Einthoven Dissertation Prizes
2002
For the fourteenth year in a row, the Netherlands Society of Cardiology (NVVC), the Interuniversity Cardiology Institute ofthe Netherlands, and the sponsor, Sanofi Synthelabo, are supporting the competition for the best three PhD theses published last year on a cardiovascular subject. The prizes carry the name of one ofthe great men in the history of Cardiology: WllUem Einthoven (1860-1927), the pioneer of the human ECG. The jury, consisting of representatives ofthe NVVC, ICIN, and Sanofi Synthelabo, were offered 16 dissertations to review. The jury members were impressed and pleased by the scientific quality ofthe work ofthe young doctors. It was not easy to decide upon the winners. The three nominees will present their work at the spring meeting ofthe NVVC, which will be held in Amsterdam on 25 April 2003. The winner of the first, second and third prize will be chosen by the audience. Summaries of the three nominated PhD theses are given below. Professor C.A. Visser Chairman of theJury
Magnetic resonance Imaging of coronary artery bypass grafts The study described in this thesis was supported by a grant from the Netherlands Heart Foundation (NHF 97.173).
Magnetic resonance imaging (MRI) allows noninvasive evaluation ofepicardial conductance vessels. Extensive work in native coronary artenes has been performed using elegant MRI techniques demonstrating their ability to distinguish patent from ocduded coronary arteries, to detect proximal stenosis, and to quantify flow. However, the detection of stenosis in grafts and native coronary arteries has remained difficult. The purpose ofthis thesis was: 1. to validate a technically improved MR technique for flow mapping in grafts,"2 2. to determine the value of MRI with flow mapping in differentiating stenotic from nonstenotic grafts and recipient vessels in patients with recurrent angina after coronary artery bypass grafting (CABG),3 3. to evaluate with MR flow mapping functional reference values in angiographic normal grafis and the effect ofpercutaneous intervention (PCI) on graft function,4 4. to determine the value of MR angiography in detecting vein graft stenosis5 and native coronary artery disease.6 188
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Figure la. AMRI in a patientwitha veingraftto the LCX (small arrow) and LAD (large arrow). The line inA2 indicates the plane oftheflow scan. PanelBshowsthe stressflowscan, which is enlarged in panel C. Ao-ascending aorta, PA-pulmonaryartery, #-ternal wire,
*,stent
An improved MRflow technique was developed and validated in vitro and in vivo using Doppler flow measurements."2 Subsequently, a total of 166
grafts were studied in 69 consecutive patients who were scheduled for coronary angiography because of recurrent angina after CABG.3 MRI
Netherlands Heart Journal, Volume I1, Number 4, April 2003
-m~01 Graft to LAD
Graft to LCX
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Fjgure l b. LCK= left circumflex coronary ar-tey, LAD-lef anterior descending branch. witi fast flow mapping at baseline and during adenosine-induced stress was performed. Grafts were divided into those with (n=48) and those without luminal stenosis >70% in the graft or recipient vessels. Sensitivity and specificity of MRI in detecting single vein grafts/recipient vessels with stenosis .70% were 96 and 92%, respectively (figure 1). These values were 94 and 71% for detecting sequential vein grafts/recipient vessels with stenosis .70%. Thus, MRI with flow mapping accurately identifies grafts and recipient vessels with significant stenosis. In the next study,4 we revealed functional reference values in nonstenotic single and sequential vein grafts. Moreover, the feasibility of MRI to evaluate the effect of PCI on graft ftmction was studied. In a subgroup of38 patients MR angiography in addition to coronary angiography was performed.5 The sensitivity and specificity of MR angiography in identifying graft occlusion were 83 and 100%, respectively. For identifying graft stenosis >50% these values were 82 and 88%. Thus, three-dimensional MRangiography not only allows differentiation between patent and occluded vein grafts but also assessment of vein graft disease with a fair diagnostic accuracy.
In a multicentre study,6 in which we participated, coronary MR angiography allowed accurate detection ofmajor vessel coronary artery disease and identification (or exdusion) of left main or three-vessel disease among patients referred for their first coronary angiogram. Future research should focus on further improvements in spatial resolution of MRI, motion correction techniques, and on reduction in imaging time. With these improvements to come, MR flow mapping together with three-dimensional MR angiography may offer perspective for noninvasive screening ofpatients who present with recurrent angina following CABG. m S.E. Langerak. Leiden University Medical Centre, Leiden. Refsmnces 1
2
3
Ncthcdands Heart Joumal, Volume 11, Number 4, April 2003
Langerak SE, Kunz P, Vliegen HW, Lamb HJ, Jukema JW, Wall EE van der, et al. Improved MR flow mapping in coronary artery bypass grafts during adenosine-induced stress. Radioloyy2001;218:540-7. Langerak SE, Kunz P, Vliegen HW, Jukema JW, Zwinderman AH, Steendijk P, et al. MR flow mapping in coronary artery bypass grafts: a validation study with Doppler flow measurements. Radiology 2002;222:127-35. Langerak SE, Vliegen HW, Jukema JW, Kunz P, Zwinderman AH, Lamb HJ, et al. Value of magnetic resonance imaging for the noninvasive detection ofstenosis in coronary artery bypass grafts and recipient coronary arteries. Circulation 2003 in press.
4
5
6
Langerak SE, Vliegen HVW, Jukema JW, Zwinderman AH, Lamb HJ, de Roos A, et al. Vein graft function improves in patients after percutaneous intervention: evaluation by magnetic resonance flow mapping. Radiology 2003 in press. Langerak SE, Vliegen HW, Roos A de, Zwinderman AH, Jukema JW, Kunz P, et al. Detection of vein graft disease using high-resolution magnetic resonance angiography. Circulation 2002;105:328-33. Kim WY, Danias PG, Stuber M, Flamm SD, Plein S, Nagel E, et al. Coronary magnetic resonance angiography for the detection of coronary stenoses. N Engi J Med 2001;345:1863-9.
PathIl and physilogical characteristics of coronary artery diease Both pathomorphological and functional aspects of coronary atherosclerotic disease were studied in this thesis. The first part concerned the association between the inflammatory state of atherosclerotic lesions and clinical manifestations of coronary syndromes. Inflammation plays an important role in the initiation, development, progression and complications of atherosclerotic vascular disease. The introduction of directional coronary atherectomy (DCA) has provided a unique opportunity to examine the role of inflammation in patients with stable and acute coronary syndromes. DCA of culprit coronary lesions was performed in 150 patients. Plaques of patients presenting with unstable 189
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2002
For the fourteenth year in a row, the Netherlands Society of Cardiology (NVVC), the Interuniversity Cardiology Institute ofthe Netherlands, and the sponsor, Sanofi Synthelabo, are supporting the competition for the best three PhD theses published last year on a cardiovascular subject. The prizes carry the name of one ofthe great men in the history of Cardiology: WllUem Einthoven (1860-1927), the pioneer of the human ECG. The jury, consisting of representatives ofthe NVVC, ICIN, and Sanofi Synthelabo, were offered 16 dissertations to review. The jury members were impressed and pleased by the scientific quality ofthe work ofthe young doctors. It was not easy to decide upon the winners. The three nominees will present their work at the spring meeting ofthe NVVC, which will be held in Amsterdam on 25 April 2003. The winner of the first, second and third prize will be chosen by the audience. Summaries of the three nominated PhD theses are given below. Professor C.A. Visser Chairman of theJury
Magnetic resonance Imaging of coronary artery bypass grafts The study described in this thesis was supported by a grant from the Netherlands Heart Foundation (NHF 97.173).
Magnetic resonance imaging (MRI) allows noninvasive evaluation ofepicardial conductance vessels. Extensive work in native coronary artenes has been performed using elegant MRI techniques demonstrating their ability to distinguish patent from ocduded coronary arteries, to detect proximal stenosis, and to quantify flow. However, the detection of stenosis in grafts and native coronary arteries has remained difficult. The purpose ofthis thesis was: 1. to validate a technically improved MR technique for flow mapping in grafts,"2 2. to determine the value of MRI with flow mapping in differentiating stenotic from nonstenotic grafts and recipient vessels in patients with recurrent angina after coronary artery bypass grafting (CABG),3 3. to evaluate with MR flow mapping functional reference values in angiographic normal grafis and the effect ofpercutaneous intervention (PCI) on graft function,4 4. to determine the value of MR angiography in detecting vein graft stenosis5 and native coronary artery disease.6 188
A
77m..,
"
r . :.1
o__.,
Figure la. AMRI in a patientwitha veingraftto the LCX (small arrow) and LAD (large arrow). The line inA2 indicates the plane oftheflow scan. PanelBshowsthe stressflowscan, which is enlarged in panel C. Ao-ascending aorta, PA-pulmonaryartery, #-ternal wire,
*,stent
An improved MRflow technique was developed and validated in vitro and in vivo using Doppler flow measurements."2 Subsequently, a total of 166
grafts were studied in 69 consecutive patients who were scheduled for coronary angiography because of recurrent angina after CABG.3 MRI
Netherlands Heart Journal, Volume I1, Number 4, April 2003
-m~01 Graft to LAD
Graft to LCX
~~~~~~~3O ~ ~ ~ ~ ~ ~ ~ ~ 3 35S 35
10~ ~~
15~~~~~~~~0
5
0
~~~500 TIm
uwr
1000O R wan of EN (mu)
500 Tim Saoaft IN wan of
0
1000
MOr
(a)
Fjgure l b. LCK= left circumflex coronary ar-tey, LAD-lef anterior descending branch. witi fast flow mapping at baseline and during adenosine-induced stress was performed. Grafts were divided into those with (n=48) and those without luminal stenosis >70% in the graft or recipient vessels. Sensitivity and specificity of MRI in detecting single vein grafts/recipient vessels with stenosis .70% were 96 and 92%, respectively (figure 1). These values were 94 and 71% for detecting sequential vein grafts/recipient vessels with stenosis .70%. Thus, MRI with flow mapping accurately identifies grafts and recipient vessels with significant stenosis. In the next study,4 we revealed functional reference values in nonstenotic single and sequential vein grafts. Moreover, the feasibility of MRI to evaluate the effect of PCI on graft ftmction was studied. In a subgroup of38 patients MR angiography in addition to coronary angiography was performed.5 The sensitivity and specificity of MR angiography in identifying graft occlusion were 83 and 100%, respectively. For identifying graft stenosis >50% these values were 82 and 88%. Thus, three-dimensional MRangiography not only allows differentiation between patent and occluded vein grafts but also assessment of vein graft disease with a fair diagnostic accuracy.
In a multicentre study,6 in which we participated, coronary MR angiography allowed accurate detection ofmajor vessel coronary artery disease and identification (or exdusion) of left main or three-vessel disease among patients referred for their first coronary angiogram. Future research should focus on further improvements in spatial resolution of MRI, motion correction techniques, and on reduction in imaging time. With these improvements to come, MR flow mapping together with three-dimensional MR angiography may offer perspective for noninvasive screening ofpatients who present with recurrent angina following CABG. m S.E. Langerak. Leiden University Medical Centre, Leiden. Refsmnces 1
2
3
Ncthcdands Heart Joumal, Volume 11, Number 4, April 2003
Langerak SE, Kunz P, Vliegen HW, Lamb HJ, Jukema JW, Wall EE van der, et al. Improved MR flow mapping in coronary artery bypass grafts during adenosine-induced stress. Radioloyy2001;218:540-7. Langerak SE, Kunz P, Vliegen HW, Jukema JW, Zwinderman AH, Steendijk P, et al. MR flow mapping in coronary artery bypass grafts: a validation study with Doppler flow measurements. Radiology 2002;222:127-35. Langerak SE, Vliegen HW, Jukema JW, Kunz P, Zwinderman AH, Lamb HJ, et al. Value of magnetic resonance imaging for the noninvasive detection ofstenosis in coronary artery bypass grafts and recipient coronary arteries. Circulation 2003 in press.
4
5
6
Langerak SE, Vliegen HVW, Jukema JW, Zwinderman AH, Lamb HJ, de Roos A, et al. Vein graft function improves in patients after percutaneous intervention: evaluation by magnetic resonance flow mapping. Radiology 2003 in press. Langerak SE, Vliegen HW, Roos A de, Zwinderman AH, Jukema JW, Kunz P, et al. Detection of vein graft disease using high-resolution magnetic resonance angiography. Circulation 2002;105:328-33. Kim WY, Danias PG, Stuber M, Flamm SD, Plein S, Nagel E, et al. Coronary magnetic resonance angiography for the detection of coronary stenoses. N Engi J Med 2001;345:1863-9.
PathIl and physilogical characteristics of coronary artery diease Both pathomorphological and functional aspects of coronary atherosclerotic disease were studied in this thesis. The first part concerned the association between the inflammatory state of atherosclerotic lesions and clinical manifestations of coronary syndromes. Inflammation plays an important role in the initiation, development, progression and complications of atherosclerotic vascular disease. The introduction of directional coronary atherectomy (DCA) has provided a unique opportunity to examine the role of inflammation in patients with stable and acute coronary syndromes. DCA of culprit coronary lesions was performed in 150 patients. Plaques of patients presenting with unstable 189
~5O
E
1.0
53
E
E
52
40
0.8
30..
0.6 ';06
S
FFR
