Showing papers by "Michael J. Mack published in 2009"

Assessment of the SYNTAX score in the Syntax study

Abstract: Aims: The SYNTAX™ score has been designed to better anticipate the risks of percutaneous or surgical revascularisation, taking into account the functional impact of the coronary circulation with all its anatomic components including the presence of bifurcations, total occlusions, thrombus, calcification, and small vessels. The purpose of this paper is to describe the baseline assessment of the SYNTAX™ score in the Syntax randomised trial, the corelab reproducibility, the potential difference in score assessment between the investigator and the corelab, and to ascertain the impact on one-year outcome after either percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) in patients with complex coronary artery disease. Methods and results: To assess the reliability of Syntax™ scoring, 100 diagnostic angiograms from the Syntax trial were randomly selected and assessed independently by two observers. Intra-observer variability was assessed by analysing 91 sets of angiograms after an interval of at least eight weeks by one of the observers. Clinical outcomes in the randomised cohort of the Syntax trial up to one year are presented with stratification by tertile group of the SYNTAX™ score. The weighted kappa value for the inter-observer reproducibility on the global score was 0.45, while the intra-observer weighted kappa value was 0.59. The SYNTAX™ score as calculated by investigators consistently underscored the corelab score by 3.4 points. When the Syntax randomised cohort was stratified by tertiles of the SYNTAX™ score, there were similar or nonsignificantly different MACCE rates in those with low or intermediate scores; however in the top tertile the MACCE rate was greater in those receiving PCI compared to CABG. Conclusions: The SYNTAX™ score is a visual coronary score with an acceptable corelab reproducibility that has an impact on the one-year outcome of those having PCI, whereas it has no effect on the one-year outcome following surgical revascularisation. The SYNTAX™ score tool is likely to be useful in a wide range of patients with complex coronary disease.

Transapical aortic valve implantation: is it ready for prime time?

Abstract: d rom http/academ ic.p.com /ejcts/articlect/36/2/229/517126 by gest on 18 Feruary 2019 Transcatheter aortic valve implantation (TAVI) is now a clinical reality with the commercial approval of two devices in Europe and the enrollment in the United States (US) pivotal trial of one of the devices currently nearing completion. The experience in Leipzig as well as in many other centres highlights the emerging role of transcatheter valve therapy for the management of critical aortic stenosis in high-risk patients. There are two approaches by which most of the devices are currently placed: a transfemoral (TF) approach in which the valve is placed retrograde through the femoral artery, and a transapical (TA) route in which the valve is placed through the apex of the left ventricle in an antegrade fashion, accessed through a small left thoracotomy incision. There have now been over 6000 transcatheter valves implanted worldwide with an estimated 75% of them placed by the TF approach. Walther and colleagues from Leipzig have pioneered the TA approach for TAVI, and in doing so have set the standard for this procedure in terms of defining the technique, optimal patient selection, perioperative management and fastidious, complete reporting of results [1]. In this issue of the journal, Walther et al. focus on a particularly high-risk group of patients in need of aortic valve replacement, those who have undergone previous cardiac surgery including coronary artery bypass grafting (CABG), mitral valve and aortic valve surgery [2]. They report excellent results in treating this high-risk group of patients by TAVI. These results were achieved in part due to three important factors. First, the procedures were performed by an experienced team of surgeons, cardiologists and anaesthesiologists working in a collaborative relationship. They were able to perform the procedures in an optimal workplace, a hybrid operating room, and they had unfettered patient selection for a single-procedure approach, allowing perhaps the only opportunity to truly evaluate the TA approach. Each of these aspects is noteworthy and deserving of further comment. Transcatheter valve procedures combine aspects of traditional surgical operations performed under general anaesthesia with imaging guidance more germane to cardiac catherisation laboratories. Programmes which have achieved the highest degrees of success along with the best results with TAVI are those in which a collaborative working environment is

Does percutaneous coronary intervention compromise the outcome of subsequent coronary artery bypass grafting

Abstract: Percutaneous coronary intervention (PCI) has traditionally been used as first-line therapy for limited coronary artery disease while coronary artery bypass grafting (CABG) has been the mainstay of therapy for patients with more advanced multivessel and left main disease. With the more frequent use

Percutaneous mitral valve therapy: when? Which patients?

Abstract: Purpose of review Transcatheter management of valvular heart disease is an emerging area of intense interest. Patients with mitral regurgitation present a large clinical unmet need for therapeutic advances. Recent findings A large randomized, pivotal trial of one device, which performs an edge-to-edge repair, has recently completed enrolment and is awaiting all patients to reach the primary clinical endpoint. A host of other devices are still in preclinical or early clinical feasibility trials after having undergone device iteration. Clinical trials with two devices have been stopped because of disappointing early results. Summary Although the field of transcatheter treatment of aortic stenosis is proceeding at a brisk pace with commercial approval of two devices in Europe, percutaneous treatment of mitral regurgitation has progressed at a much more measured pace because of varying cause of the disease, complexity of valvular anatomy, imaging, and delivery issues.