JACC VOL. 67, NO. 4, 2016
Letters
FEBRUARY 2, 2016:455–61
plaque volume, which had an area under the curve of
characterized the fateful plaques associated with
0.84 for predicting ACS, was not reported in this
an acute coronary event. In our subsequent study (3),
study (2). This is of particular interest considering
we reported that PR and LAP plaques predicted
recent studies that have demonstrated that low-
higher likelihood of acute coronary events during a
attenuated plaque burden improves determination
short-term follow up of 2 years. In the latter paper,
of functionally significant stenosis by fractional flow
we also analyzed the relationship between spotty
reserve (5). It would have been of significant interest
calcification and acute coronary events; even though
if quantitative plaque analysis was incorporated in
the presence of spotty calcification was 2-fold higher
this study.
in the eventful compared with uneventful plaques,
Lastly, the indication for 122 (49%) of patients to
the difference was statistically not significant. On
serial CTA was for follow-up after percutaneous
the basis of this study, we defined high-risk plaque
coronary intervention. Could the authors clarify
(HRP) as the 2-feature or 1-feature positive plaques
whether this was performed for a clinical or research
with PR and/or LAP in the latest study (1). In addition
indication?
to the higher likelihood of events arising from HRP, we also observed that the period between the
*Dennis T.L. Wong, MBBS (Hons)
computed
*MonashHeart
the cardiac event associated with HRP was signifi-
Monash University
cantly shorter than the event arising from non-HRP
tomography
(CT)
angiography
and
South Australian Health and Medical Research
(1.7 1.8 vs. 3.4 2.4 years, p ¼ 0.0005). We agree
Institute (SAHMRI)
with Dr. Wong that the plaque volume, LAP volume,
246 Clayton Road
and LAP area/plaque area as obtained in the intra-
Clayton, Victoria 3150
vascular ultrasound studies (4) and as presented in
Australia
our previous study (3) should be included in CT
E-mail: [email protected]
angiographic assessment. However, in our unpub-
http://dx.doi.org/10.1016/j.jacc.2015.09.107
lished experience, we have encountered napkin ring
Please note: Dr. Wong has reported that he has no relationships relevant to the contents of this paper to disclose. Daniel Berman, MD, served as Guest Editor for this paper.
sign (5) rather infrequently. In the serial CT angiographic study, 122 patients after percutaneous coronary intervention were eval-
REFERENCES 1. Motoyama S, Ito H, Sarai M, et al. Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow up. J Am Coll Cardiol 2015;66:337–46.
uated for clinical indications such as the recurrence of chest pain symptoms, or follow-up per discretion of the physician. We excluded all the patients from serial assessment who had sustained a cardiac event
2. Motoyama S, Sarai M, Harigaya H, et al. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol 2009;54:49–57.
before second CT angiogram was undertaken.
3. Otsuka K, Fukuda S, Tanaka A, et al. Napkin-ring sign on coronary CT angiography for the prediction of acute coronary syndrome. J Am Coll Cardiol Img 2013;6:448–57.
Hajime Ito, MD, PhD
4. Stone GW, Maehara A, Lansky AJ, et al. A prospective natural-history study of coronary atherosclerosis. N Engl J Med 2011;364:226–35. 5. Diaz-Zamudio M, Dey D, Schuhbaeck A, et al. Automated quantitative plaque burden from coronary CT angiography noninvasively predicts hemodynamic significance by using fractional flow reserve in intermediate coronary lesions. Radiology 2015;276:408–15.
Sadako Motoyama, MD, PhD* Masayoshi Sarai, MD, PhD Yukio Ozaki, MD, PhD Jagat Narula, MD, PhDy *Department of Cardiology Fujita Health University 1-98 Dengakugakubo Katsukake, Toyoake Aichi 470-1192 Japan
REPLY: Plaque Characterization by Coronary Computed Tomography Angiography and
E-mail: [email protected]
Association With Acute Coronary Syndrome
yDivision of Cardiology
OR Mount Sinai Hospital and
We thank Dr. Wong for the interest in our study (1)
Icahn School of Medicine at Mount Sinai
and excellent suggestions. In our initial study
One Gustave L. Levy Place
wherein we compared the culprit lesion of acute
Box 1030
coronary syndrome (ACS) with the target lesions in
New York, New York 10029
stable angina (2), positive remodeling (PR), low-
E-mail: [email protected]
attenuation plaques (LAP), and spotty calcification
http://dx.doi.org/10.1016/j.jacc.2015.10.074
459
460
JACC VOL. 67, NO. 4, 2016
Letters
FEBRUARY 2, 2016:455–61
Please note: Dr. Narula has received research support from Philips and GE Healthcare in the form of an equipment grant to institution, unrelated to the current project. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Daniel Berman, MD, served as Guest Editor for this paper.
symptoms. A benefit of this size is remarkable given the extreme-risk patient population that has been included. However, it is concerning that 42% of patients who died between year 1 and year 2 did so from non-
REFERENCES
cardiovascular causes. Additionally, in a separate
1. Motoyama S, Ito H, Sarai M, et al. Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow up. J Am Coll Cardiol 2015;66: 337–46.
study looking at health status in the CoreValve
2. Motoyama S, Kondo T, Sarai M, et al. Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes. J Am Coll
very poor quality of life, and 1.4% quality-of-life
Cardiol 2007;50:319–26.
comes for the inoperable group of the PARTNER IB
3. Motoyama S, Sarai M, Harigaya H, et al. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol 2009;54:49–57. 4. Stone GW, Maehara A, Lansky AJ, et al., for PROSPECT Investigators. A prospective natural-history study of coronary atherosclerosis. N Engl J Med 2011;364:226–35. 5. Narula J, Achenbach S. Napkin-ring necrotic cores: defining circumferential extent of necrotic cores in unstable plaques. J Am Coll Cardiol Img 2009;2: 1436–8.
Extreme Risk Group, the proportion of patients with a poor outcome was 39% at 6 months (22% death, 16% decline). In similar studies looking at 5-year outtrial (Placement of Aortic Transcatheter Valve Trial), 48% had multiple readmissions in the first year (readmission rates were not reported in this study) (3). These observations suggest that frail elderly patients often have competing risks contributing to their all-cause mortality. To treat one disease process, only for another to take its place, should not be the objective of an invasive expensive treatment with complications. The total life expectancy now sur-
When Is TAVR in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery Appropriate?
passes the extra years of life lived in good health in high-income nations, and this difference continues to widen (4). This aging population of patients with more comorbidities may be at risk for overtreatment. Now that the safety and efficacy of transcatheter aortic valve replacement is established, the current research efforts have to reorient to appropriate patient selection.
Aortic stenosis is the most common valve disease and is expected to rise because of an increase in life expectancy. Although physicians have learned how to care for critically ill old patients and enable many to survive major surgical procedures, operating on patients at very high risk is often not appropriate or
*Femi Philip, MD *Department of Internal Medicine Interventional Cardiology, Cardiovascular Medicine University of California, Davis 4860 Y Street, Suite 2820 Sacramento, California 95817 E-mail: [email protected]
technically feasible. Given these considerations, we read with much interest the recent paper and editorial by Yakubov et al. (1) and Pilgrim and Windecker (2), respectively,
http://dx.doi.org/10.1016/j.jacc.2015.09.108 Please note: Dr. Philip has reported that he has no relationships relevant to the contents of this paper to disclose. Antonio Colombo, MD, served as Guest Editor for this paper.
in the Journal evaluating the 2-year outcomes after transfemoral
self-expanding
transcatheter
aortic
valve replacement in 489 extreme-risk patients. They found that the rate of all-cause mortality or major stroke was 39% at 2 years. The rates of all-cause mortality,
cardiovascular
mortality,
and
major
stroke were 36.6%, 26.2%, and 5.1 %, respectively, at 2 years. The multivariable predictors of all-cause mor-
REFERENCES 1. Yakubov SJ, Adams DH, Watson DR. 2-Year outcomes after iliofemoral selfexpanding transcatheter aortic valve replacement in patients with severe aortic stenosis deemed extreme risk for surgery. J Am Coll Cardiol 2015;66: 1327–34. 2. Pilgrim T, Windecker S. Transcatheter aortic valve replacement: lessons gained from extreme-risk patients. J Am Coll Cardiol 2015;66:1335–8.
facility. In addition, at 2 years, 94% of patients had
3. Kapadia SR, Leon MB, Makkar RR. 5-Year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015;385:2485–91.
New York Heart Association functional class I to II
4. Heath I. What do we want to die from? BMJ 2010;341:c3883.
tality at 2 years included the presence of coronary artery disease and admission from an assisted living
Letters
FEBRUARY 2, 2016:455–61
plaque volume, which had an area under the curve of
characterized the fateful plaques associated with
0.84 for predicting ACS, was not reported in this
an acute coronary event. In our subsequent study (3),
study (2). This is of particular interest considering
we reported that PR and LAP plaques predicted
recent studies that have demonstrated that low-
higher likelihood of acute coronary events during a
attenuated plaque burden improves determination
short-term follow up of 2 years. In the latter paper,
of functionally significant stenosis by fractional flow
we also analyzed the relationship between spotty
reserve (5). It would have been of significant interest
calcification and acute coronary events; even though
if quantitative plaque analysis was incorporated in
the presence of spotty calcification was 2-fold higher
this study.
in the eventful compared with uneventful plaques,
Lastly, the indication for 122 (49%) of patients to
the difference was statistically not significant. On
serial CTA was for follow-up after percutaneous
the basis of this study, we defined high-risk plaque
coronary intervention. Could the authors clarify
(HRP) as the 2-feature or 1-feature positive plaques
whether this was performed for a clinical or research
with PR and/or LAP in the latest study (1). In addition
indication?
to the higher likelihood of events arising from HRP, we also observed that the period between the
*Dennis T.L. Wong, MBBS (Hons)
computed
*MonashHeart
the cardiac event associated with HRP was signifi-
Monash University
cantly shorter than the event arising from non-HRP
tomography
(CT)
angiography
and
South Australian Health and Medical Research
(1.7 1.8 vs. 3.4 2.4 years, p ¼ 0.0005). We agree
Institute (SAHMRI)
with Dr. Wong that the plaque volume, LAP volume,
246 Clayton Road
and LAP area/plaque area as obtained in the intra-
Clayton, Victoria 3150
vascular ultrasound studies (4) and as presented in
Australia
our previous study (3) should be included in CT
E-mail: [email protected]
angiographic assessment. However, in our unpub-
http://dx.doi.org/10.1016/j.jacc.2015.09.107
lished experience, we have encountered napkin ring
Please note: Dr. Wong has reported that he has no relationships relevant to the contents of this paper to disclose. Daniel Berman, MD, served as Guest Editor for this paper.
sign (5) rather infrequently. In the serial CT angiographic study, 122 patients after percutaneous coronary intervention were eval-
REFERENCES 1. Motoyama S, Ito H, Sarai M, et al. Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow up. J Am Coll Cardiol 2015;66:337–46.
uated for clinical indications such as the recurrence of chest pain symptoms, or follow-up per discretion of the physician. We excluded all the patients from serial assessment who had sustained a cardiac event
2. Motoyama S, Sarai M, Harigaya H, et al. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol 2009;54:49–57.
before second CT angiogram was undertaken.
3. Otsuka K, Fukuda S, Tanaka A, et al. Napkin-ring sign on coronary CT angiography for the prediction of acute coronary syndrome. J Am Coll Cardiol Img 2013;6:448–57.
Hajime Ito, MD, PhD
4. Stone GW, Maehara A, Lansky AJ, et al. A prospective natural-history study of coronary atherosclerosis. N Engl J Med 2011;364:226–35. 5. Diaz-Zamudio M, Dey D, Schuhbaeck A, et al. Automated quantitative plaque burden from coronary CT angiography noninvasively predicts hemodynamic significance by using fractional flow reserve in intermediate coronary lesions. Radiology 2015;276:408–15.
Sadako Motoyama, MD, PhD* Masayoshi Sarai, MD, PhD Yukio Ozaki, MD, PhD Jagat Narula, MD, PhDy *Department of Cardiology Fujita Health University 1-98 Dengakugakubo Katsukake, Toyoake Aichi 470-1192 Japan
REPLY: Plaque Characterization by Coronary Computed Tomography Angiography and
E-mail: [email protected]
Association With Acute Coronary Syndrome
yDivision of Cardiology
OR Mount Sinai Hospital and
We thank Dr. Wong for the interest in our study (1)
Icahn School of Medicine at Mount Sinai
and excellent suggestions. In our initial study
One Gustave L. Levy Place
wherein we compared the culprit lesion of acute
Box 1030
coronary syndrome (ACS) with the target lesions in
New York, New York 10029
stable angina (2), positive remodeling (PR), low-
E-mail: [email protected]
attenuation plaques (LAP), and spotty calcification
http://dx.doi.org/10.1016/j.jacc.2015.10.074
459
460
JACC VOL. 67, NO. 4, 2016
Letters
FEBRUARY 2, 2016:455–61
Please note: Dr. Narula has received research support from Philips and GE Healthcare in the form of an equipment grant to institution, unrelated to the current project. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Daniel Berman, MD, served as Guest Editor for this paper.
symptoms. A benefit of this size is remarkable given the extreme-risk patient population that has been included. However, it is concerning that 42% of patients who died between year 1 and year 2 did so from non-
REFERENCES
cardiovascular causes. Additionally, in a separate
1. Motoyama S, Ito H, Sarai M, et al. Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow up. J Am Coll Cardiol 2015;66: 337–46.
study looking at health status in the CoreValve
2. Motoyama S, Kondo T, Sarai M, et al. Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes. J Am Coll
very poor quality of life, and 1.4% quality-of-life
Cardiol 2007;50:319–26.
comes for the inoperable group of the PARTNER IB
3. Motoyama S, Sarai M, Harigaya H, et al. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol 2009;54:49–57. 4. Stone GW, Maehara A, Lansky AJ, et al., for PROSPECT Investigators. A prospective natural-history study of coronary atherosclerosis. N Engl J Med 2011;364:226–35. 5. Narula J, Achenbach S. Napkin-ring necrotic cores: defining circumferential extent of necrotic cores in unstable plaques. J Am Coll Cardiol Img 2009;2: 1436–8.
Extreme Risk Group, the proportion of patients with a poor outcome was 39% at 6 months (22% death, 16% decline). In similar studies looking at 5-year outtrial (Placement of Aortic Transcatheter Valve Trial), 48% had multiple readmissions in the first year (readmission rates were not reported in this study) (3). These observations suggest that frail elderly patients often have competing risks contributing to their all-cause mortality. To treat one disease process, only for another to take its place, should not be the objective of an invasive expensive treatment with complications. The total life expectancy now sur-
When Is TAVR in Patients With Severe Aortic Stenosis Deemed Extreme Risk for Surgery Appropriate?
passes the extra years of life lived in good health in high-income nations, and this difference continues to widen (4). This aging population of patients with more comorbidities may be at risk for overtreatment. Now that the safety and efficacy of transcatheter aortic valve replacement is established, the current research efforts have to reorient to appropriate patient selection.
Aortic stenosis is the most common valve disease and is expected to rise because of an increase in life expectancy. Although physicians have learned how to care for critically ill old patients and enable many to survive major surgical procedures, operating on patients at very high risk is often not appropriate or
*Femi Philip, MD *Department of Internal Medicine Interventional Cardiology, Cardiovascular Medicine University of California, Davis 4860 Y Street, Suite 2820 Sacramento, California 95817 E-mail: [email protected]
technically feasible. Given these considerations, we read with much interest the recent paper and editorial by Yakubov et al. (1) and Pilgrim and Windecker (2), respectively,
http://dx.doi.org/10.1016/j.jacc.2015.09.108 Please note: Dr. Philip has reported that he has no relationships relevant to the contents of this paper to disclose. Antonio Colombo, MD, served as Guest Editor for this paper.
in the Journal evaluating the 2-year outcomes after transfemoral
self-expanding
transcatheter
aortic
valve replacement in 489 extreme-risk patients. They found that the rate of all-cause mortality or major stroke was 39% at 2 years. The rates of all-cause mortality,
cardiovascular
mortality,
and
major
stroke were 36.6%, 26.2%, and 5.1 %, respectively, at 2 years. The multivariable predictors of all-cause mor-
REFERENCES 1. Yakubov SJ, Adams DH, Watson DR. 2-Year outcomes after iliofemoral selfexpanding transcatheter aortic valve replacement in patients with severe aortic stenosis deemed extreme risk for surgery. J Am Coll Cardiol 2015;66: 1327–34. 2. Pilgrim T, Windecker S. Transcatheter aortic valve replacement: lessons gained from extreme-risk patients. J Am Coll Cardiol 2015;66:1335–8.
facility. In addition, at 2 years, 94% of patients had
3. Kapadia SR, Leon MB, Makkar RR. 5-Year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015;385:2485–91.
New York Heart Association functional class I to II
4. Heath I. What do we want to die from? BMJ 2010;341:c3883.
tality at 2 years included the presence of coronary artery disease and admission from an assisted living
