Publications

Intravascular imaging has evolved alongside interventional cardiology as an adjunctive tool for assessing plaque pathology and for guiding and optimizing percutaneous coronary intervention (PCI) in challenging lesions. The two modalities which have dominated the field are intravascular ultrasound (IVUS), which relies on sound waves and optical coherence tomography (OCT), relying on light waves. These approaches however have limited efficacy in assessing plaque morphology and vulnerability that are essential for guiding PCI in complex lesions and identifying patient at risk that will benefit from emerging therapies targeting plaque evolution. These limitations are complementary and, in this context, it has been recognized and demonstrated in multi-modality studies that the concurrent use of IVUS and OCT can help overcome these deficits enabling a more complete and accurate plaque assessment. The Conavi Novasight Hybrid IVUS-OCT catheter is the first commercially available device that is capable of invasive clinical coronary assessment with simultaneously acquired and co-registered IVUS and OCT imaging. It represents a significant evolution in the field and is expected to have broad application in clinical practice and research. In this review article we present the limitations of standalone intravascular imaging techniques, summarize the data supporting the value of multimodality imaging in clinical practice and research, describe the Novasight Hybrid IVUS-OCT system and highlight the potential utility of this technology in coronary intervention and in the study of atherosclerosis.

BMF smoke is an important cause of non-smoking COPD. We have previously reported that patients with BMF-COPD have predominant airway involvement and less parenchymal involvement. We aimed to study the effect of 2-weeks treatment with oral corticosteroids on spirometric indices &amp; quality of life of BMF-COPD as assesed by SGRQ. <b>Methods:</b> 25 BMF-COPD subjects (mean age 63.6±8.3, all females) participated in a 2-week placebo treatment followed by a 2-week steroid treatment period in a single-blind, placebo-controlled manner. Prednisolone in a dose of 30 mg/day was administered during the steroid treatment period. Pre and post bronchodilator spirometry was performed at baseline after 2weeks of placebo treatment and after 2weeks of steroid treatment. The differences in total SGRQ scores were measured at the end of each treatment period. <b>Results:</b> Pre bronchodilator FEV₁ FVC and FEF25-75% did not change within 2 weeks of steroid treatment. However, significant changes were noted in post-bronchodilator FEV1 (p=0.001), FVC (p=0.016) and FEF 25-75% (p=0.006) values. Total SGRQ values increased after placebo treatment (mean change: +5.75± 9.25:p=0.008)and reduced after steroid treatment (mean change: -9.27 ± 15.5:p=0.009). <b>Conclusion:</b> 2 weeks of oral corticosteroid treatment significantly improved post bronchodilator spirometric indices as well as quality of life in subjects with BMF-COPD.

Case 1 A 58-year-old man was admitted to our coronary care with troponin negative unstable angina. His risk factors included, being an exsmoker for a year, treated hypertension and dyslipidaemia. Medication on admission was aspirin and a statin. ECG showed Twave inversion laterally. Nine years previously he had a bare metal stent implanted in his circumflex artery following a lateral infarction the preceding year. Angiography done during his acute presentation revealed an in-stent restenosis in the previously treated circumflex artery and a diffusely diseased marginal branch. The left anterior decending coronary (LAD) was normal and the right coronary artery (RCA) had a non-flow limiting lesion in the mid-vessel with a fractional flow reserve (FFR) of 0.79. Intravascular ultrasound (IVUS) of the circumflex artery was performed using a 20 MHz Eagle eye IVUS catheter (Volcano Therapeutics, Rancho Cordova, CA, USA). The length of the stented segment was 30mm and had a minimal luminal area (MLA) 4.6 mm2. Neo-intimal formation was visible throughout the stent (Figure 1). This gave a neointimal hyperplasia (NIH) volume of 80.3 mm3. The NIH on virtual histology had a tissue composition of necrotic core (NC) 13.6%, (0.08 mm2, 2.4 mm3), calcified tissue 16.8%, (0.10 mm2, 3.0 mm3), fibrofatty 5.8%, (0.03 mm2, 1.04 mm3), fibrotic tissue 63.9%, (0.38 mm2, 11.5 mm3). Distal to the MLA at distance of 18 mm IVUS revealed an eccentric soft neo-intimal ruptured plaque1,2 (Figure 1C) within the stent. The necrotic core was 22% with remnant plaque burden of 54% at the plaque rupture site (Figure 1 C’). Just distal to ruptured plaque the vessel wall was intact and the plaque burden was higher 65% with no necrotic core in contact with the lumen (Figure 1D”). This ruptured lesion was subsequently managed with a drug eluting stent (DES) that also covered the MLA. The histological findings of a similar plaque rupture are illustrated in Case 2.

Research demonstrates that Chronic Obstructive Pulmonary Disease (COPD) is not only preventable, but treatable.Despite these efforts, COPD continues to claim many lives, and disable many more, without any cure in sight.Our inability to reverse the devastating course of COPD is in part due to the fact that it is often recognized late, after the disease has advanced.In addition, COPD is a complex disease with protean pulmonary and non-pulmonary manifestations punctuated by episodic escalations of respiratory symptoms in a predominately older patient population with multiple comorbidities.The major objective of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) is to improve the diagnosis, assessment and prevention of COPD by increasing awareness while simultaneously stimulating new research.GOLD publishes an annual report that provides recommendations, however, it is clear that some major issues regarding COPD management are not certain, and that limited or contradictory data exists in important areas that requires further information to guide recommendations.The GOLD scientific committee recently conducted a public forum where controversial topics were discussed to define the current gaps in knowledge regarding the diagnosis, assessment and treatment of COPD.Herein, we summarize the results of that discussion.

Background: Nonfluoroscopic electromechanical mapping (NEM) has been proposed as a new technique for the evaluation of electrical and mechanical functioning of the myocardium. In this system, linear local shortening (LLS) is the parameter used for assessment of local mechanical properties. To validate this parameter, we compared LLS with regional wall motion (RWM) data derived from contrast left ventriculograms acquired in the same patients. Methods and results: Angiographic left ventricular RWM was analyzed using the area–length method. The right anterior oblique view was divided in five segments, the left anterior oblique view in two. Through a comparison of enddiastolic and endsystolic areas drawn from a computer-defined central point to the respective wall delineation, RWM was calculated as change in area. In the first approach, we compared area changes to comparable NEM segments. In the second part of the study, LLS values for normokinetic, hypokinetic, akinetic and dyskinetic segments were correlated to the change in angiographic RWM. In the first approach, the overall comparison of segments yielded a correlation coefficient of 0.67 (P<0.0005). In the second part of the study, differences in LLS values between dyskinetic (LLS=−3.68±8.86%), akinetic (2.84±3.96%), hypokinetic (9.35±4.27%) and normokinetic (13.66±7.98%) segments were highly significant (overall ANOVA: P<0.0005). Conclusion: NEM is a powerful tool for invasive electromechanical assessment of myocardial function.

Introduction: New Generation drug eluting stents (DES) have overcome the limitations of bare metal stents and first generation DES resulting in lower risk of ischemic events in women. Hypothesis: We sought to compare increasing total stent length per patient for 3-yr outcomes in DM and non-DM women after percutaneous coronary intervention (PCI) with new generation DES. Methods: The WIN-DES collaboration is a pooled database of women undergoing PCI with coronary stents in 26 randomized trials. We compared total stent length per patient treated with new generation DES in quartiles (Among DM - Q1: 8-18mm, Q2: 18-24mm, Q3: 24-38mm and Q4: 38+mm; among non-DM Q1: 8-18mm, Q2: 18-24mm, Q3: 24-36mm and Q4: 36+mm). 3-yr outcomes were analyzed in a time to event manner and adjusted using multivariable methods. Major adverse cardiovascular events (MACE) were defined as a composite of death, myocardial infarction (MI) or target lesion revascularization (TLR). Results: The study sample comprised 5403 patients, of which 31.8% (n = 1719) had DM. In both DM and non-DM groups, patients in Q4 had greater prevalence of B2/C type and calcified lesions with smaller stent diameter compared to others. 3-yr MACE increased from Q1-Q4 in DM and non-DM patients, albeit DM patients experienced higher event rates ( Figure ). After multivariable adjustment, findings were unchanged, and increasing stent length remained associated with greater risk of 3-yr MACE in DM (p-trend=0.003) and non-DM (p-trend &lt;0.0001) patients. No interaction was observed between DM status and stent length for any outcomes. Conclusions: Despite the use of new generation DES, increasing total stent length per patient was associated with greater risk of MACE in both DM and non-DM women undergoing PCI. Women with DM experienced worse outcomes, and a greater risk of TLR regardless of total stent length. Meticulous attention to stent optimization and post PCI pharmacotherapy is needed to mitigate long-term adverse outcomes in women.

Ostial atherosclerotic lesions are distinct from other lesion sites in terms of outcomes following percutaneous interventions. Despite aggressive lesion modification strategies, long-term outcome is hampered by restenosis. Various stent designs have failed to show significant improvement in target lesion revascularization (TLR) rates. The present study evaluates the clinical outcomes following sirolimus-eluting stent implantation for ostial lesions.The sirolimus-eluting stent (SES) was the device of choice at our institute for all coronary interventions from April 2002 to March 2003. This study population is comprised of 50 patients who received drug-eluting stents for atherosclerotic ostial lesions during this period. Sixty-eight percent of the patients were male and 24 patients (48%) had a history of previous revascularization. Indication for intervention were as follows: acute myocardial infarction, 7 patients (14%), stable angina, 23 patients (46%), unstable angina, 20 patients (40%). Angioplasty and stent implantations were done according to the standard protocol. All patients were prospectively followed up for major adverse cardiac events. The event-free survival was 90% at one year. There were 5 (10%) target vessel revascularization, 3 (6%) myocardial infarctions and 1 (2%) death during a mean follow-up of 414.5 +/- 54.5 days. TLR was required in 4 (8%) patients.SES implantation is feasible in ostial locations and is associated with low subsequent revascularization.

No abstract is provided for this article.

To evaluate the hypothesis that furosemide inhibits indirect bronchoconstrictor challenges by altering airway epithelial ion transport, we studied its effects on indirect bronchoconstriction induced by inhaled metabisulfite (MBS) and nasal potential difference (PD) in seven subjects with mild asthma. Its effect on direct bronchoconstriction by the inhaled muscarinic agonist methacholine (MC) was studied in six of these subjects. Each subject inhaled furosemide, 30 mg, in a randomized, double-blind, placebo-controlled fashion immediately before challenge with MBS (0.3 to 160 mg/ml in increasing doubling concentrations) and, in another study, MC (0.125 to 32 mg/ml) aerosols from a nebulizer attached to a dosimeter. PC20MBS and PC20MC, the concentration of each agent needed to lower FEV1 by 20%, were calculated by linear interpolation of the log dose-response curves. Furosemide had no effect on resting lung function, but it caused a significant threefold reduction in sensitivity to MBS (PC20MBS: GM ± GSEM, 15.1 ± 1.6 mg/ml after placebo and 40.7 ± 1.7 mg/ml after furosemide; p < 0.001) with a protective index of 64.8 ± 10.7%. Furosemide caused no change in sensitivity to MC (PC20 MC: GM ± GSEM, 2.37 ± 1.61 mg/ml after placebo and 2.19 ± 1.751 mg/ml after furosemide; NS). In a third study, furosemide, 30 mg, and placebo were inhaled through the nose in a randomized double-blind fashion immediately prior to inhalation of a PC20 concentration of MBS through the nose. Nasal PD was measured before and after placebo or furosemide, and again after MBS inhalation. Neither placebo nor furosemide had any effect on nasal PD compared with the same-day baseline; likewise, MBS had no effect on nasal PD whether preceded by placebo or furosemide. A positive control, 10−3 M amiloride inhaled nasally using the same apparatus, reduced nasal PD by 36.3 ± 5.4% in six normal subjects (p < 0.05). We conclude that inhaled furosemide inhibits MBS-induced bronchoconstriction but does not directly reduce smooth-muscle contractility or affect electrogenic epithelial ion transport. The mechanism whereby furosemide protects against MBS challenge remains uncertain.