was significant reduction in late lumen loss in the Sparrow® drug-eluting stent group compared to the Sparrow® bare metal stent group (0.25 ± 0.16 mm vs. 0.97 + 0.76 mm, p = 0.008, 95% CI -1.19 to -0.22). Up to 12 months of clinical follow-up there no cases of death, myocardial infarction and target vessel revascularization Of note, there was no stent thrombosis. Conclusion: In patients undergoing percutaneous transluminal angioplasty in coronary arteries with reference diameter <= 2.75 mm, the use of Sparrow® drug-eluting stent, compared to the Sparrow® bare metal stent, resulted in significant less late loss without occurrence of clinical events that weigh against the security of device.

INTRODUÇÃO: A cineangiocoronariografia é um procedimento médico invasivo que envolve sentimentos de medo e ansiedade. Estudos internacionais têm avaliado o efeito da música como técnica de intervenção para redução da ansiedade utilizando-a antes, durante e depois da cineangiocoronariografia. Contudo, os resultados de sua aplicação durante o procedimento não são consensuais. OBJETIVO: A proposta do presente estudo foi avaliar o efeito da música, aplicada durante a realização do procedimento, na ansiedade de pacientes submetidos à cineangiocoronariografia pela primeira vez. MÉTODOS: Os desfechos estudados foram o nível de ansiedade medido pelo Inventário de Ansiedade Beck, a frequência cardíaca e pressão arterial, ambas medidas pelo método intra-arterial. Participaram do estudo 300 pacientes randomizados entre o grupo controle (procedimento padrão) ou grupo música (cineangiocoronariografia realizada com a intervenção musical). Foi realizado o cegamento da pesquisadora durante toda a coleta e análise estatística dos dados. RESULTADOS: Os grupos eram semelhantes em relação às características de base, bem como dados sobre os hábitos musicais dos pacientes e dados da cineangiocoronariografia. Não foram observadas diferenças entre os grupos controle e música para todos os desfechos estudados: nível de ansiedade (p=0,072), pressão arterial sistólica (p=0,379), pressão arterial diastólica (p=0,152) e frequência cardíaca (p=0,853). Notou-se também que, mesmo antes da realização do procedimento, 80,9% do grupo controle e 76,9% do grupo música já apresentavam o menor nível de ansiedade (mínima). As mulheres mostraram-se mais ansiosas do que os homens (p=0,000 pré-exame e p=0,022 pós-exame). Não houve relação na comparação entre ansiedade e diferentes faixas etárias (p=0,352 pré-exame, p=0,198 pós-exame). CONCLUSÃO: A música aplicada no presente estudo durante a cineangiocoronariografia não se mostrou efetiva na redução dos níveis de ansiedade, pressão arterial e frequência cardíaca dos pacientes submetidos ao procedimento pela primeira vez. Constatou-se também que as mulheres são mais ansiosas do que os homens e que não houve relação entre o nível de ansiedade e faixas etárias / BACKGROUND: Coronary angiography is an invasive medical procedure that involves feelings of fear and anxiety. International studies have evaluated the effects of music intervention to reduce anxiety by using it before, during and after coronary angiography. However, the results of this strategy are not clear. OBJECTIVE: The aim of this study was to evaluate the effect of music, employed during the procedure, on anxiety of patients undergoing coronary angiography for the first time. METHODS: Outcomes were anxiety level measured by the Beck Anxiety Inventory, heart rate and blood pressure, both measured by intra-arterial method. The study included 300 patients randomized between the control group (standard procedure) or music group (standard procedure with a music intervention). The researcher was blinded throughout the data collection and statistical analysis. RESULTS: Baseline variables were adequatly balanced between both groups, as well as data on musical habits and coronary angiography. No differences were observed between the control group and music group in any of the outcomes: level of anxiety (p = 0.072), systolic blood pressure (p = 0.379), diastolic blood pressure (p = 0.152) and heart rate (p = 0.853). It was also noted that even before the procedure, 80.9% of the control group and 76.9% of the music group had low level of anxiety. Women were more anxious than men (p = 0.000 pre-test and p = 0.022 post-test). No relationship was found between anxiety and age (p = 0.352 pre-test, p = 0.198 post-test). CONCLUSION: The music used in this study during coronary angiography was not effective in reducing anxiety levels, blood pressure or heart rate in patients undergoing the procedure for the first time. It was also found that women are more anxious than men and that there was no relationship between anxiety levels and age

A angiografia coronariana por tomografia computadorizada (ACTC) é um exame bem estabelecido no diagnóstico da doença arterial coronariana. Entretanto, segmentos coronarianos submetidos a implante de stent podem apresentar limitação na avaliação luminal. O objetivo deste estudo é avaliar o valor adicional da perfusão miocárdica por tomografia computadorizada (PMTC) à avaliação anatômica isolada pela ACTC em portadores de stent, tendo o cateterismo (CATE) como referência. Quarenta e seis pacientes (56,9±7,2 anos, 28 homens) com indicação clínica de CATE em até 60 dias foram submetidos à avaliação combinada de ACTC e PMTC, por meio de tomógrafo de 64 detectores (Aquillion 64, Toshiba). A aquisição foi iniciada com a fase de estresse (PMTC) usando-se dipiridamol a 0,56mg/kg/4min e 60ml de contraste a 3ml/s, seguido de reversão com aminofilina 240mg e metoprolol (até 20mg). Em seguida, realizou-se a ACTC com 80-90ml de constraste a 5ml/s. Os dados da PMTC, da ACTC, e do CATE foram analisados por dois observadores independentes, sem informações clínicas dos pacientes. Primariamente analisou-se a ACTC, seguida da avaliação da PMTC. Concluída esta fase, os observadores tinham a possibilidade de reclassificar os segmentos coronarianos submetidos a stent cuja avaliação estivesse limitada ou inadequada por artefatos. A dose total média de radiação foi 15,83±4,93 mSv e todos os exames foram adequados. Um total de 129 segmentos coronarianos foi avaliado na ACTC, bem como os respectivos territórios miocárdicos pela PMTC. Destes, 54 territórios (42%) eram relacionados à presença de stents, sendo 19 com stents de avaliação adequada e 23 com avaliação luminal limitada, porém possível, e 12 segmentos de avaliação inadequada (sem possibilidade de avaliação luminal). Os valores de sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia para a ACTC isolada nos territórios com stents foram de, respectivamente: 85%, 76%, 85%, 76% e 81%, e com o uso combinado da ACTC + PMTC foram de, respectivamente 88%, 95%, 97%, 83% e 92% (p=0,0314). Nos territórios com stent e avaliação luminal prejudicada (limitada ou inadequada) os valores para análise da ACTC isolada foram de, respectivamente: 83%, 71%, 75%, 80% e 77% e após a análise da ACTC + PMTC foram de, respectivamente: 89%, 94%, 94%, 89% e 92% (p = 0,0441). A avaliação combinada da ACTC + PMTC permitiu melhorar a acurácia diagnóstica da avaliação de obstrução coronariana significativa em pacientes portadores de stents, comparativamente à avaliação isolada da ACTC / Coronary computed tomography angiography (coronary CTA) is a well established examination in the diagnosis of coronary artery disease (CAD). However, the segments with prior coronary stent implantation may have limited luminal evaluation. The aim of this study is to assess the incremental value of myocardial computed tomography perfusion (myocardial CTP) to the anatomical assessment by coronary CTA alone in patients with stents, using catheterization (CAT) as a reference method. Forty-six patients (56.9 ± 7.2 years, 28 men) referred to CAT by clinical indication within 60 days, were evaluated with combined evaluation of coronary CTA and myocardial CTP through 64-detector CT scanner (Aquillion 64, Toshiba). The acquisition protocol began with the stress phase (myocardial CTP), using dipyridamole to 0.56 mg/kg/4min and 60ml of contrast (3ml/s), followed by a bolus of aminophylline 240 mg and metoprolol (up to 20mg). After, it was performed the coronary CTA wih 80-90ml of contrast (5 ml/s). Data from the myocardial CTP, coronary CTA and CAT were analyzed by two independent observers, with no knowledge to clinical information. The observers reviewed the coronary CTA findings, and in a second time performed the evaluation of myocardial CTP. So, they had the possibility to reclassify segments with coronary stent that were considered with limited or inadequate assessment due to artifacts. Mean total dose of radiation was 15.83 ± 4.93 mSv, and all examinations were interpretable. A total of 129 coronary segments were evaluated by coronary CTA, and also were their correspondent myocardial territories by myocardial CTP. Of these, 54 territories (42%) were related to the presence of stents, 19 stents with adequate evaluation, 23 with limited evaluation, but possible, and 12 with inadequate evaluation (no luminal assessment possible). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the coronary CTA in territories with stents were respectively: 85%, 76%, 85%, 76% and 81%, and the combined use of coronary CTA + Myocardial CTP were respectively 88%, 95%, 97%, 83% and 92% (p=0.0314). In territories with impaired luminal stent evaluation (limited or inadequate), the values for analysis of coronary CTA alone were: 83%, 71%, 75%, 80% and 77%, and after analysis of myocardial CTP were, respectively: 89%, 94%, 94%, 89% and 92% (p = 0.0441). The combined evaluation of the coronary CTA and myocardial CTP has improved the diagnostic accuracy of the evaluation of significant coronary obstruction in patients with stents, compared to the assessment of coronary CTA alone