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Prediction of reocclusion after coronary thrombolysis
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IACC Val . 23 . No.
7 Jane 1194 :1735-6
LETTERS TO THE EDITOR
and an unspecific number [eight or less] in the Rey et al . [4] report), we hope that the addition of a description of our experience in this unique high risk population of newborns will be helpful to others who embark on the procedure . DANIEL A. KVESELIS, MD CRAIG L BYRUM, MD Dlri n,fPedinuicCardiology Stare Unisrrairy of New York Health Science Center at Syracuse 725 Jrviag Avenue. Suite 8M Symeuse, New York 13210
Bogy of culprit vessel reocclusion from the technical aspects of methodology. A . LANCER, MD Coronary Care Unit Division of Cardology Sr. Mich.,)'. Hasp ral 30,%.d Street, Suit, 701A Toronto. Ontario U58 1111S, Canada Reference I . Vest G, Meyer A. Vmhmp FWA . el Y . Cutely Ieew msephotit sent summis severity is Ire prtddies at rraoelusiw aA. r mnuy eoumbelys§: avsopaph's much, ofamABBCO7em%.IAm Cast Cas al1993 :12:1731-62.
Refereseces I . BureymkiJa, Kvesess DA, Byam G . Kenny R.EW, Sm1h PC. (haven WE. Isolated lechhgaefarbaaomvawlopiaofofsuaeelpahmnery,e meisinthvrnwbmn.J Am Con Cardml191ra :19a-7. 2 . Send B. Keese IF . Felons KE, Lack IE . Babm dlapmn at uitkW puhnosaee smnosa a the fleet week of Ife . J Am Cal C.Wiei 19,;1 1:821-4. 3 . All Khm MA, A .Vmsef B, Halter IC, Barker IT, Minim CE Sawyer W . Centel pWmomry valve emrl055 in patients less then 1 year of4e : tralmeet with pennants madatimml bal oon pammaey velvubp'vtry . Am Heal 11919:117:1111-14. 4 . Rry C, Massche P. Present, C . DupeinC. Peevuseaus hamimdnd hellos, v ertsp6ss of conlmiml puhnomry valve stenmis with a special span an IN es and rmo„le,.I Am Cut Canclial 19P ;11:813-20. 5 . Qumhi SA, Led- FJ, Martin RP. Osma ion with propessively lmlerbakms car severe vemeis athe pulmonary valve PM-64 in the Ian nemwel perlsd and early infancy . at Heart J 1989p62 :3114 .
Prediction of Reocclusion After Coronary Thrombolysis In a recent article, Veen et al . (I) demonstrate a reocclusion rate of -30% at 3 months in a culprit vessel that was patent within 48 h of thromholytic therapy. These results provid- new and important information . Given the relatively high rate of rocclusiou, as observed and discussed by the authors, I wondered whether additional information with respect to angiographic grading would shed more light . Reocclusion was defined as grade 5 (total occlusion) or 4 (91% to 99% diameter stenosis with incomplete vessel filling within three cycles), whereas grade 3 (same as grade 4 but with complete filling within three cycles) was considered indicative of potency . Thus, the assessment of potency is not only dependent on assessment of severity of the stenosis but also rate of filling within three cycles. Could the authors provide the results divided by grade 4 and then grade 5, rather than a sum of these two, and how many of the grade 3 stenoses at baseline became grade 4 at 3 months? This information would be of further help in separating the paihophysi-
Reply Longer wandered whether the reocdusio rate could have been influenced by technical difficulties in separating grade 3 from grade 4 stenosis. We agree that it can sometimes be difficult to separate grade 3 fro,. grade 4 stenosis by visual assessment of lbw (f7ade 3 defined as 91% to 99% stenosis with distal felling within three cardiac cycles and grade 4 defined as 91% to 99% sreuosis with distal filling in more than three cardiac cycles). However, in the APRICOT (1) study we did not have great difficulties in making this separatist because most grade 4 occlusions showed distal filling in more than five cardiac cycles. We found a grade 3 stenosis at : firs angiography in 72 patients . At the second aagiogeaphy 28 stenses were still grade 3;S progressed rogmde 4; aed25 progressed tog ade 5 . Thus, of the 72 atenoset only 5 (6 .9%) changed from grade 3 to grade 4. Or the 30 reocclusions 5 (16 .7%) were grade 4, and 25 (93.3%) were grade 5. Thus, the largest pat of the reocehrsions found in the group with grade 3 stenosis at first angiog aphy was grade S at second singiegraphy and thus clearly reecchrded . Furthermore, of the five reocclusions having grade 4 stenosis, four showed distal tiling in more than five cardiac cycles, making the separation from grate 3 stenosis quite easy. Therefore, ft seems unlikely that the data on roccusion were influenced by possible dif lcuhies in separating grade 3 from grade 4 sterosis by visual assessment. GERRIT VEEN, MD FREEK W. A. VERHEUGT, MD, FACC DeparlmentoCadiology Free Unirer.try Haapiml P.O. Box 7057 Amsterdam, The Netherlands 1007 MB Rderence I . Van 0, Meyer A, Vernal FwA, et a. Culprit lesion murphobgy met menses, .enty in the pmakron of rwrulmoa after emnmr y tmmbayda anyepaphic meats aftbe APRICOT cloudy. J AmCel Cited 1993;22 :1733.62.
IACC Val . 23 . No.
7 Jane 1194 :1735-6
LETTERS TO THE EDITOR
and an unspecific number [eight or less] in the Rey et al . [4] report), we hope that the addition of a description of our experience in this unique high risk population of newborns will be helpful to others who embark on the procedure . DANIEL A. KVESELIS, MD CRAIG L BYRUM, MD Dlri n,fPedinuicCardiology Stare Unisrrairy of New York Health Science Center at Syracuse 725 Jrviag Avenue. Suite 8M Symeuse, New York 13210
Bogy of culprit vessel reocclusion from the technical aspects of methodology. A . LANCER, MD Coronary Care Unit Division of Cardology Sr. Mich.,)'. Hasp ral 30,%.d Street, Suit, 701A Toronto. Ontario U58 1111S, Canada Reference I . Vest G, Meyer A. Vmhmp FWA . el Y . Cutely Ieew msephotit sent summis severity is Ire prtddies at rraoelusiw aA. r mnuy eoumbelys§: avsopaph's much, ofamABBCO7em%.IAm Cast Cas al1993 :12:1731-62.
Refereseces I . BureymkiJa, Kvesess DA, Byam G . Kenny R.EW, Sm1h PC. (haven WE. Isolated lechhgaefarbaaomvawlopiaofofsuaeelpahmnery,e meisinthvrnwbmn.J Am Con Cardml191ra :19a-7. 2 . Send B. Keese IF . Felons KE, Lack IE . Babm dlapmn at uitkW puhnosaee smnosa a the fleet week of Ife . J Am Cal C.Wiei 19,;1 1:821-4. 3 . All Khm MA, A .Vmsef B, Halter IC, Barker IT, Minim CE Sawyer W . Centel pWmomry valve emrl055 in patients less then 1 year of4e : tralmeet with pennants madatimml bal oon pammaey velvubp'vtry . Am Heal 11919:117:1111-14. 4 . Rry C, Massche P. Present, C . DupeinC. Peevuseaus hamimdnd hellos, v ertsp6ss of conlmiml puhnomry valve stenmis with a special span an IN es and rmo„le,.I Am Cut Canclial 19P ;11:813-20. 5 . Qumhi SA, Led- FJ, Martin RP. Osma ion with propessively lmlerbakms car severe vemeis athe pulmonary valve PM-64 in the Ian nemwel perlsd and early infancy . at Heart J 1989p62 :3114 .
Prediction of Reocclusion After Coronary Thrombolysis In a recent article, Veen et al . (I) demonstrate a reocclusion rate of -30% at 3 months in a culprit vessel that was patent within 48 h of thromholytic therapy. These results provid- new and important information . Given the relatively high rate of rocclusiou, as observed and discussed by the authors, I wondered whether additional information with respect to angiographic grading would shed more light . Reocclusion was defined as grade 5 (total occlusion) or 4 (91% to 99% diameter stenosis with incomplete vessel filling within three cycles), whereas grade 3 (same as grade 4 but with complete filling within three cycles) was considered indicative of potency . Thus, the assessment of potency is not only dependent on assessment of severity of the stenosis but also rate of filling within three cycles. Could the authors provide the results divided by grade 4 and then grade 5, rather than a sum of these two, and how many of the grade 3 stenoses at baseline became grade 4 at 3 months? This information would be of further help in separating the paihophysi-
Reply Longer wandered whether the reocdusio rate could have been influenced by technical difficulties in separating grade 3 from grade 4 stenosis. We agree that it can sometimes be difficult to separate grade 3 fro,. grade 4 stenosis by visual assessment of lbw (f7ade 3 defined as 91% to 99% stenosis with distal felling within three cardiac cycles and grade 4 defined as 91% to 99% sreuosis with distal filling in more than three cardiac cycles). However, in the APRICOT (1) study we did not have great difficulties in making this separatist because most grade 4 occlusions showed distal filling in more than five cardiac cycles. We found a grade 3 stenosis at : firs angiography in 72 patients . At the second aagiogeaphy 28 stenses were still grade 3;S progressed rogmde 4; aed25 progressed tog ade 5 . Thus, of the 72 atenoset only 5 (6 .9%) changed from grade 3 to grade 4. Or the 30 reocclusions 5 (16 .7%) were grade 4, and 25 (93.3%) were grade 5. Thus, the largest pat of the reocehrsions found in the group with grade 3 stenosis at first angiog aphy was grade S at second singiegraphy and thus clearly reecchrded . Furthermore, of the five reocclusions having grade 4 stenosis, four showed distal tiling in more than five cardiac cycles, making the separation from grate 3 stenosis quite easy. Therefore, ft seems unlikely that the data on roccusion were influenced by possible dif lcuhies in separating grade 3 from grade 4 sterosis by visual assessment. GERRIT VEEN, MD FREEK W. A. VERHEUGT, MD, FACC DeparlmentoCadiology Free Unirer.try Haapiml P.O. Box 7057 Amsterdam, The Netherlands 1007 MB Rderence I . Van 0, Meyer A, Vernal FwA, et a. Culprit lesion murphobgy met menses, .enty in the pmakron of rwrulmoa after emnmr y tmmbayda anyepaphic meats aftbe APRICOT cloudy. J AmCel Cited 1993;22 :1733.62.