Optimal percentage of biventricular pacing to obtain CRT response: how high is high enough

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
AF Esteves ◽  
L Parreira ◽  
D Mesquita ◽  
M Fonseca ◽  
JM Farinha ◽  
...  
Keyword(s):  
Beta Blockers ◽  
Biventricular Pacing ◽  
Survival Function ◽  
Cardiac Resynchronization ◽  
Rank Test ◽  
P Value ◽  
Absolute Increase ◽  
Cut Point ◽  
Crt Response

Abstract Funding Acknowledgements Type of funding sources: None. Background The greatest benefit with cardiac resynchronization therapy (CRT) is achieved when biventricular pacing (BivP) percentage (%) is close to 100%. However, in some patients that goal can be challenging to obtain. Purpose Determine whether a lower BivP% could lead to similar CRT response and events, as compared with patients with BivP% >98%. Methods Patients with CRT followed up in a remote-monitoring network were retrospectively analyzed. BivP% was assessed and response to CRT was defined as an absolute increase in left ventricle ejection fraction (LVEF) >5% or a relative increase in LVEF >15%. Low BivP% was defined as <98%. Clinical, echocardiographic data and all-cause death during follow-up were evaluated. ROC curve and AUC were obtained to determine the discriminative power of BivP% as predictor of CRT response. Optimal cut-point value was obtained and patients were divided according to this value. Kaplan-Meyer survival function was used to compare survival in the different groups and the Log-rank test was used for comparison between the groups. Results 88 patients, 76% male, median age 73.5 (IQR 65.75-79.25) years were included. A CRT-D was implanted in 69%. Etiology was ischemic in 44%. 93% were under beta-blockers. Median LVEF before CRT was 27% (IQR 20.25-32).  44 patients (50%) had low BivP% (median 91%, IQR 96-99), 55% due to atrial fibrillation and 52% due to frequent premature ventricular complexes. After optimization of medical therapy, device programming and/or interventional procedures, we obtained a BivP >98% in 26 out of the 44 patients (59%). However, in 18 patients (20%) BivP% was <98% (median 95, IQR 92.25-96). 66% patients were CRT responders. Median follow-up was 36 (IQR 23.75-84) months. During follow-up, all-cause mortality was 27% (24 patients). Optimal cut-point value for predicting CRT response was 91% BivP% (AUC 0.644, p-value 0.047, 95% CI 0.496-0.792). The characteristics of the two groups didn’t differ significantly (Table). Survival was significantly higher in patients with BivP% >91% (Log-rank 3.667, p-value 0.050) – Figure. Conclusion In this population, BivP% >91% was sufficient to achieve CRT-response and was associated with a better survival. BivP% <91%(n = 4)BivP% >91%(n = 84)p-valueAge in years, median (IQR)72.50 (70.50-73.75)74.00 (65.00-80.00)0.666CRT-D, n (%)3 (75.0)58 (69.0)0.999Ischemic cardiopathy, n (%)3 (75.0)35 (41.7)0.311LVEF before CRT, median (IQR)27 (19-39)27 (20-32)0.795Beta-blockers, n (%)4 (100.0)78 (95.1)0.999Abstract Figure.

P1171Optimal fusion vs. biventricular pacing in cardiac resynchronization therapy: long-term results of 540 consecutive patients

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
D A Radu ◽  
C N Iorgulescu ◽  
S N Bogdan ◽  
A I Deaconu ◽  
A Nastasa ◽  
...  
Keyword(s):  
Biventricular Pacing ◽  
Statistical Significance ◽  
Left Ventricular ◽  
Long Term Results ◽  
Cardiac Resynchronization ◽  
P Value ◽  
Data Set ◽  
P Values

Abstract Background Right ventricular (RV) stimulation induces supplemental dyssynchrony in case of left bundle branch block (LBBB) patients. Isolated left ventricular (LV) pacing has been proven superior to biventricular pacing (BiV) in terms of acute hemodynamic response. Purpose We sought to determine whether an optimised isolated LV pacing algorithm called "optimal fusion" (OFu) produces better and sustainable effects when compared to BiV in the long term. Methods 540/760 (reasonable data collection) consecutive patients implanted with CRT in CEHB were analysed. The follow-up included 7 hospital visits for each patient (between baseline and 3 years). Demographics, risk factors, usual serum levels, pre-procedural planning factors, clinical, ECG, TTE and biochemical markers were recorded. Statistical analysis was performed using software. Data were reported as either p-values from crosstabs (discrete) or mean differences, p-values and confidence intervals from t-tests (continuous). A p-value of .05 was chosen for statistical significance (SS). Results The overall group consisted of 51% OFu (275) and the rest BiV patients. Subjects in OFu were younger (-4.379 ys; <.001; (-7.028;-1.729)), more often females (40.9 vs. 24.9%; <.002), more obese (40.1 vs. 29.6%; <0.40) and had more structural disease other than ischaemic scar burden (10.8 vs. 2.7%; <.005). Procedures in OFu were mainly "de novo" (93 vs. 73.4%; <.000), more often CRT-Ds (58.2 vs. 42.9%; <.005) and more frequently in sinus rhythm (99.4 vs. 62.3%; <.000) and with typical LBBB (77.2 vs. 45%; <.000). Baseline PR interval was shorter in OFu (-32.20 msec; <.033; (-61.58;-2.58)). Notably, OFu patients started from a lower EF (-3.29%; <.001; (-5.156;-1.441)), had more dyssynchrony as evaluated by Pitzalis’ index (34.32 msec; <.017; (6.132;62.522)) and poorer initial mechanical performance by dP/dt (-104.83 mm Hg/sec; <.012; (-185.301;-24.366)). There was no SS difference in clinical parameters at 3 years. Mean EF was higher in OFu (38.59 vs. 34.82%; NS; (4.183;-4.755)) while both EDVs (170.40 vs. 161.40 ml; NS; (-82.40;100.40)) and ESVs (115.36 vs. 102.67 ml; NS; (-82.65;108.03)) were lower. When looking at absolute Δs, OFu performed much better in the long term: EF (+15.81 vs. +8.86%; NS; (-17.06877;3.17710)), EDV (-46.07 vs. – 10.1 ml; NS; (-19.88;102.60)) and ESV (-55.91 vs. -17.46 ml; NS; (-39.88;124.71)). The cumulated super-responder/responder (SR/R) percentage at 1 year was much higher in OFu (83.43 vs. 57.75; <.040). Conclusions The benefit of OFu is definitely sustainable in the long term. Structural response is constantly superior with OFu when compared to BiV although the current data set did not yield SS when comparing absolute means. However, parameter Δs are clearly in favor of OFu which produced a SS higher cumulated rate of SR/Rs over 3 years of follow-up.

scholarly journals Long‐Term Outcome of Patients With Congenital Heart Disease Undergoing Cardiac Resynchronization Therapy

2021 ◽  
Author(s):  
Peter Kubuš ◽  
Jana Rubáčková Popelová ◽  
Jan Kovanda ◽  
Kamil Sedláček ◽  
Jan Janoušek
Keyword(s):  
New York ◽  
Congenital Heart Disease ◽  
Heart Disease ◽  
Congenital Heart ◽  
Heart Association ◽  
Cardiac Resynchronization ◽  
New York Heart Association ◽  
Crt Response

Background Cardiac resynchronization therapy (CRT) is rarely used in patients with congenital heart disease, and reported follow‐up is short. We sought to evaluate long‐term impact of CRT in a single‐center cohort of patients with congenital heart disease. Methods and Results Thirty‐two consecutive patients with structural congenital heart disease (N=30) or congenital atrioventricular block (N=2), aged median of 12.9 years at CRT with pacing capability device implantation, were followed up for a median of 8.7 years. CRT response was defined as an increase in systemic ventricular ejection fraction or fractional area of change by >10 units and improved or unchanged New York Heart Association class. Freedom from cardiovascular death, heart failure hospitalization, or new transplant listing was 92.6% and 83.2% at 5 and 10 years, respectively. Freedom from CRT complications, leading to surgical system revision (elective generator replacement excluded) or therapy termination, was 82.7% and 72.2% at 5 and 10 years, respectively. The overall probability of an uneventful therapy continuation was 76.3% and 58.8% at 5 and 10 years, respectively. There was a significant increase in ejection fraction/fractional area of change ( P <0.001) mainly attributable to patients with systemic left ventricle ( P =0.002) and decrease in systemic ventricular end‐diastolic dimensions ( P <0.05) after CRT. New York Heart Association functional class improved from a median 2.0 to 1.25 ( P <0.001). Long‐term CRT response was present in 54.8% of patients at last follow‐up and was more frequent in systemic left ventricle ( P <0.001). Conclusions CRT in patients with congenital heart disease was associated with acceptable survival and long‐term response in ≈50% of patients. Probability of an uneventful CRT continuation was modest.

Biventricular pacing-induced acute response in baroreflex sensitivity has predictive value for midterm response to cardiac resynchronization therapy

2009 ◽  
Vol 297 (1) ◽  
pp. H233-H237 ◽  
Author(s):  
Maaike G. J. Gademan ◽  
Rutger J. van Bommel ◽  
C. Jan Willem Borleffs ◽  
SumChe Man ◽  
Joris C. W. Haest ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Predictive Value ◽  
Baroreflex Sensitivity ◽  
Biventricular Pacing ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Arterial Baroreflex ◽  
Resynchronization Therapy ◽  
Acute Response

In a previous study we demonstrated that the institution of biventricular pacing in chronic heart failure (CHF) acutely facilitates the arterial baroreflex. The arterial baroreflex has important prognostic value in CHF. We hypothesized that the acute response in baroreflex sensitivity (BRS) after the institution of cardiac resynchronization therapy (CRT) has predictive value for midterm response. One day after implantation of a CRT device in 33 CHF patients (27 male/6 female; age, 66.5 ± 9.5 yr; left ventricular ejection fraction, 28 ± 7%) we measured noninvasive BRS and heart rate variability (HRV) in two conditions: CRT device switched on and switched off (on/off order randomized). Echocardiography was performed before implantation (baseline) and 6 mo after implantation (follow-up). CRT responders were defined as patients in whom left ventricular end-systolic volume at follow-up had decreased by ≥15%. Responders (69.7%) and nonresponders (30.3%) had similar baseline characteristics. In responders, CRT increased BRS by 30% ( P = 0.03); this differed significantly ( P = 0.02) from the average BRS change (−2%) in the nonresponders. CRT also increased HRV by 30% in responders ( P = 0.02), but there was no significant difference found compared with the increase in HRV (8%) in the nonresponders. Receiver-operating characteristic curve analysis revealed that the percent BRS increase had predictive value for the discrimination of responders and nonresponders (area under the curve, 0.69; 95% confidence interval, 0.51–0.87; maximal accuracy, 0.70). Our study demonstrates that a CRT-induced acute BRS increase has predictive value for the echocardiographic response to CRT. This finding suggests that the autonomic nervous system is actively involved in CRT-related reverse remodeling.

T-cell clonality in peripheral blood as a predictor of progression to systemic treatment in patients with stage IB mycosis fungoides (MF).

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e19538-e19538
Author(s):  
Suravi Raychaudhuri ◽  
Charli-Joseph Yann ◽  
Michelle Mintz ◽  
Laura Pincus ◽  
Chiung-Yu Huang ◽  
...  
Keyword(s):  
T Cell ◽  
Peripheral Blood ◽  
Systemic Treatment ◽  
Rank Test ◽  
P Value ◽  
Advanced Stage ◽  
Stage Ib ◽  
Log Rank Test ◽  
Secondary Outcomes

e19538 Background: A major unmet clinical need in the care of early-stage MF patients is the identification of those with a high risk of failing skin directed therapy or progressing to advanced disease. Herein, we inquired if the identification of a clonal T-cell receptor (TCR) gene rearrangement by PCR in peripheral blood could predict the clinical outcome, particularly the need for systemic treatment, in patients with stage IB MF. Methods: This is a retrospective cohort study of patients with stage IB MF who underwent peripheral blood TCR clonality analysis by PCR. The primary outcome of the study was time from diagnosis to initiation of systemic treatment. Secondary outcomes were: (1) time to progression to advanced-stage disease (stages IIB-IV) and (2) overall survival. Patients were censored at time of last clinical follow up. Log rank test was used to compare the survival distributions of the two groups; p value < 0.05 was considered significant. Results: From May 2014 to October 2019, 56 consecutive stage IB pts with > 6 months follow up were included in this analysis. Peripheral blood TCR clonality status was available in 42 patients: 18 pts had a positive TCR clone and 24 did not. Median follow up time was 36 months (range 8.5 – 198 months). At 3 years, 39% of patients with peripheral clone had progressed to systemic treatment versus 8% of those without a peripheral clone (log rank test, p-value = 0.003). For the secondary outcomes, at 3 years 17% of patients with peripheral clone had progressed to advanced stage versus 4% of those without (log rank test, p-value = 0.10); 5% of patients with peripheral clone had died versus 0% of those without (log rank test, p-value = 0.03). Conclusions: Detection of a predominant TCR clone by PCR in the peripheral blood is an important prognostic marker in the initial workup of MF, as its presence is highly correlated with subsequent progression to systemic treatment and death. If this finding is validated, it can be used to risk stratify and individualize therapy for MF patients.[Table: see text]

Cardiac resynchronization therapy: optimization and follow-up

2015 ◽  
pp. 420-431
Author(s):  
Marta Sitges ◽  
Genevieve Derumeaux
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Imaging Techniques ◽  
Biventricular Pacing ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Cardiac Imaging Techniques ◽  
Resynchronization Therapy

Cardiac imaging techniques have an important role in the follow-up of patients undergoing cardiac resynchronization therapy (CRT) as they provide objective evidence of changes in cardiac dimensions and function. The role of echocardiography is well established in the assessment of left ventricular reverse remodelling and the evaluation of secondary (functional) mitral regurgitation. Additionally, echocardiography might be used for optimizing the programming of atrio-ventricular (AV) and inter-ventricular (VV) delays of current CRT devices. Acute benefits from this optimization have been demonstrated, but longer follow-up studies have failed to show a clear benefit of optimized CRT on top of simultaneous biventricular pacing on the outcome of patients with CRT. This chapter reviews the role of imaging in assessing follow-up and outcome of patients undergoing CRT, as well as the rationale, the methods used, and the clinical impact of optimization of the programming of CRT devices.

scholarly journals Septal contraction predicts acute haemodynamic improvement and paced QRS width reduction in cardiac resynchronization therapy

2020 ◽  
Vol 21 (8) ◽  
pp. 845-852 ◽  
Author(s):  
Stian Ross ◽  
Eirik Nestaas ◽  
Erik Kongsgaard ◽  
Hans H Odland ◽  
Trine F Haland ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Diastolic Pressure ◽  
Electrical Response ◽  
Electrical Parameter ◽  
Biventricular Pacing ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Device Implantation ◽  
Crt Response

Abstract Aims  Three distinct septal contraction patterns typical for left bundle branch block may be assessed using echocardiography in heart failure patients scheduled for cardiac resynchronization therapy (CRT). The aim of this study was to explore the association between these septal contraction patterns and the acute haemodynamic and electrical response to biventricular pacing (BIVP) in patients undergoing CRT implantation. Methods and results  Thirty-eight CRT candidates underwent speckle tracking echocardiography prior to device implantation. The patients were divided into two groups based on whether their septal contraction pattern was indicative of dyssynchrony (premature septal contraction followed by various amount of stretch) or not (normally timed septal contraction with minimal stretch). CRT implantation was performed under invasive left ventricular (LV) pressure monitoring and we defined acute CRT response as ≥10% increase in LV dP/dtmax. End-diastolic pressure (EDP) and QRS width served as a diastolic and electrical parameter, respectively. LV dP/dtmax improved under BIVP (737 ± 177 mmHg/s vs. 838 ± 199 mmHg/s, P &lt; 0.001) and 26 patients (68%) were defined as acute CRT responders. Patients with premature septal contraction (n = 27) experienced acute improvement in systolic (ΔdP/dtmax: 18.3 ± 8.9%, P &lt; 0.001), diastolic (ΔEDP: −30.6 ± 29.9%, P &lt; 0.001) and electrical (ΔQRS width: −23.3 ± 13.2%, P &lt; 0.001) parameters. No improvement under BIVP was observed in patients (n = 11) with normally timed septal contraction (ΔdP/dtmax: 4.0 ± 7.8%, P = 0.12; ΔEDP: −8.8 ± 38.4%, P = 0.47 and ΔQRS width: −0.9 ± 11.4%, P = 0.79). Conclusion  Septal contraction patterns are an excellent predictor of acute CRT response. Only patients with premature septal contraction experienced acute systolic, diastolic, and electrical improvement under BIVP.

High Rate of Survival in Transformed Lymphoma after Autologous Stem Cell Transplant (ASCT): Pathologic Analysis and Comparison with De Novo DLBCL.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1137-1137
Author(s):  
Stephen S. Smith ◽  
Brian Bolwell ◽  
Anjali Advani ◽  
Steven Andresen ◽  
Josephine Chan ◽  
...  
Keyword(s):  
De Novo ◽  
Cleveland Clinic ◽  
B Cell Lymphoma ◽  
Rank Test ◽  
P Value ◽  
Cell Transplant ◽  
Transformed Lymphoma ◽  
Baseline Characteristics ◽  
Pathologic Analysis

Abstract Introduction: Survival gains in follicular lymphoma (FL) have been variably attributed to improved first line and salvage therapies, and a decreasing frequency of histologic transformation (HT). Although ASCT is often used in patients (pts) with transformed lymphoma (TL), optimal pt selection and factors predictive of outcome are unclear. Although immunohistochemistry (IHC) has been applied to prognostication in de novo DLBCL, few studies have investigated IHC as a prognostic factor in TL. The purpose of this analysis was to review outcomes using ASCT for TL at the Cleveland Clinic Taussig Cancer Insitute (CCTCI) in light of modern IHC-based pathologic analysis. Methods: All pts undergoing ASCT for diffuse large B-cell lymphoma from 2003–2008 at CCTCI (n=130) were identified. IHC analysis for markers CD10, BCL2, BCL6, and MUM-1 was available for 56 pts, who were analyzed further. Pts with TL (n=25) were compared as a group to de novo cases (n=31). Baseline characteristics were compared using Fisher’s exact and Wilcoxon rank-sum tests. Relapse-free and overall survival (RFS and OS) were estimated with the Kaplan-Meier method and compared via log-rank test. Cox proportional hazards analysis was used to examine features predicting outcome after ASCT. Results: Median age was 57 years. Of 25 TL pts, 16 had prior FL, 1 each had small lymphocytic lymphoma and nodular LP Hodgkin lymphoma, and 7 presented with coexistent DLBCL and FL in the same biopsy specimen. Among 18 TL pts with metachronous presentation, HT occurred at a median of 26 months (range, 8–198 months). Pathologic characteristics (%) are: Group CD10 BCL6 MUM-1 BCL2 GCB phenotype* MedianKI67 index t(14;18) *Criteria from Hans et al, Blood2004;103(1):275–82 TL 84 95 38 84 92 70 8/10 de novo 61 88 43 63 71 80 1/8 P value .08 .62 1.0 .18 .09 .63 .02 Age and disease status at time of transplant were similar between groups. Three de novo pts and 2 TL patients underwent ASCT during first remission; all others underwent ASCT for relapsed/refractory disease. With a median follow-up of 25 months, 4 year RFS was 64% vs. 59% (p=.82) and OS 63% vs. 59% (p=.68) for TL and de novo pts, respectively (see Figures 1 and 2). No IHC feature predicted RFS or OS. Elevated LDH at time of ASCT predicted poor RFS (HR 4.6, p=.008) and OS (HR 6.3, p=.005) on multivariate analysis, and increasing number of prior regimens predicted poor RFS only (HR 1.4, p=.003). Conclusions: TL resembled de novo DLBCL in terms of IHC characteristics, but a higher proportion of TL cases bore the t(14;18) translocation. ASCT was effective in treating TL, with a 4-year RFS and OS exceeding 60%. This was indistinguishable from outcomes for de novo DLBCL pts treated with ASCT over the same period. Baseline characteristics were similar between TL and de novo pts. Survival in FL may be improving in part due to good outcomes using ASCT for TL. Confirmation of our observed RFS/OS among TL pts requires longer follow-up, given the ongoing risk of relapse of indolent disease. Outcome after ASCT cannot be predicted by IHC, and novel approaches are needed to improve pt selection and elucidate the biology of HT. Figure 1: RFS Figure 1:. RFS Figure 2: OS Figure 2:. OS

Changing treatment paradigms in the era of targeted therapies.

2014 ◽  
Vol 32 (4_suppl) ◽  
pp. 518-518
Author(s):  
Philipp Marius Papavassilis ◽  
Edwin Herrmann ◽  
Laura-Maria Krabbe ◽  
Lothar Hertle ◽  
Martin Boegemann ◽  
...  
Keyword(s):  
Targeted Therapy ◽  
Rank Test ◽  
P Value ◽  
Line Treatment ◽  
New Agents ◽  
Exact Test ◽  
Significant Survival ◽  
Significant Difference ◽  
The University

518 Background: Our goal was to describe the change of treatment paradigms for metastatic renal cell carcinoma (mRCC) since targeted therapy became available in 2006. Methods: In this cohort population study we retrospectively investigated all mRCC patients who were treated with targeted therapy between 06/2006 and 06/2012 in the Department of Urology of the University of Münster. To distinguish nominal variables Fisher's exact test was used, in other respects Pearson's χ² test. For metrical variables the Mann-Whitney-U-Test was used. The log-rank test was chosen to derive differences between two or more groups with regard to survival. A p value <0,05 was considered statistically significant. Results: 50/158 (31.6%) patients with a median follow-up of 362 days were initially treated with immunotherapy. The most often used second line treatment after immunotherapy was sorafenib (29 patients, 58.0%). As first line treatment sunitinib was chosen most frequently (68 patients, 63.0%). There was no statistically significant difference in survival between the patients who were treated with immunotherapy and those who were not (572 vs. 554 days, p=0,745). 134 (84.4%) patients received cytoreductive nephrectomy before systemic treatment start. Comparing the survival curves there was a significant survival benefit in favor of nephrectomized patients (632 vs. 169 days, p<0,0001). Conclusions: After introduction of the new agents treatment paradigms have changed substantially. Immunotherapy is used only rarely. Cytoreductve nephrectomy should continue to be regarded as standard treatment.

scholarly journals Chlamydia pneumoniae and Atherosclerosis following Carotid Endarterectomy

2003 ◽  
Vol 30 (4) ◽  
pp. 333-339 ◽  
Author(s):  
Babak S. Jahromi ◽  
Michael D. Hill ◽  
Kate Holmes ◽  
Stuart Hutchison ◽  
William S. Tucker ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Chlamydia Pneumoniae ◽  
Carotid Atherosclerosis ◽  
Survival Function ◽  
Causal Link ◽  
Rank Test ◽  
Carotid Disease ◽  
Arterial Infection ◽  
All Cause Mortality

Background:Seroepidemiological studies have shown an association between raised antibody titres against Chlamydia pneumoniae, and carotid atherosclerosis or stroke. However, direct evidence for a causal link between arterial infection with C. pneumoniae and carotid disease remains weak. We hypothesized that long-term follow-up of patients with pathologically-proven arterial C. pneumoniae infection might provide further insight into the role of C. pneumoniae in carotid atherosclerosis.Methods:We followed a cohort of 70 carotid endarterectomy patients for ipsilateral restenosis, contralateral progression, and all-cause mortality (four year median follow-up period). All patients had presence or absence of C. pneumoniae in their carotid plaques documented by immunohistochemistry after endarterectomy. A survival function was generated and the log-rank test was used to assess the difference in survival between subjects with and without documented chlamydial infection in their plaque.Results:Baseline demographic and cardiovascular risk factors were similar between the two groups, and survival analysis demonstrated no difference (p>0.05) in all-cause mortality, or all-cause mortality combined with restenosis and progression.Conclusion:Our data finds no causal role for C. pneumoniae in restenosis or progression of carotid disease or mortality in this patient population with advanced carotid atherosclerosis.

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