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RETROSPECTIVE ANALYSIS OF CORONARY FRACTIONAL FLOW RESERVE FOR THE ASSESSMENT OF CORONARY ARTERY DISEASE IN A TERTIARY ACADEMIC CENTRE
S100
associated with an increased risk of in-stent restenosis (ISR) and stent thrombosis (ST). Limited data on optimal stent selection or the use of non-cardiac stents is available. Our objective was to examine the short- and intermediate-term safety of percutaneous coronary intervention (PCI) using RACER renal stents. METHODS: Between Aug 1, 2011 and December 31, 2013 there were 5,808 cases of PCI with implantation of at least one stent in the University of Ottawa Heart Institute PCI registry. RACER stents were implanted in 0.06% of PCI cases with thirty-four lesions treated in thirty-three patients in CAs with a diameter of 5mm (N ¼ 27) or saphenous vein grafts (N ¼ 6). There were no exclusion criteria and all consecutive patients were reported. A retrospective chart review was conducted to determine baseline patient data, procedural characteristics, and intermediate term outcomes. RESULTS: The majority of target lesions for native CAs involved the right coronary artery (67.9%) with fewer cases involving left main, left anterior descending (7.1%), left circumflex (3.6%), and right posterolateral segment CAs (3.6%). Most lesions were treated with a single RACER stent, while a minority (native CA 17.9%, SVG 16.7%) had two adjacent RACER stents implanted. Mean stent length, diameter, deployment pressure, and post-dilated balloon diameter and pressure were calculated. A successful angiographic result was achieved in all cases with no major complications or urgent surgical interventions. Median duration of follow-up for all patients was 117 days (interquartile range 232), with five patients having only in-hospital follow-up data available. Two deaths occurred which were unrelated to complications involving their RACER stents. The first patient had a RACER stent implanted following resuscitation from an out-of-hospital cardiac arrest and subsequently died 2 years later from refractory arrhythmia with repeat angiography confirming patency of the stent. The second patient died five days following implantation due to ventricular free-wall rupture secondary to a late presentation myocardial infarction. There were no instances of ST, ISR, target vessel or lesions revascularization, or other major adverse cardiovascular events. CONCLUSION: The use of RACER renal stents for PCI in very large diameter CAs represents a promising strategy with no major safety concerns identified in our cohort. Further research is required to more definitely establish the short- and long-term safety of this strategy.
086 REPEAT CORONARY ANGIOGRAPHY AND REVASCULARISATION PROCEDURES DURING FOLLOW-UP OF PATIENTS WITH A PRIOR HISTORY OF CORONARY ARTERY BYPASS GRAFTING A Murphy, C Janssen, DR Wong, A Della Siega, SD Robinson Glasgow, United Kingdom BACKGROUND:
CABG is an effective treatment for symptomatic multi-vessel coronary artery disease. However, the development of coronary graft disease or progression of native
Canadian Journal of Cardiology Volume 30 2014
coronary atherosclerosis places patients at risk of future adverse events or recurrent angina. We sought to ascertain the frequency and outcome of repeat coronary angiography in patients with prior CABG METHODS: We submitted an information request to the British Columbia Cardiac Registry, requesting the details of all patients in British Columbia who had undergone CABG between the years of 2001 to 2009 inclusive. Outcomes including death, angiography and further PCI/CABG for this cohort were collated to 31st December 2013. RESULTS: Results for 17316 patients were available. The mean age was 65.9 +/- 9.7 years and most patients were male (81.5%). All cause mortality at 30 days, 90 days, 1 year, 3 years and 4 years were 1.8%, 2.4%, 3.5%, 6.6% and 8.4% respectively. During the follow up period, 3116 (18.0%) patients had a subsequent coronary angiogram at a mean interval of 1193 days (3.3 years) from date of index CABG. 1412 (8.2%) patients subsequently underwent PCI. 63(0.3%) patients had a repeat CABG. Repeat coronary angiography was performed in 3.4% of patients within 1 year of index CABG and 8.6% within 4 years. Repeat angiography was more likely in younger patients, females and those with PVD or cerebrovascular disease. Diabetics were also more likely to get repeat angiography, particularly if they were treated with insulin. Patients taking beta blockers, aspirin or statins at the time of index CABG were less likely to undergo subsequent angiography. The indication for repeat angiography was acute coronary syndrome (ACS) in 40.6% of cases, and 42.9% for recurrent angina.2.6% of patients received PCI within 1 years of index CABG, and 5.4% within 4 years. The majority of PCIs (52.2%) were performed for ACS whilst 40.4% were offered for recurrent angina.Of those patients who underwent repeat CABG, 35.3% recieved this within 30 days of index CABG. CONCLUSION: Using long term follow up from a large provincial cardiac database, we have found that the majority of CABG patients subsequently undergoing coronary angiography do not receive revascularisation. Further work is necessary to explore the indications for performing angiography and repeat revascularisation in patients with a prior history of CABG.
087 RETROSPECTIVE ANALYSIS OF CORONARY FRACTIONAL FLOW RESERVE FOR THE ASSESSMENT OF CORONARY ARTERY DISEASE IN A TERTIARY ACADEMIC CENTRE JE Toma, R Good, S Kalra, R Barthwal, J Watt, D Austin, H Beydoun, T Lee, H Curran, N Nadeem, B Kidwai, L Title, C Kells, A Quraishi, MP Love Halifax, Nova Scotia INTRODUCTION: The use of fractional flow reserve (FFR) derived from coronary pressure wire measurements for the assessment of coronary lesion severity has been well integrated in interventional practice for several years. Although prospective, randomized trial data validating the use of FFR measurements in clinical practice exist, few studies have reported retrospective analysis of the success and limitations of
Abstracts
FFR in a real-world clinical setting. We sought to assess the rates of different management outcomes (medical therapy, PCI or CABG) following FFR measurements in an academic tertiary care centre in Atlantic Canada and the rate of revascularization of coronary lesions treated medically based on FFR and other clinical data. METHODS: The provincial CVIS database (Cardiovascular Information Management System, Philips Healthcare, Netherlands) was used to identify all patients that underwent FFR measurement from November 2007 to February 2013 in Halifax, Nova Scotia. Medical records, including coronary angiography reports, in-patient records, radiology reports, operative records and discharge summaries were reviewed for each study patient. RESULTS: 1124 individual FFR measurements were performed in 927 patients (mean age 66 11 years, 73% male, 67% acute coronary syndrome presentation). Left anterior descending territory vessels represented the majority of cases (56%) with left main assessment in only 6%. 670 pressure wire interrogated lesions were treated medically (average FFR 0.88 0.06), 308 underwent PCI (FFR 0.74 0.07) and 146 underwent CABG (FFR 0.73 0.08). In the subgroup treated medically, only 21 interrogated lesions (3.1%) with mean FFR 0.86 0.05 underwent subsequent revascularization within 1 year. Kaplan-Meyer 1-year freedom from revascularization curves for lesions treated medically following FFR interrogation are illustrated in Fig. 1. CONCLUSION: FFR assessment remains a highly accurate and robust method for assessment of coronary lesion severity. Almost 97% of coronary lesions treated medically following FFR assessment did not require revascularization in the following 12 months. We conclude that FFR measurement, in conjunction with angiographic assessment and clinical judgment, is highly predictive of clinical outcomes in a real-world tertiary care setting.
S101 BACKGROUND: Common means for the administration of drugs include the preferred non-invasive peroral, topical, transmucosal and inhalation routes. Many medications such as peptide, protein, antibody, vaccine and gene based drugs cannot be delivered using these routes because they may be systemically or remotely toxic at the therapeutically relevant dose, susceptible to enzymatic degradation or, poorly absorbed into the circulation to be effective. For these reasons many protein and peptide drugs must be delivered by injection or nanoneedle array. Neither of these delivery Methods provide for targeted delivery in which the drug is only active in a specific area of the body. We describe a novel approach for local drug delivery, which utilizes antibody-coated devices to capture genetically engineered circulating angiogenic cells (CACs). The CACs are genetically engineered to express H2Kk surface antigen, recognized by the antibody coated device, and a therapeutic molecule. The H2Kk surface antigen, found only in some rare murine strains, makes it an attractive selection marker when transgenically expressed in mammalian cells. METHODS AND RESULTS: Recombinant DNA technology and cell transfection were employed for CAC genetic modification. 316L stainless-steel discs, cobalt-chromium discs, and expanded polytetrafluoroethylene (ePTFE) graft material were functionalized with polydopamine (PDA). The glycoprotein avidin or an anti-H2Kk antibody were then immobilized on the PDA functionalized surfaces and their bioactivity tested in vitro. DNA sequencing verified the construction of a plasmid vector for double gene expression of H2Kk and human acalcitonin gene-related peptide (a-CGRP), a potent vasodilator. Transfection of COS-1 cells and bone marrow (BM) derived porcine CACs showed the production of H2Kk and a-CGRP. Successful PDA functionalization could be shown by visual assessment. Avidin functionalized surfaces were shown to bind 4-Fluorescein labeled biotin. H2Kk antibody coated surfaces bound both COS-1 cells and CACs engineered to express H2Kk surface antigen in vitro. CONCLUSION: Double transgenic expression can be achieved in both COS-1 cells and BM-derived porcine CACs. PDA can functionalize various materials commonly used for vascular devices. Immobilized H2Kk antibody selectively binds both H2Kk-COS-1 cells and H2Kk-CACs. These findings provide the basis for in vivo studies to determine whether engineered CACs can be selectively captured by implanted antibodycoated devices and release therapeutically relevant compounds. If effective in vivo, this novel technology could be adopted for the local delivery of protein/gene-based drugs to treat a variety of diseases.
088 ANTIBODY COATING ON IMPLANTABLE INTRAVASCULAR DEVICES TO SELECTIVELY CAPTURE GENETICALLY ENGINEERED CELLS FOR LOCAL DRUG DELIVERY: AN IN VITRO FEASIBILITY STUDY
089 IN VIVO EVALUATION OF INFARCTED TISSUE DEGRADATION AFTER ISCHEMIA USING NIR SPECTROSCOPY IN PIG HEARTS
Q Zhang, J Barfield, M Kutryk
Y Yang
Toronto, Ontario
Winnipeg, Manitoba
associated with an increased risk of in-stent restenosis (ISR) and stent thrombosis (ST). Limited data on optimal stent selection or the use of non-cardiac stents is available. Our objective was to examine the short- and intermediate-term safety of percutaneous coronary intervention (PCI) using RACER renal stents. METHODS: Between Aug 1, 2011 and December 31, 2013 there were 5,808 cases of PCI with implantation of at least one stent in the University of Ottawa Heart Institute PCI registry. RACER stents were implanted in 0.06% of PCI cases with thirty-four lesions treated in thirty-three patients in CAs with a diameter of 5mm (N ¼ 27) or saphenous vein grafts (N ¼ 6). There were no exclusion criteria and all consecutive patients were reported. A retrospective chart review was conducted to determine baseline patient data, procedural characteristics, and intermediate term outcomes. RESULTS: The majority of target lesions for native CAs involved the right coronary artery (67.9%) with fewer cases involving left main, left anterior descending (7.1%), left circumflex (3.6%), and right posterolateral segment CAs (3.6%). Most lesions were treated with a single RACER stent, while a minority (native CA 17.9%, SVG 16.7%) had two adjacent RACER stents implanted. Mean stent length, diameter, deployment pressure, and post-dilated balloon diameter and pressure were calculated. A successful angiographic result was achieved in all cases with no major complications or urgent surgical interventions. Median duration of follow-up for all patients was 117 days (interquartile range 232), with five patients having only in-hospital follow-up data available. Two deaths occurred which were unrelated to complications involving their RACER stents. The first patient had a RACER stent implanted following resuscitation from an out-of-hospital cardiac arrest and subsequently died 2 years later from refractory arrhythmia with repeat angiography confirming patency of the stent. The second patient died five days following implantation due to ventricular free-wall rupture secondary to a late presentation myocardial infarction. There were no instances of ST, ISR, target vessel or lesions revascularization, or other major adverse cardiovascular events. CONCLUSION: The use of RACER renal stents for PCI in very large diameter CAs represents a promising strategy with no major safety concerns identified in our cohort. Further research is required to more definitely establish the short- and long-term safety of this strategy.
086 REPEAT CORONARY ANGIOGRAPHY AND REVASCULARISATION PROCEDURES DURING FOLLOW-UP OF PATIENTS WITH A PRIOR HISTORY OF CORONARY ARTERY BYPASS GRAFTING A Murphy, C Janssen, DR Wong, A Della Siega, SD Robinson Glasgow, United Kingdom BACKGROUND:
CABG is an effective treatment for symptomatic multi-vessel coronary artery disease. However, the development of coronary graft disease or progression of native
Canadian Journal of Cardiology Volume 30 2014
coronary atherosclerosis places patients at risk of future adverse events or recurrent angina. We sought to ascertain the frequency and outcome of repeat coronary angiography in patients with prior CABG METHODS: We submitted an information request to the British Columbia Cardiac Registry, requesting the details of all patients in British Columbia who had undergone CABG between the years of 2001 to 2009 inclusive. Outcomes including death, angiography and further PCI/CABG for this cohort were collated to 31st December 2013. RESULTS: Results for 17316 patients were available. The mean age was 65.9 +/- 9.7 years and most patients were male (81.5%). All cause mortality at 30 days, 90 days, 1 year, 3 years and 4 years were 1.8%, 2.4%, 3.5%, 6.6% and 8.4% respectively. During the follow up period, 3116 (18.0%) patients had a subsequent coronary angiogram at a mean interval of 1193 days (3.3 years) from date of index CABG. 1412 (8.2%) patients subsequently underwent PCI. 63(0.3%) patients had a repeat CABG. Repeat coronary angiography was performed in 3.4% of patients within 1 year of index CABG and 8.6% within 4 years. Repeat angiography was more likely in younger patients, females and those with PVD or cerebrovascular disease. Diabetics were also more likely to get repeat angiography, particularly if they were treated with insulin. Patients taking beta blockers, aspirin or statins at the time of index CABG were less likely to undergo subsequent angiography. The indication for repeat angiography was acute coronary syndrome (ACS) in 40.6% of cases, and 42.9% for recurrent angina.2.6% of patients received PCI within 1 years of index CABG, and 5.4% within 4 years. The majority of PCIs (52.2%) were performed for ACS whilst 40.4% were offered for recurrent angina.Of those patients who underwent repeat CABG, 35.3% recieved this within 30 days of index CABG. CONCLUSION: Using long term follow up from a large provincial cardiac database, we have found that the majority of CABG patients subsequently undergoing coronary angiography do not receive revascularisation. Further work is necessary to explore the indications for performing angiography and repeat revascularisation in patients with a prior history of CABG.
087 RETROSPECTIVE ANALYSIS OF CORONARY FRACTIONAL FLOW RESERVE FOR THE ASSESSMENT OF CORONARY ARTERY DISEASE IN A TERTIARY ACADEMIC CENTRE JE Toma, R Good, S Kalra, R Barthwal, J Watt, D Austin, H Beydoun, T Lee, H Curran, N Nadeem, B Kidwai, L Title, C Kells, A Quraishi, MP Love Halifax, Nova Scotia INTRODUCTION: The use of fractional flow reserve (FFR) derived from coronary pressure wire measurements for the assessment of coronary lesion severity has been well integrated in interventional practice for several years. Although prospective, randomized trial data validating the use of FFR measurements in clinical practice exist, few studies have reported retrospective analysis of the success and limitations of
Abstracts
FFR in a real-world clinical setting. We sought to assess the rates of different management outcomes (medical therapy, PCI or CABG) following FFR measurements in an academic tertiary care centre in Atlantic Canada and the rate of revascularization of coronary lesions treated medically based on FFR and other clinical data. METHODS: The provincial CVIS database (Cardiovascular Information Management System, Philips Healthcare, Netherlands) was used to identify all patients that underwent FFR measurement from November 2007 to February 2013 in Halifax, Nova Scotia. Medical records, including coronary angiography reports, in-patient records, radiology reports, operative records and discharge summaries were reviewed for each study patient. RESULTS: 1124 individual FFR measurements were performed in 927 patients (mean age 66 11 years, 73% male, 67% acute coronary syndrome presentation). Left anterior descending territory vessels represented the majority of cases (56%) with left main assessment in only 6%. 670 pressure wire interrogated lesions were treated medically (average FFR 0.88 0.06), 308 underwent PCI (FFR 0.74 0.07) and 146 underwent CABG (FFR 0.73 0.08). In the subgroup treated medically, only 21 interrogated lesions (3.1%) with mean FFR 0.86 0.05 underwent subsequent revascularization within 1 year. Kaplan-Meyer 1-year freedom from revascularization curves for lesions treated medically following FFR interrogation are illustrated in Fig. 1. CONCLUSION: FFR assessment remains a highly accurate and robust method for assessment of coronary lesion severity. Almost 97% of coronary lesions treated medically following FFR assessment did not require revascularization in the following 12 months. We conclude that FFR measurement, in conjunction with angiographic assessment and clinical judgment, is highly predictive of clinical outcomes in a real-world tertiary care setting.
S101 BACKGROUND: Common means for the administration of drugs include the preferred non-invasive peroral, topical, transmucosal and inhalation routes. Many medications such as peptide, protein, antibody, vaccine and gene based drugs cannot be delivered using these routes because they may be systemically or remotely toxic at the therapeutically relevant dose, susceptible to enzymatic degradation or, poorly absorbed into the circulation to be effective. For these reasons many protein and peptide drugs must be delivered by injection or nanoneedle array. Neither of these delivery Methods provide for targeted delivery in which the drug is only active in a specific area of the body. We describe a novel approach for local drug delivery, which utilizes antibody-coated devices to capture genetically engineered circulating angiogenic cells (CACs). The CACs are genetically engineered to express H2Kk surface antigen, recognized by the antibody coated device, and a therapeutic molecule. The H2Kk surface antigen, found only in some rare murine strains, makes it an attractive selection marker when transgenically expressed in mammalian cells. METHODS AND RESULTS: Recombinant DNA technology and cell transfection were employed for CAC genetic modification. 316L stainless-steel discs, cobalt-chromium discs, and expanded polytetrafluoroethylene (ePTFE) graft material were functionalized with polydopamine (PDA). The glycoprotein avidin or an anti-H2Kk antibody were then immobilized on the PDA functionalized surfaces and their bioactivity tested in vitro. DNA sequencing verified the construction of a plasmid vector for double gene expression of H2Kk and human acalcitonin gene-related peptide (a-CGRP), a potent vasodilator. Transfection of COS-1 cells and bone marrow (BM) derived porcine CACs showed the production of H2Kk and a-CGRP. Successful PDA functionalization could be shown by visual assessment. Avidin functionalized surfaces were shown to bind 4-Fluorescein labeled biotin. H2Kk antibody coated surfaces bound both COS-1 cells and CACs engineered to express H2Kk surface antigen in vitro. CONCLUSION: Double transgenic expression can be achieved in both COS-1 cells and BM-derived porcine CACs. PDA can functionalize various materials commonly used for vascular devices. Immobilized H2Kk antibody selectively binds both H2Kk-COS-1 cells and H2Kk-CACs. These findings provide the basis for in vivo studies to determine whether engineered CACs can be selectively captured by implanted antibodycoated devices and release therapeutically relevant compounds. If effective in vivo, this novel technology could be adopted for the local delivery of protein/gene-based drugs to treat a variety of diseases.
088 ANTIBODY COATING ON IMPLANTABLE INTRAVASCULAR DEVICES TO SELECTIVELY CAPTURE GENETICALLY ENGINEERED CELLS FOR LOCAL DRUG DELIVERY: AN IN VITRO FEASIBILITY STUDY
089 IN VIVO EVALUATION OF INFARCTED TISSUE DEGRADATION AFTER ISCHEMIA USING NIR SPECTROSCOPY IN PIG HEARTS
Q Zhang, J Barfield, M Kutryk
Y Yang
Toronto, Ontario
Winnipeg, Manitoba