Coronary Artery Disease: Larose E

Chow BJ, Larose E, Bilodeau S, Ellins ML, Galiwango P, Kass M, Sheth T, Jassal DS, Kirkpatrick ID, Mancini GB, Mayo J, Abraham A, White J. · Department of Medicine, University of Ottawa Heart Institute, Ontario, Canada. · Can J Cardiol. · Pubmed #19279980 links to  free full text

This publication has no abstract.

Larose E, Rodés-Cabau J, Delarochelliere R, Barbeau G, Noel B, Bertrand O. · Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval Hospital, Sainte-Foy, Quebec. · Can J Cardiol. · Pubmed #17932594 No free full text.

Abstract: Cardiovascular magnetic resonance is a noninvasive imaging modality that provides superior anatomical and functional information in the absence of ionizing radiation. The cardiovascular magnetic resonance imaging program has been active at the Quebec Heart Institute at Laval Hospital for two years, now providing advanced imaging studies to over 42 referral centres from eastern and central Quebec as well as providing training for national and international fellows. The program benefits from the collborative work of cardiologists and radiologists, who both bring to the table their unique expertise. The following text reviews current clinical applications useful in the daily practice of the cardiovascular specialist.

Bertrand OF, Larose E, De Larochellière R, Proulx G, Nguyen CM, Déry JP, Gleeton O, Barbeau G, Noël B, Rouleau J, Boudreault JR, Roy L, Rodés-Cabau J. · Laval Hospital, Quebec, Canada. · Can J Cardiol. · Pubmed #17932589 No free full text.

Abstract: Outpatient practice after percutaneous coronary intervention (PCI) is gaining momentum due to constantly optimizing results. Furthermore, the availability of limited beds to handle the large volume of coronary interventions also promotes outpatient practice. The present report relates the current experience with same-day discharge and defines persisting challenges in promoting accelerated in-hospital turnover. Since the mid-1990s, there have been several reports on same-day discharge following uncomplicated procedures. Overall, the success of outpatient PCI practice is based on a few technological and pharmacological advances. First, the systematic use of stents and potent antiplatelet agents have revolutionized the acute success rates of PCI by virtually eliminating the risks of acute vessel closure within the first 24 h following a successful procedure. Second, the miniaturization of catheter sizes has also simplified access site management, accelerated ambulation time and limited the risks of puncture site bleeding. In this regard, the transradial approach initially described in Canada and later popularized in Europe has transformed the acute care of patients after PCI. Today, however, the practice of transradial PCI still varies largely from country to country. From the literature review, it appears that after a short period of observation (4 h to 6 h), the majority of eligible patients who have undergone uncomplicated coronary stenting can be discharged on the same day. Whereas implementation of same-day discharge to referring centres is simple, home discharge requires the development of structured outpatient programs with dedicated resources to assist the patient and family with short-term logistics, to provide reassurance, to serve as a 'safety net' and, lastly, to promote medication compliance and cardiovascular risk factor management. Further studies are required to better define the cost-minimization effects of outpatient PCI practice, as well as patient perception of fast-track PCI. It is proposed that outpatient PCI will likely continue to expand over the next decade.

Rodés-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E, Dagenais F, Déry JP, Mathieu P, Rousseau M, Barbeau G, Baillot R, Gleeton O, Perron J, Nguyen CM, Roy L, Doyle D, De Larochellière R, Bogaty P, Voisine P. · Department of Cardiology and Cardiac Surgery, Quebec Heart Institute, Laval Hospital, Quebec, Canada. · Circulation. · Pubmed #19029471 No free full text.

Abstract: BACKGROUND: The objective of the present study was to compare the midterm follow-up results of percutaneous coronary intervention (PCI) and coronary bypass graft surgery (CABG) for the treatment of unprotected left main coronary artery disease in octogenarians. METHODS AND RESULTS: A total of 249 consecutive patients > or =80 years of age diagnosed with left main coronary artery disease underwent coronary revascularization in our center between January 2002 and January 2008; 145 patients underwent CABG, and 104 patients had PCI. Major adverse cardiac and cerebrovascular events (MACCE [cardiac death, myocardial infarction, cerebrovascular event, revascularization]) were evaluated at a mean follow-up of 23 +/- 16 months. Patients who underwent PCI were older; had higher creatinine levels, lower ejection fraction, and higher EuroSCORE; and presented more frequently with an acute coronary syndrome. Drug-eluting stents were used in 48% of PCI patients. A propensity score analysis was performed to adjust for baseline differences between the 2 groups. Survival free of cardiac death or myocardial infarction (PCI, 65.4%; CABG, 69.7%) and MACCE-free survival (PCI, 56.7%; CABG, 64.8%) at follow-up were similar between the groups (adjusted hazard ratio for survival free of cardiac death or myocardial infarction, 1.28; 95% CI, 0.64 to 2.56; P=0.47; adjusted hazard ratio for MACCE-free survival, 1.11; 95% CI, 0.59 to 2.0; P=0.73). The EuroSCORE value was an independent predictor of MACCE regardless of the type of revascularization (hazard ratio, 1.17 for each EuroSCORE increase of 1 point; 95% CI, 1.09 to 1.25; P<0.0001). CONCLUSIONS: In this single-center, nonrandomized study, there were no significant differences in cardiac death or myocardial infarction and MACCE between CABG and PCI for the treatment of left main coronary artery disease in octogenarians after a mean follow-up of 2 years. Baseline EuroSCORE was the most important predictor of MACCE regardless of the type of revascularization. Randomized studies comparing both revascularization strategies in this high-risk coronary population are warranted.

Lachance P, Déry JP, Rodés-Cabau J, Potvin JM, Barbeau G, Bertrand OF, Gleeton O, Larose E, Nguyen CM, Noël B, Proulx G, Roy L, De Larochellière R. · Quebec Heart and Lung Institute, Quebec City, Quebec, Canada. · Cardiovasc Revasc Med. · Pubmed #18928947 No free full text.

Abstract: PURPOSE: Fractional flow reserve (FFR) is often performed to assess the severity of coronary artery stenoses. However, the usefulness of measuring FFR when a noninvasive test has been obtained prior to coronary angiography has not been studied. METHODS AND MATERIALS: We retrospectively reviewed 122 patients who underwent noninvasive stress test with cardiac imaging (SPECT or stress echocardiography) prior to FFR assessment of a coronary lesion. The usefulness of FFR measurement was determined. FFR was judged useful if decision to revascularize the patient reflected the result of FFR rather than the result of the stress test. RESULTS: A total of 136 lesions were evaluated. Of these, 66 were associated with a positive noninvasive test and 70 had no ischemia present in the territory of the evaluated vessel. When FFR was negative (> or =0.75) and the test positive (57 lesions), revascularization was deferred in 55. When FFR was positive (<0.75) and the functional test negative (8 lesions), revascularization was performed in 8. FFR measurement changed the clinical decision to revascularize the patient in 55 (83%) of the 66 lesions with ischemia documented on noninvasive tests compared to 8 (11%) of the 70 lesions without ischemia (P<.0001). CONCLUSION: FFR can be helpful in patients with coronary artery disease even when noninvasive testing is performed prior to coronary angiography. In this study, FFR measurement had the greatest impact in the evaluation of lesions with documented ischemia on noninvasive tests. In these patients, appropriate use of FFR based on the operator's judgment can prevent unnecessary revascularizations of intermediate lesions.

Turmel J, Boulet LP, Series F, Poirier P, Tardif JC, Rodes-Cabau J, Larose E, Bertrand OF. · Laval Hospital/Quebec Heart-Lung Institute, Quebec City, Montreal, Canada. · Acta Cardiol. · Pubmed #18664026 No free full text.

Abstract: OBJECTIVE: Recent data suggested a relationship between carotid artery intima/media thickness and airway hyperresponsiveness (AHR). Our objective was to assess the potential relationship between AHR and coronary atherosclerosis plaque volume as assessed by 3-dimensional intravascular ultrasound (IVUS). METHODS: Thirty-six subjects had a spirometry and methacholine challenge, skin prick tests, blood sampling and induced sputum analysis. RESULTS: We found five (13.9%) patients who presented AHR to methacholine. There was no significant difference between patients with and without AHR, in plaque volume (221 +/- 45 mm3 vs. 189 +/- 13 mm3, P = 0.4), lumen volume (187 +/- 11 mm3 vs. 221 +/- 11 mm3, P = 0.2), or in total vessel volume (377 +/- 20 mm3 vs. 415 +/- 20 mm3, P = 0.5), respectively. No relationship was found between AHR, cell counts and coronary atherosclerotic plaque, lumen or total vessel volumes. There were significantly more eosinophils (1.69 +/- 1.75% vs. 0.21 +/- 0.31%, P = 0.0007) and lymphocyte counts (3.75 +/- 1.59% vs. 2.25 +/- 1.12%, P = 0.03) in patients with AHR compared to patients without. CONCLUSION: In patients with stable coronary artery disease, the incidence of AHR was low and there was no relationship between AHR or airway inflammation and coronary atherosclerosis.

Faik I, Mongrain R, Leask RL, Rodes-Cabau J, Larose E, Bertrand O. · Department of Mechanical Engineering, McGill University, 817 Sherbrooke Street West, Montreal, Quebec H3A 2K6, Canada. · Biomed Mater. · Pubmed #18458417 No free full text.

Abstract: Stenting is becoming the major interventional cardiology procedure worldwide. However restenosis remains a major limitation to the effectiveness of stents. Alterations to the local hemodynamics in the stented segment of the artery could be a potential factor in the development of in-stent restenosis. The characterization of wall shear stress and of blood flow patterns in a stented artery is therefore necessary for a good understanding of the role of hemodynamics in the development of in-stent restenosis. We have used a time-dependent 3D numerical model of a stented coronary artery to study the characteristics of the blood flow and the shear stress distribution. Our results show that the presence of the stent produces significant secondary flow that is limited to an annulus in the near wall region. Low shear stress zones were localized in the vicinity of the struts while the tips of the struts exhibited high values of shear stress. These results support the hypothesis that local hemodynamics may affect the development of in-stent restenosis and could influence the choice of stent geometries for future stent designs.

Bertrand OF, Faurie B, Larose E, Nguyen CM, Gleeton O, Déry JP, Noël B, Proulx G, Roy L, Costerousse O, De Larochellière R, Rodés-Cabau J. · Department of Cardiology, Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie, affilié à l'Université Laval, 2725, Chemin Ste Foy, Québec, Canada, G1V 4G5. · J Invasive Cardiol. · Pubmed #18316823 links to  free full text

Abstract: OBJECTIVES: This study compared acute and late outcomes following a strategy of selective drug-eluting stent (DES) use guided by a set of 4 criteria defining higher risk of in-stent restenosis compared to an exclusive DES strategy in 362 patients with multilesion (n = 900) percutaneous coronary interventions. RESULTS: At a mean follow up of 412 +/- 110 days, major adverse cardiac events (death, myocardial infarction, revascularization) were 16.8% in the exclusive DES group compared to 18.4% in the selective DES group (p = 0.78). By univariate analysis, revascularization rates (9.9% in the exclusive DES group versus 10.5% in the selective DES group; p = 1.0) and target lesion revascularization (TLR) rates (5.5% versus 6.2%; p = 0.77) were similar in the 2 groups. By multivariate analysis adjusted by propensity score to account for differences in baseline characteristics, the strategy of exclusive DES use was not associated with lower risks of revascularization (hazard ratio [HR]: 0.91, 95% confidence interval [CI] 0.64-1.29) or TLR (HR: 0.81, 95% CI 0.59-1.08) compared with selective DES use. Using the Academic Research Consortium criteria, stent thrombosis occurred in 6/161 (3.7%) cases in the exclusive DES group and in 1/201 (0.5%) case in the selective DES group (p = 0.03). CONCLUSIONS: In patients with multiple coronary lesions, a selective DES strategy for lesions at higher risk of restenosis and bare-metal stents for other lesions was safe and effective when compared to the exclusive use of DES. A large, prospective, randomized trial is required to validate a criteria-based selective DES strategy compared to systematic DES use.

Turmel J, Sériès F, Boulet LP, Poirier P, Tardif JC, Rodés-Cabeau J, Larose E, Bertrand OF. · Laval Hospital/Quebec Heart-Lung Institute, Quebec City, Canada. · Int J Cardiol. · Pubmed #18221805 No free full text.

Abstract: BACKGROUND: Sleep apnea hypopnea syndrome (SAHS) is a predictive factor of cardiovascular disease. We hypothesized that SAHS could influence coronary atherosclerosis plaque volume as assessed by 3-dimensional intravascular ultrasound (3D-IVUS). METHODS: Participating patients were identified from 2 studies assessing the progression of atherosclerosis in stable coronary artery disease using coronary 3D-IVUS. RESULTS: Nineteen patients, aged 61+/-8 years, with a body mass index of 29+/-5 kg/m(2) were studied. Increased apnea-hypopnea index (AHI) >or=15 was found in 12/19 patients (63%). Patients with AHI>or=15 had larger coronary atherosclerotic plaque volume than patients with AHI<15 (238+/-69 mm(3) vs 169+/-64 mm(3), p=0.047) and the difference was even larger in patients with obstructive apnea/hypopnea episodes compared to patients without (243+/-70 mm(3) vs 170+/-59 mm(3), p=0.03). There was a significant positive correlation between obstructive AHI and coronary atherosclerotic plaque volume (r=0.6, p=0.01). A significant positive correlation was also demonstrated between respiratory arousal index and coronary atherosclerotic plaque volume (r=0.6, p=0.02) and between total arousal index and coronary atherosclerotic plaque volume (r=0.5, p=0.03). CONCLUSION: In patients with stable coronary artery disease, there was a significant relationship between the frequency of obstructive sleep apnea/hypopnea episodes and sleep fragmentation and the importance of coronary atherosclerotic plaque volume. 3D-IVUS is well suited to correlate coronary atherosclerosis and sleep breathing disorders at early stages.

Brulotte S, Roy L, Larose E. · Quebec Heart Institute at Laval Hospital. · Can J Cardiol. · Pubmed #17876387 links to  free full text

Abstract: Congenital absence of the pericardium is a rare defect of which recognition is critical because it can be associated with catastrophic outcomes. While some carriers of this condition may present with a lethal complication, most are asymptomatic, and the defect is found incidentally. The case of a 49-year-old woman is described who presented with acute myocardial necrosis and absence of obstructive coronary artery disease, and in whom a complete left pericardial defect was found. An investigation was undertaken to determine the role of the defect in this patient's presentation and to recommend the best possible therapy. Finally, a review of literature focusing on congenital absence of the pericardium, as well as a discussion of clinical presentation, imaging techniques and therapeutic options, is also presented.

Rodés-Cabau J, Facta A, Larose E, DeLarochellière R, Déry JP, Nguyen CM, Roy L, Proulx G, Gleeton O, Barbeau G, Noël B, Rouleau J, Boudreault JR, Bertrand OF. · Interventional Cardiology Laboratories, Quebec Heart Institute-Laval Hospital, Laval, Quebec, Canada. · Am J Cardiol. · Pubmed #17697821 No free full text.

Abstract: The objective of this study was to evaluate the clinical and angiographic factors associated with significant saphenous vein graft (SVG) atherosclerosis progression at mid-term follow-up in a series of unselected coronary patients who had previously received a coronary artery bypass graft (CABG). A total of 123 SVGs from 86 patients who underwent cardiac catheterization twice, 15 +/- 12 months apart, were included in the study. None of the SVGs presented any > or =50% diameter stenosis (DS) lesion or underwent any intervention at baseline. All SVGs were divided into 3 segments and each SVG segment was scored from 0 to 3 depending on the presence of lesions, with percent DS ranging from 0% to 19% (score 0), 20% to 29% (score 1), 30% to 39% (score 2), and > or =40% (score 3). The SVG atherosclerotic burden score (ABS) was calculated by adding the score obtained for each of the 3 SVG segments. Significant progression was defined as > or =10% increase in lesion percent DS or > or =0.6 mm decrease in minimal lumen diameter between baseline and follow-up studies. Mean age of the study population was 66 +/- 9 years, and most of the patients were receiving statin therapy with mean low-density lipoprotein cholesterol of 85 +/- 26 mg/dl. Significant angiographic progression occurred in > or =1 SVG in 41 patients (48%). On multivariate analysis, the variables associated with SVG atherosclerosis progression were SVG ABS (odds ratio [OR], 1.52 for each increase of 1 point in SVG ABS; 95% confidence interval [CI] 1.1 to 2.29) and high-density lipoprotein (HDL) cholesterol (OR 1.38 for each decrease of 5 mg/dl in HDL cholesterol levels, 95% CI 1.09 to 1.85). Twenty-two patients (26%) had a cardiac event at follow-up related to SVG disease progression. The percent DS of the SVG segment at baseline was associated with SVG disease progression leading to a cardiac event (OR 3.67 for each increase of 5% in percent DS, 95% CI 2.11 to 6.38). In conclusion, simple clinical and angiographic variables such as HDL cholesterol, ABS, and lesion severity remain independent predictors of significant SVG atherosclerosis progression in mild to moderately diseased SVGs despite mean low-density lipoprotein levels <90 mg/dl.

Larose E, Kinlay S, Selwyn AP, Yeghiazarians Y, Yucel EK, Kacher DF, Libby P, Ganz P. · Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States. · Atherosclerosis. · Pubmed #17391676 No free full text.

Abstract: OBJECTIVES: To determine whether gadolinium-DTPA (Gd-DTPA) facilitates discrimination of fibrous, lipid or calcified constituents during intravascular magnetic resonance imaging (IVMRI) of human atherosclerotic arteries. BACKGROUND: Atherosclerotic plaques that cause fatal thrombosis due to rupture have high content of lipid relative to fibrous tissue. We recently demonstrated that IVMRI identifies lipid, fibrous, and calcified components within atherosclerotic human arteries with favorable sensitivity and specificity. Gd-DTPA, a T1-shortening agent, selectively amplifies the signal from fibrous tissue on T1 weighted (T1w) surface MRI. METHODS: A 0.030 in. diameter receiver coil coupled to a 1.5T MR scanner was positioned in iliac arteries of nine subjects with atherosclerosis. Previously validated multi-parametric analysis of T1w and moderate T2w images identified 137 fibrous, lipid and calcified regions of interest within 37 arterial segments. T1w imaging was repeated following 0.1 mmol/kg IV Gd-DTPA infusion. RESULTS: Computer-derived mean gray value in fibrous regions increased by 34.2% with Gd-DTPA (95% CI 24.3-43.5%, p=0.0001) while lipid and calcified regions showed only a non-significant increase of 4.3% (95% CI -0.6 to 9.2%, p=0.0825) and 3.8% (95% CI -1.1 to 7.7%, p=0.103), respectively. The increase in mean gray value with Gd-DTPA was greater for fibrous than for lipid or calcified regions (p=0.0001). CONCLUSIONS: Gd-DTPA selectively enhances signal intensity of fibrous constituents during IVMRI of human atherosclerotic arteries and thus identifies key tissue characteristics associated with plaque stability. These findings have important implications for the assessment of plaque-stabilizing therapies and ultimately for reducing cardiovascular events.

Larose E, Rogers CD, Simon DI. · Quebec Heart Institute at Laval Hospital, Chemin Sainte-Foy, Quebec Canada. · J Interv Cardiol. · Pubmed #16881985 No free full text.

Abstract: While the advantages of drug-eluting stents (DES) have been demonstrated in moderate and small-sized vessels, the benefits of DES use in selected larger vessels are increasingly recognized. In the following case presentation, the use of a DES outside the approved vessel diameter to treat left main coronary artery disease led to retrograde migration of the stent over the guiding catheter. Solutions to capturing and retrieving a stent in this position are discussed and our approach to resolving the situation is presented.

Larose E, Yeghiazarians Y, Libby P, Yucel EK, Aikawa M, Kacher DF, Aikawa E, Kinlay S, Schoen FJ, Selwyn AP, Ganz P. · Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. · Circulation. · Pubmed #16203910 links to  free full text

Abstract: BACKGROUND: Development and validation of novel imaging modalities to assess the composition of human atherosclerotic plaques will improve the understanding of atheroma evolution and could facilitate evaluation of therapeutic strategies for plaque modification. Surface MRI can characterize tissue content of carotid but not deeper arteries. This study evaluated the usefulness of intravascular MRI (IVMRI) to discern the composition of human iliac arteries in vivo. METHODS AND RESULTS: Initial studies validated IVMRI against histopathology of human atherosclerotic arteries ex vivo. A 0.030-inch-diameter IVMRI detector coil was advanced into isolated human aortoiliac arteries and coupled to a 1.5-T scanner. Information from combined T1-, moderate T2-, and proton-density-weighted images differentiated lipid, fibrous, and calcified components with favorable sensitivity and specificity and allowed accurate quantification of plaque size. The validated approach was then applied to image iliac arteries of 25 human subjects in vivo, and results were compared with those of intravascular ultrasound (IVUS). IVMRI readily visualized inner and outer plaque boundaries in all arteries, even those with extensive calcification that precluded IVUS interpretation. It also revealed the expected heterogeneity of atherosclerotic plaque content that was noted during ex vivo validation. Again, IVUS did not disclose this heterogeneity. The level of interobserver and intraobserver agreement in the interpretation of plaque composition was high for IVMRI but poor for IVUS. CONCLUSIONS: IVMRI can reliably identify plaque composition and size in arteries deep within the body. Identification of plaque components by IVMRI in vivo has important implications for the understanding and modification of human atherosclerosis.