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Over the past twenty years, technical advances in coronary
arteriography have contributed to our understanding of the
pathophysiologic aspects and natural history of coronary artery
disease. Probably more than 700. 000 coronary arterio grams are
performed annually throughout the world. Usually, these
arteriograms are interpreted visually to determine the morphologic
extent and severity of coronary artery disease. These subjective
determinations, which are hampered . by relatively large intra- and
interobserver variations, are used as a basis for critically
important therapeutic decisions: Which arteries are to be
revascular ized, which lesions are suitable for coronary bypass
surgery or for percutaneous coronary angioplasty? To improve on
this clinical decision making, on the treat ment and follow-up of
such patients, new, objective and reproducible techniques for the
assessment of the extent and severity of coronary artery disease,
both in terms of anatomy and functional significance of the
lesions, must be made widely available. With such new procedures
and technologies the efficacy of new thera peutic procedures, the
effects of vasodilating and constricting drugs, and the results of
long-term studies on the regression and progression of
atherosclerotic plaque can be determined in an objective and
cost-effective manner.
In this fourth book in the series on quantitative coronary
arteriography (QCA) with the earlier three volumes published in
1986, 1988 and 1991, the latest developments in this exciting field
are covered. Both the methodolog ical and clinical application
aspects of these advances are presented in a comprehensive manner
in a total of 37 chapters by world renowned experts. The book is
subdivided into a total of eight parts, beginning with the more
methodological issues, such as QCA and other modalities (3
chapters), cine film versus digital arteriography (3 chapters),
quality control in QCA (4 chapters), and coronary blood flow and
flow reserve (3 chapters). Since QCA has been well established as
the technique for the assessment of regression and progression in
atherosclerotic disease, and of restenosis after recanaliz ation
procedures, major clinical trials in both groups are described
extensively by their principal investigators in a total of 11
chapters. In addition, the QCA results after the application of
various recanalization techniques are presented in another eight
chapters. In the last part the experiences with various
intracoronary prostheses with the emphasis on QCA are discussed in
five chapters. This large increase in application oriented chapters
means that QCA is well alive and gaining momentum. Although the
accuracy and precision of the analytical methods steadily improve
with the increasing complexity of the algorithms, there is still
always the human factor involved in these processes in terms of
frame selection, segment definition, etc.
From the Foreword by Eric J. Topol In the past five years,
interventional cardiology has entered a new era of evaluating
percutaneous transcatheter technologies to treat coronary artery
disease and prevent restenosis. Cardiologists attempting to follow
this new and exciting field may easily be confused by the growth
and expansion of new devices, the technical details relevant to
each device and enthusiastic claims of success. This monograph is a
comprehensive and objective assessment of restenosis from the
perspective of these new technologies including stenting,
atherectomy, rotational abrasion and lasers, written by innovators
and pioneers. The international breadth of experience is reflected
in the summary of experiences from both sides of the Atlantic, at
times with conflicting observations and results which in itself is
valuable, given the diverse experience to date. In addition to the
lucid summaries of the early and late results of these new devices,
important issues in the methodology of restenosis research are
addressed, including limitations of quantitative coronary
arteriography in evaluating the new devices and important advances
in alternatives to arteriography such as intravascular imaging. As
a whole, this monograph is exceptionally worthwhile owing to its
complete, up-to-date, balanced and visionary elements. There is no
question that the new coronary device era has ushered in some
excitement, and some despair. This book serves a pivotal purpose by
weaving so many new concepts together, establishing the groundwork
for further development of mechanical approaches to limit
restenosis. I heartily recommend this text to all interventional
cardiologists interested in practical and research aspects of
restenosis.
This is the fifth volume in this series on quantitative coronary
arteriography (QCA) published over the last nine years. Research
and applications in this exciting, field are covered in a total of
26 chapters by world renowned experts. This book is subdivided into
a total of 6 parts, each emphasizing the latest progress in these
respective fields. In Part One a comprehensive overview is given of
the current knowledge and research in endothelial function, which
is of eminent importance for the further understanding of the
pathophysiology of coronary artery disease in patients.
Fortunately, the use of QCA tools is not limited anymore to leading
research institutes; over the last several years these tools have
been installed in many cardiology centers world wide. To understand
the current possibili ties, limitations and future expectations of
QCA, several relevant topics are presented in Part Two. First of
all, the questions about why and how QCA systems should be
validated both at the development site and at the appli cation
sites, and whether data from different vendors and core
laboratories can be pooled, are discussed. As the X-ray
cardiovascular world steadily moves into the digital imaging era,
differences and similarities between the conventional cinefilm and
the modern digital approaches are presented. Cur rently. the
widespread use of digital imaging is still hindered by the lack of
proper archival and exchange media. Requirements and possible
solutions for this problem are handled in this section as well.
In June 1989, a third conference concentrating on the progress in
quantita tive coronary angiography and related techniques was held
in Rotterdam, again very successful as the two preceding events in
1985 and 1987. Tech nical as well as clinical aspects of digital
and digitized coronarography, morphometry, parametric imaging and
functional quantification of the human coronary circulation were
presented and discussed by prominent exponents of those groups who
have been active in this particular field for many years. This book
contains the chapters representing the lectures held by leading
experts during the symposium that update the knowledge currently
available, including most recent aspects in angioscopy and
intravascular ultrasound imaging. It also includes a historical
review on the development of angiogra phic techniques from the very
early days on to our times given by one of the pioneers in heart
catheterization and angiography, Dr. Kurt Amplatz. Those who had
the chance to listen to his talk, will surely remember his
impressive, humorous lecture as one of the highlights of this
meeting."
Since the introduction of coronary angioplasty in 1977, this
procedure has gained a steadily increasing position in the
treatment of coronary artery obstmction. From the available
evidence it can be estimated, that this thera peutic tool will get
even more additional momentum of many ten-thousands of patients to
be treated in the next few years, due to a growing fraction of
patients who are candidates for this intervention. Information
about the indications, benefits and risks of coronary angioplasty
is accumulating rapidly in addition to publications about
refinements of the technique itself. Recently, a number of
investigators have realized that coronary angioplasty is not only a
therapeutic tool, but can, during the procedure, be used as a
source of diagnostic information. When the catheter is placed in a
coronary artery obstruction, inflation of the balloon produces
transient myocardial ischemia. Before, during, and after this
period of severe ischemia, studies of the perfor mance of the
myocardium at risk can be carried out. The fact that therapeutic
coronary angioplasty is carried out in a cardiac catheterization
laboratory which is by definition optimally equipped for the
measurement of hemodynamic parameters, has probably also
contributed to the effectuation of these investigations. The
combination of hemodynamic and biochemical parameters with
morphological information from the coronary angiogram can be
utilized for the quantification of myocardial involvement and the
success of coronary dilatation with angioplasty. Studies of
interactions with pharmacological substances are also feasible and
informative."
There are few techniques that have influenced therapeutic
strategies in modem cardiology to a similar extent as coronary
arteriography. Bypass surgery as well as transluminal coronary
angioplasty would not have been possible without coronary
angiography serving as a 'midwife' in their evolu tion. Despite the
widespread and long-standing use in clinical practice, however, the
interpretation of coronary angiograms has not changed very much
since the early days. Most angiogr s are still reviewed in a visual
and semi-quantitative and thus often very subjective way. In the
face of an almost exploding field for interventional
catheterization including thrombolysis, balloon dilatation, and
other rapidly evolving techniques for transluminal
revascularization or recanalization, a more detailed and
quantitative analysis of coronary arteriograms is urgently
required. In addition to the delineation of coronary morphology, we
need dynamic and functional information about flow and perfusion to
understand the physiological significance of anatomic
abnormalities. Coronary arteriography contains and can provide most
of this information. With the application of appropriate
techniques, it can be made available in the catheterization
laboratory even during the patient's investiga tion, thus
facilitating and improving clinical decision making. Objective and
reproducible analysis will furthermore enhance our understanding
about the pathophysiology of coronary disease."
In recent years there has been an increasing interest in
quantitative analysis of coronary cineangiograms and already for a
longer time of left ventricular cin- eangiograms. The needfor
quantitationofcoronary arterialdimensions has been stimulated by
the introduction ofnew therapeutic procedures in the catheteriza-
tionlaboratory, suchas the balloon dilatationtechnique (PTCA) and
thromboly- tic therapy, by the need to study the vasoactive
responses of pharmaceutical agents, and also by the desire to study
the progressive nature ofcoronary artery disease with the ultimate
goal to find ways to bring a halt to the progression of coronary
atherosclerosis or even achieve regression of the disease. Parallel
with these clinical developments, rapid technical developments in
computerarchitect- ures and semiconductor memories have made it
possible to digitize and store cineframesor selected portions
thereof in image processors and to analyze these pictorial data
quantitatively at affordable prices. More than 15 years of research
have been directed by various groups towards the semi- or
fully-automated delineation of the left ventricular boundaries on a
frame-to-frame basis. Yet not a single system with fully-automated
capability is commercially available. In the mean time many
different left ventricular wall motion models have been developed,
again with little consensuson which model is to be preferred as no
golden standard exists.
Obstruction of coronary blood flow and the resultant consequences
are the center stage pathophysiologic events in cardiology today.
The speculations of Jenner, Burns, Heberdin, McKenzie, Prinzmetal
and many others had until now been left to observations of isolated
tissue and intact animal experimentation. Only with the advent of
Gruentzig's technique, which allowed us to 'work safely inside the
coronary arteries' are we able to observe the effects of coronary
occlusion in living conscious man. PTCA provides not only a
therapeutic modality for non-operatively opening coronary
obstructions, but has also provided the best model for studying the
effects of acute ischemia on the heart. The procedure also lead the
way to all other interventional cardiology developments, including
modern thrombolysis in the setting of acute myocardial infarction.
In his previous works, Serruys has examined how PTCA can serve as a
model for studying acute ischemia. In this book, he and his
co-authors discuss the effects of balloon-induced ischemia on the
electrocardiographic changes, coronary blood flow dynamics, cardiac
muscle metabolism and left ventricular function, as well as
measures to counter these effects and provide for reperfusion in
unstable angina and acute myocardial infarction. Technology has
expanded the 'eyes' of the observer of these events. The authors
use many techniques including ECG recording from surface,
endocardium, and intracoronary electrodes; angiographic assessment
of coronary flow pattern using digital techniques, as well as
doppler flow measurements; biochemical assessment of metabolic
products stimulated by ischemia; and digital angiographic and echo
doppler assessment of left ventricular function.
Quantitative coronary angiography has become an invaluable tool for
the interventional cardiologist, providing objective and
reproducible measurements of coronary artery dimensions, which can
be used to study progression or regression of coronary
atherosclerosis, as well as the immediate and long term effects of
percutaneous interventions. Until recently, this powerful imaging
technology was confined to a small number of so-called high level
institutions. Fortunately, with the development of digital cardiac
imaging equipment and adaptation of cine-angiographically based
computer software for on-line use in the catheterization room,
quantitative coronary angiography is now available to all
interventionalists. This book is a timely guide for the impending
QCA user, providing practical as well as theoretical and scientific
information. A comprehensive evaluation of the clinical usefulness
of QCA is covered, from the fundamental principles through
experimental validation studies, application to clinical trials of
a wide range of pharmacological and interventional therapies in the
full spectrum of clinical presentation of coronary disease
syndromes, evaluation of the therapeutic efficacy of various new
devices for coronary intervention, together with extensive
presentation of its physiological, functional and anatomical
correlations, by comparison with other intracoronary measurement
and imaging techniques. In addition, evolving theories and concepts
in the ever topical restenosis phenomenon' after percutaneous
intervention, based on serial QCA studies, are presented and
discussed and a potentially unifying methodological approach to
further study of this ubiquitous problem is offered. This book,
thanks to the collaboration of many experts in the field of
intracoronary imaging and measurement, provides stimulating,
interesting and practical information, both for the academic
scientist and practising clinician.
Quantitative coronary angiography has become an invaluable tool for
the interventional cardiologist, providing objective and
reproducible measurements of coronary artery dimensions, which can
be used to study progression or regression of coronary
atherosclerosis, as well as the immediate and long term effects of
percutaneous interventions. Until recently, this powerful imaging
technology was confined to a small number of so-called high level
institutions. Fortunately, with the development of digital cardiac
imaging equipment and adaptation of cine-angiographically based
computer software for on-line use in the catheterization room,
quantitative coronary angiography is now available to all
interventionalists. This book is a timely guide for the impending
QCA user, providing practical as well as theoretical and scientific
information. A comprehensive evaluation of the clinical usefulness
of QCA is covered, from the fundamental principles through
experimental validation studies, application to clinical trials of
a wide range of pharmacological and interventional therapies in the
full spectrum of clinical presentation of coronary disease
syndromes, evaluation of the therapeutic efficacy of various new
devices for coronary intervention, together with extensive
presentation of its physiological, functional and anatomical
correlations, by comparison with other intracoronary measurement
and imaging techniques. In addition, evolving theories and concepts
in the ever topical restenosis phenomenon' after percutaneous
intervention, based on serial QCA studies, are presented and
discussed and a potentially unifying methodological approach to
further study of this ubiquitous problem is offered. Thisbook,
thanks to the collaboration of many experts in the field of
intracoronary imaging and measurement, provides stimulating,
interesting and practical information, both for the academic
scientist and practising clinician.
Since the introduction of coronary angioplasty in 1977, this
procedure has gained a steadily increasing position in the
treatment of coronary artery obstmction. From the available
evidence it can be estimated, that this thera peutic tool will get
even more additional momentum of many ten-thousands of patients to
be treated in the next few years, due to a growing fraction of
patients who are candidates for this intervention. Information
about the indications, benefits and risks of coronary angioplasty
is accumulating rapidly in addition to publications about
refinements of the technique itself. Recently, a number of
investigators have realized that coronary angioplasty is not only a
therapeutic tool, but can, during the procedure, be used as a
source of diagnostic information. When the catheter is placed in a
coronary artery obstruction, inflation of the balloon produces
transient myocardial ischemia. Before, during, and after this
period of severe ischemia, studies of the perfor mance of the
myocardium at risk can be carried out. The fact that therapeutic
coronary angioplasty is carried out in a cardiac catheterization
laboratory which is by definition optimally equipped for the
measurement of hemodynamic parameters, has probably also
contributed to the effectuation of these investigations. The
combination of hemodynamic and biochemical parameters with
morphological information from the coronary angiogram can be
utilized for the quantification of myocardial involvement and the
success of coronary dilatation with angioplasty. Studies of
interactions with pharmacological substances are also feasible and
informative."
In June 1989, a third conference concentrating on the progress in
quantita tive coronary angiography and related techniques was held
in Rotterdam, again very successful as the two preceding events in
1985 and 1987. Tech nical as well as clinical aspects of digital
and digitized coronarography, morphometry, parametric imaging and
functional quantification of the human coronary circulation were
presented and discussed by prominent exponents of those groups who
have been active in this particular field for many years. This book
contains the chapters representing the lectures held by leading
experts during the symposium that update the knowledge currently
available, including most recent aspects in angioscopy and
intravascular ultrasound imaging. It also includes a historical
review on the development of angiogra phic techniques from the very
early days on to our times given by one of the pioneers in heart
catheterization and angiography, Dr. Kurt Amplatz. Those who had
the chance to listen to his talk, will surely remember his
impressive, humorous lecture as one of the highlights of this
meeting."
There are few techniques that have influenced therapeutic
strategies in modem cardiology to a similar extent as coronary
arteriography. Bypass surgery as well as transluminal coronary
angioplasty would not have been possible without coronary
angiography serving as a 'midwife' in their evolu tion. Despite
the widespread and long-standing use in clinical practice, however,
the interpretation of coronary angiograms has not changed very much
since the early days. Most angiogr~s are still reviewed in a visual
and semi-quantitative and thus often very subjective way. In the
face of an almost exploding field for interventional
catheterization including thrombolysis, balloon dilatation, and
other rapidly evolving techniques for transluminal
revascularization or recanalization, a more detailed and
quantitative analysis of coronary arteriograms is urgently
required. In addition to the delineation of coronary morphology, we
need dynamic and functional information about flow and perfusion to
understand the physiological significance of anatomic
abnormalities. Coronary arteriography contains and can provide most
of this information. With the application of appropriate
techniques, it can be made available in the catheterization
laboratory even during the patient's investiga tion, thus
facilitating and improving clinical decision making. Objective and
reproducible analysis will furthermore enhance our understanding
about the pathophysiology of coronary disease.
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