Angina pectoris is usually related to a significantstenosis of 1 or more coronary arteries.1 Progression ofa stenosis may lead to chronic total occlusion of thevessel, with the absence of myocardial infarction.2

Patients with a chronic totally occluded coronary(TOC) artery may experience exertional angina, possi-bly from an inverted shunt of coronary flow from theoccluded segment(s) through collaterals to the nonoc-cluded segments in times of increased blood flowrequirements.3 Therapeutic options are limited because

medical treatment is not always sufficient, and coro-nary angioplasty is associated with both a high failurerate4 and a high restenosis or reocclusion rate. There-fore patients with significant symptoms are routinelyreferred for coronary bypass surgery.5 However, vari-ous recent improvements in guide wire technologyhave considerably increased the success rates of percu-taneous attempts at recanalization.6-8 The efficacy ofsuccessful recanalization has been proven in the latefollow-up by exercise test9 and early after the proce-dure by cardiac pacing.10,11 Dobutamine stressechocardiography (DSE), an established technique forthe detection of myocardial ischemia,12 has not beenused to test the effects of recanalization of TOC arteryearly after a successful procedure. Therefore we per-formed DSE to investigate whether a successful proce-

From the Thoraxcenter, University Hospital Rotterdam-Dijkzigt, and Erasmus University.Submitted Dec. 19, 1997; accepted March 27, 1998.Reprint requests: Don Poldermans, MD, PhD, Thoraxcenter, Room Ba 300, Dr Mole-waterplein 40, 3015GD Rotterdam, The Netherlands.E-mail: poldermans@hlkd.azr.nlCopyright © 1998 by Mosby, Inc.0002-8703/98/$5.00 + 0 4/1/90932

Early recovery of wall motion abnormalities afterrecanalization of chronic totally occluded coronaryarteries: A dobutamine echocardiographic,prospective, single-center experienceRiccardo Rambaldi, MD, Jaap N. Hamburger, MD, Marcel L. Geleijnse, MD, Don Poldermans, MD, PhD, Geert J.Kimman, MD, Aric A. Aiazian, MD, Paolo M. Fioretti, MD, PhD, Folkert J. Ten Cate, MD, PhD, Jos R.T.C. Roelandt,MD, PhD, and Patrick W. Serruys, MD, PhD Rotterdam, The Netherlands

Background Patients with symptomatic myocardial ischemia from a chronic totally occluded coronary (TOC) arteryare usually referred for coronary artery bypass surgery. Because guide wire technology has improved considerably inrecent years, percutaneous coronary angioplasty has become a useful technique in opening chronic TOC arteries. We eval-uated the early functional results of successful percutaneous recanalization by performing dobutamine stress echocardiogra-phy (DSE).

Methods Fifteen patients with a chronic TOC artery who underwent a successful recanalization were prospectivelystudied. Each patient had a DSE within 24 hours before and 48 hours after the procedure. Wall motion was scored accord-ing to a 16-segment/5-point model. A clinical and angiographic follow-up of 6 months was obtained.

Results The wall motion score index at rest improved from 1.26 ± 0.23 before to 1.22 ± 0.21 after the procedure (P <.05). Of those 10 segments that improved at rest, 7 were collateral recipients and 3 were collateral donors. The number ofischemic segments decreased from 46 before to 4 after the procedure (P < .0001). Wall motion score index at peak stressimproved from 1.34 ± 0.20 before to 1.15 ± 0.12 after the procedure (P < .05). DSE was positive for ischemia in 15patients before and 2 patients after the procedure (P < .0001). Angina was present in 12 patients before and in 2 patientsafter recanalization (P < .0001). Two patients (13%) had angiographic reocclusion and 5 (33%) restenosis after 6 monthsof follow-up.

Conclusions Successful percutaneous recanalization of chronic TOC artery results in an early improvement of both clini-cal status and resting or stress-induced wall motion abnormalities, as detected by DSE. (Am Heart J 1998;136:831-6.)

dure resulted in an early reduction of myocardialischemia in patients who underwent guide wire percu-taneous recanalization of a chronic TOC artery.

MethodsPatient population

Patients were prospectively included according to presenceof angina pectoris or objective signs of ischemia in relation toa chronic TOC artery. An attempt was made to recanalize thetarget occlusion by use of various guide wire technologies.These included the excimer laser guide wire (SpectraneticsCorp) in case of a failed attempt with conventional guidewires. An informed consent was obtained from all patientsaccording to the guidelines of the Medical Ethics Committeeof the University Hospital Rotterdam.

Angiographic dataA TOC artery was considered chronic if more than 4 weeks

of angiographically proven duration4 elapsed between thediagnostic coronary angiography and the date of the attemptat recanalization. For each patient the echocardiographic 16-segment model13 was assigned to each coronary field andwhen collaterals were found, the corresponding echocardio-graphic segments were divided into either collateral donorsor collateral recipients.

Dobutamine stress echocardiographyDSE was performed within 24 hours before and 48 hours

after the procedure. Dobutamine was administered as fol-

lows: 10 µg/kg/min for 3 minutes, increasing by 10µg/kg/min every 3 minutes to a maximum of 40µg/kg/min. In submaximal nondiagnostic DSE, atropinewas added as follows: 0.25 mg repeated to a maximum of1.0 mg in 4 minutes. Criteria for a positive DSE werestress-induced new or worsened wall motion abnormali-ties. Additional criteria were ST-segment elevation of 0.1mV after the J point in patients without prior myocardialinfarction and horizontal or downsloping ST-segmentdepression of 0.1 mV 80 ms after the J point and angina.Pretest criteria for interruption of DSE were achieved 85%of the maximal for sex- and age-predicted target heart rate,achieved maximal dose of both dobutamine and atropine,new significant wall motion abnormalities, horizontal ordownsloping ST-segment depression >0.2 mV 80 ms afterthe J point compared with the baseline, ST-segment eleva-tion >0.1 mV 80 ms after the J point in patients withoutprior myocardial infarction, severe angina, symptomaticreduction in systolic blood pressure >40 mm Hg frombaseline, hypertension (blood pressure >240/120 mm Hg),significant cardiac tachyarrhythmias, and any serious sideeffect attributed to dobutamine infusion such as headache,dizziness, or a symptomatic vagal activation.12

Echocardiographic imagingThe left ventricle was divided in 16 segments13 and

visually assessed for both systolic wall thickening andinward wall motion. Each segment was graded on a 5-point scoring system (1 = normokinesis or hyperkinesis, 2= mild hypokinesis, 3 = severe hypokinesis, 4 = akinesis,

American Heart JournalNovember 1998Rambaldi et al832

Hyper- Hyper-Subject Age (y) Sex AP (CCS) Prior MI tension Smoke Diabetes cholesterolemia FamHx

1 48 F 3 0 + 0 + 0 02 71 F 3 + + 0 0 0 03 39 M 2 + 0 + 0 + +4 57 M 3 + 0 + 0 0 +5 69 M 3 0 + 0 0 0 06 62 M 3 0 0 0 0 0 +7 36 M 2 0 0 + 0 + 08 67 M 3 + 0 0 0 + 09 54 M 3 0 0 + 0 + 0

10 67 F 3 + 0 0 0 0 011 67 F 3 + + 0 0 + 012 62 M 3 + + + 0 0 013 45 M 2 + 0 0 0 + +14 58 M 2 0 + 0 0 0 015 50 M 4 + 0 + 0 0 0

Mean ± SD 56 ± 11 2.8Total 11 M 9 MI 6 6 1 6 4

AP, Angina pectoris; COS, Canadian Classification; FamHx, family history; MI, myocardial infarction.

Table I. Pretest baseline characteristics of the patient population

and 5 = dyskinesis) by an experienced observer blinded toboth preprocedural and postprocedural data. The scoringwas repeated by the same observer and in case of intraob-server disagreement the judgment of a second observerwas obtained. Ischemia was defined as a deterioration inscore at any stage of the test in 1 or more segments,unless an akinetic segment at rest and low-dose dobuta-mine became dyskinetic at peak stress.14 Wall motionscore index was defined as the sum of the scores of theindividual segments divided by the total number of seg-ments. The medication used during the 2 DSEs was notsignificantly different. The β-blocking agents were with-drawn 3 days before the first DSE and not reintroducedbefore the second DSE.

The angioplasty procedureThe attempt at recanalization was performed typically

using either the Choice PT wire (Scimed), Terumo Cross-wire (Terumo), or the Prima laser wire (SpectraneticsCorp). The technique of the laser wire procedure has beenextensively described elsewhere.6,7,15 After successfulcrossing of the occlusion by the guide wire, angioplastywas performed either by balloon angioplasty or a combina-tion of excimer laser coronary angioplasty (ELCA) usingthe Spectranetics 1.4 mm or 1.7 mm Vitesse-C rapidexchange coronary catheters with adjunctive balloonangioplasty. Routinely, 1 or more intracoronary stents wereimplanted to obtain an optimal procedural result. After asuccessful angioplasty, patients received heparin infusionfor 24 hours, maintaining the activated prothrombin timebetween 60 and 90 seconds.

Follow-up studyAll patients underwent a 6-month clinical and angiographic

follow-up. Functional classification was performed accordingto the Canadian Cardiovascular Society. Restenosis wasdefined as >50% diameter stenosis at the treated coronarysite, relative to the baseline value before the procedure, asdetermined by on-line quantitative angiographic analysis.

Statistical analysisUnless specified, values were expressed as mean ± SD.

Comparison of variables was performed with 2-tailed Student’st test for continuous variables and chi-square test for discretevariables. Differences of P < .05 were considered significant.

ResultsProtocol compliance

Of 34 consecutive patients with a chronic TOCartery and a DSE before the procedure, 22 (65%)patients underwent successful recanalization. Ofthese, 2 patients were excluded because of poorechocardiographic image quality and 5 for no adher-ence to the protocol. Therefore, 15 patients fulfilledthe study protocol by undergoing two DSEs: before(<24 hours) and after (<48 hours) successful recanal-ization. The pretest baseline characteristics are givenin Table I and confirm that the patient population isrepresentative of current clinical practice with coro-nary angioplasty.

American Heart JournalVolume 136, Number 5 Rambaldi et al 833

Improved Occluded Collateral donorAngina ST-T

Subject segments* vessel vessel(s) Pre Post Pre Post

1 1 RCA LAD + 0 0 +2 3 RCA LAD + + 0 03 1 RCA LAD, LCX 0 0 0 04 2 RCA LAD 0 0 0 05 3 RCA LAD, RCA + 0 + 06 6 RCA LAD, LCX + 0 0 07 5 RCA LAD + 0 0 08 1 LAD RCA + 0 0 09 5 LAD RCA + 0 0 0

10 1 LAD LCX, RCA + 0 0 +11 7 LAD LCX, RCA + 0 + +12 5 LAD LCX, RCA 0 0 + 013 2 LAD RCA + + + +14 2 LAD RCA + 0 + 015 4 LCX LAD + 0 0 +

Total 48 12 2† 5 5

LAD, Left anterior descending coronary artery; LCX, circumflex coronary artery; RCA, right coronary artery; post, postprocedure; pre, preprocedure.*Segments of the occluded coronary artery territory with improved wall motion after revascularization.†P < .0001 preprocedure vs postprocedure.

Table II. Anatomic, angiographic, preprocedure, and postprocedure clinical data

Angiographic dataThe angiographic data are given in Table II. The TOC

artery was the right coronary artery in 7 (47%) patients,the left anterior descending coronary artery in 7 (47%),and the left circumflex coronary artery in 1 (6%).

Dobutamine stress echocardiographyThe hemodynamic data of preprocedure and post-

procedure DSE are given in Table III. As shown,

there was no significant difference between the pre-procedural and postprocedural data. Wall motion scoreindex (Table IV) at rest improved from 1.26 ± 0.23before to 1.22 ± 0.21 after the procedure (P < .05). Of10 segments (in 5 patients) that improved at rest, 7 werecollateral recipients and 3 were collateral donors. DSEwas positive for ischemia in 15 patients before and in2 patients after the procedure (P < .0001). The numberof ischemic segments decreased from 46 before to 4

American Heart JournalNovember 1998Rambaldi et al834

Preprocedure

HR HR SBP SBP DP DP HR HRSubject rest peak rest peak rest peak rest peak

1 64 116 140 125 8960 14,500 80 1272 80 133 92 86 7360 11,438 90 1303 75 135 147 163 11,025 22,005 85 1304 90 143 153 153 13,770 21,879 80 1375 61 105 142 124 8662 13,020 62 1216 71 120 110 115 7810 13,800 70 1207 74 117 145 180 10,730 21,060 80 1338 70 130 163 144 11,410 18,720 76 1319 70 138 112 107 7840 14,766 74 144

10 60 115 130 130 7800 14,950 72 11311 74 142 137 103 10,138 14,626 88 11512 70 132 98 100 6860 13,200 77 15813 60 132 135 135 8100 17,820 84 14214 59 91 145 151 8555 13,741 70 11815 50 126 110 125 5500 15,750 50 117

Mean ± SD 68 ± 10 125 ± 14 130 ± 21 129 ± 25 8968 ± 2100 16,085 ± 3392 76 ± 10 130 ± 13

DP, Double (heart rate × systolic blood pressure) product in beats/mm × Hg min; HR, heart rate in beats/min; SBP, systolic blood pressure in mm Hg.

Table III. Hemodynamic data at rest and peak dobutamine preprocedure and postprocedure

WMA resting Ischemic Resting Stress segments segments WMSI WMSI

Subject Pre Post Pre Post Pre Post Pre Post

1 0 0 1 0 1.00 1.00 1.13 1.002 3 1 3 1 1.19 1.06 1.19 1.063 5 5 1 0 1.31 1.31 1.25 1.194 3 3 2 0 1.31 1.31 1.19 1.135 2 0 2 0 1.13 1.00 1.13 1.006 3 3 6 0 1.31 1.31 1.50 1.257 0 0 5 0 1.00 1.00 1.38 1.008 8 7 1 0 1.75 1.69 1.81 1.259 7 7 5 0 1.50 1.50 1.38 1.31

10 0 0 1 0 1.00 1.00 1.06 1.0011 4 4 7 0 1.25 1.25 1.56 1.2512 4 3 4 0 1.25 1.19 1.50 1.1313 4 4 5 3 1.25 1.25 1.31 1.2514 0 0 2 0 1.00 1.00 1.31 1.1915 6 2 1 0 1.63 1.38 1.38 1.31

Sum and means (±SD) 49 39 46 4* 1.26 ± 0.23 1.22 ± 0.21* 1.34 ± 0.20 1.15 ± 0.12*

Post, Postprocedure; Pre, preprocedure; WMA, wall motion abnormalities; WMSI, wall motion score index.*P < .05 preprocedure vs postprocedure.

Table IV. Preprocedure and postprocedure wall motion analysis

after the procedure (P < .0001). The number of seg-ments with wall motion abnormality, angiographi-cally supplied by the occluded coronary artery, thatexhibited wall motion improvement after revascular-ization was 48 (Table II). Wall motion score index atpeak stress improved from 1.34 ± 0.20 before to 1.15± 0.12 after the procedure (P < .05). Angina was hadduring DSE by 12 patients before and 2 patients afterthe procedure (P < .0001) (Table II).

Follow-up dataA 6-month clinical and angiographic follow-up was

available for all patients. No major cardiac events such asdeath, myocardial infarction, coronary bypass surgery,repeated percutaneous transluminal coronary angioplastyor hospital admission for unstable angina occurred in thispatient group. At 6-month follow-up, 4 (27%) patientswere in stable angina, whereas angiographically 2 (13%)patients had a reocclusion and 5 (33%) had restenosis.

DiscussionShortly after the introduction of coronary angioplasty

by Andreas Gruentzig in 1977, this technique wasattempted in patients with chronic TOC arteries. Succes-sive investigators reported on the relatively low proce-dural success rates and high restenosis rates after suc-cessful percutaneous recanalization.16-18 However, the

long-term clinical improvement,19,20 the increased rest-ing left ventricular function, and the reduction of exer-cise-induced ischemic symptoms in the late follow-upof patients after successful recanalization7 supported thecontinuing effort in developing more effective technolo-gies for percutaneous treatment of chronic TOC arteries.Typical examples of improved technology are the intro-duction of hydrophilic-coated guide wires and theexcimer laser guide wire.

Thus far, no study has documented the early func-tional impact of a successful percutaneous recanaliza-tion of a chronic TOC artery, in terms of restingregional left ventricular function and stress-inducedmyocardial ischemia. Obviously, a successful revascu-larization procedure should result in a reduction ofmyocardial ischemia. We used DSE, an establishedtechnique for the detection of myocardial ischemia,24 hours before and within 48 hours after a success-ful revascularization to evaluate the immediate func-tional outcome of the procedure.

As a main result of our study, we found a signifi-cant improvement of stress-induced wall motionabnormalities. Therefore, DSE is helpful in document-ing objectively the early functional outcome of a suc-cessful procedure. In addition, we also detected asignificant improvement of resting wall motionabnormalities involving 7 segments of the collateral-recipient and 3 segments of the collateral-donor coro-nary artery. These results suggest the presence ofdysfunctional but viable myocardium, whichimproves early after revascularization, consistent withprevious studies documenting an immediate func-tional recovery after revascularization.21 Viablemyocardium is also present in some collateral-donorsegments (although supplied by a nondiseased coro-nary artery) possibly through a stealing effect result-ing in repetitive stunning. The immediate increase ofboth coronary flow and flow reserve after revascular-ization, involving both collateral-recipient and collat-eral-donor segments, parallel with the angiographicdisappearance of collaterals, may be the vascularsubstrate of the early functional recovery detected inour patients.22

Although not aim of the present study, a reocclu-sion rate of 13% and a restenosis rate of 33% at 6-month follow-up angiography appears significantlybetter than previously reported rates in the literature.The consequent use of intracoronary stents to stabi-lize the angioplasty results could be responsible forthis favorable outcome.

American Heart JournalVolume 136, Number 5 Rambaldi et al 835

Postprocedure

SBP SBP DP DP rest peak rest peak

90 66 7200 838286 80 7740 10,400

110 100 9350 13,100132 162 10,560 22,194141 107 8742 12,947120 120 8400 14,400125 150 10,000 19,950126 109 9576 14,279137 131 10,138 18,864111 86 7992 9,718115 95 10,120 10,925112 129 8624 20,382120 120 10,080 17,040126 110 8820 12,980108 125 5400 14,625

117 ±15 113 ± 26 8849 ± 1380 14,679 ± 4185

Study limitationsA possible limitation of the present study is the inclu-

sion of patients after a successful revascularizationonly. However, the focus of this study was not theevaluation of the success rate of percutaneous revascu-larization in chronic TOC arteries, but the effectivenessof DSE to document the early functional and clinicalimpact of a successful revascularization. We believethat the demonstration of improvement of myocardialfunction early after a revascularization of a chronicTOC artery is important and may support further effortsto improve nonsurgical techniques for revascularizationof TOC arteries.

ConclusionsIn patients with symptoms or signs of myocardial

ischemia resulting from a chronic TOC artery, DSEperformed before and within 48 hours after a success-ful percutaneous recanalization documents a signifi-cant improvement of both clinical status and resting orstress-induced wall motion abnormalities.

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