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• In this multicenter clinical series of peripheral laser-assisted balloon angioplasty with an argon laser-heated, metallic-capped fiberoptic, angiographic and clinical success was achieved in a total of 155 (71%) of 219 attempted lesions. When the anatomy of the lesion was subjectively categorized by the angiographer into those considered possible or impossible to treat by conventional balloon angioplasty, clinical success was achieved in 116 (78%) of 149 lesions considered possible to treat with balloon angioplasty (39 [95%] of 41 stenoses and 77 [71%] of 108 occlusions). More importantly, clinical success was achieved in 39 (56%) of 70 lesions considered impossible to treat by conventional means. The incidence of complications, including vessel perforation (4.1%), with this new technique was equal to that reported for conventional balloon angioplasty, decreased with operator experience, and was less than that reported for argon laser angioplasty with bare fiberoptics. Thus, laser thermal angioplasty with a laser-heated, metallic-capped fiberoptic is a safe procedure that is easily learned by physicians skilled in interventional techniques. It allows for nonsurgical treatment of lesions considered difficult or impossible to treat by conventional balloon angioplasty.(Arch Surg 1989;124:1099-1103)

In a 60 month period (January 1981 to December 1985), 82 patients (79% male with a mean age of 60 years) had 83 saphenous vein grafts and 5 internal mammary artery grafts with a total of 101 stenotic sites treated with percutaneous transluminal coronary angioplasty. The mean time between bypass surgery and angioplasty was 51.2 months. The procedure was technically successful in 85% of patients, 86% of grafts and 85% of the sites attempted. In these cases, the mean diameter stenosis was reduced from 77 ± 14 to 27 ± 20% (p < 0.001), the mean pressure gradient from 49 ± 16 to 7 ± 6 mm Hg (p < 0.001). Emergency coronary artery bypass graft surgery was necessary in one patient (1.2%) whereas myocardial infarction occurred in three patients (3.6%). There were no hospital deaths.

Between March 1978 and July 1981, 217 symptomatic patients underwent coronary angioplasty as an alternative to coronary bypass surgery. Angioplasty was successful in 143 patients (66%), unsuccessful bet uncomplicated in 65 (30%) and complicated in 9 (4%) by one or more of the following criteria: Q wave myocardial infarction (2%), emergency surgery (4%) or death (0.5%). Late follow-up evaluation was obtained in 213 patients at a mean of 9 ± 1 years. Of patients in whom angioplasty was successful, 59 (42%) of 140 required another revascularization procedure (repeat angioplasty in 26% and bypass surgery in 16%).

The initial and late outcome of coronary angioplasty was studied in 148 patients < 40 years of age (mean 36.4 ± 3). Angioplasty was performed on a single vessel in 70% of patients and on multiple vessels in 30%; it was performed on a totally occluded vessel in 20%. Angioplasty was successful in 90.5% of patients, unsuccessful but uncomplicated in 7.4% and complicated by myocardial infarction in 0.7%, emergency bypass surgery in 0.7% and death in 0.7%.

From July 1, 1990 to February 28, 1991, 533 consecutive patients with 764 target vessels and 1,000 lesions underwent coronary angioplasty. Procedural success was achieved in 92.3%, untoward (major cardiac) events occurred in 3% (0.8% myocardial infarction, 1.3% emergency coronary bypass grafting and 0.9% both; there were no deaths). An unsuccessful uncomplicated outcome occurred in 4.7%. Lesion analysis using a modified American College of Cardiology/American Heart Association classification system showed that 8% were type A, 47.5% were type B and 44.5% were type C (36% of type B and 11% of type C were occlusions).

To compare the amount of myocardium jeopardized during silent ischemia and painful ischemia, 112 consecutive patients undergoing coronary arteriography with ischemia demonstrated by exercise and redistribution tomographic thallium-201 myocardial imaging (SPECT) were divided into two groups: 84 patients without anginal pain (silent ischemia) and 28 with pain (painful ischemia). The SPECT apical, mid and basal ventricular levels of the short-axis view and the apical portion of the long-axis view were divided into 20 segments.

Over a 5 year period at three centers, 53 patients underwent percutaneous transluminal angioplasty of a right coronary artery ostial stenosis. The procedure was successful in 42 patients (79%) and unsuccessful in 11, of whom 5 (9.4%) required emergency coronary artery bypass grafting because of abrupt closure. The right coronary ostial lesion had distinctive technical requirements to achieve success, including high pressure balloon inflation (10 ± 4 atm) and the need for unconventional right coronary guide catheters.

Objectives. The objective of this study was to determine the accuracy of digital supine bicycle stress echocardiography, a new technique for evaluating coronary artery disease during peak exercise.

From 1978 to 1988, coronary angioplasty was performed in 422 patients with prior coronary artery bypass surgery (264 patients with native coronary artery angioplasty and 158 patients with graft angioplasty). Angioplasty was successful in 84%, unsuccessful but uncomplicated in 11% and complicated by one or more major cardiac events in 5% (myocardial infarction 5%, emergency bypass surgery 2% and death 0.2%). Follow-up data were obtained in 99% of 356 patients with successful angioplasty. At a mean of 33 ± 26 months, 92% were alive, 73% had improvement in angina and 61% were free of angina. One or more of the following late events occurred in 67 patients (19%): myocardial infarction (6%), elective reoperation (13%) and cardiac death (6%). Repeat angioplasty was performed in 27%, with a success rate of 89% and no deaths.

One hundred sixteen patients were evaluated to determine the ability of single photon emission computed tomographic (SPECT) thallium-201 exercise and redistribution imaging to detect silent ischemia secondary to restenosis in asymptomatic patients after single and multiple vessel percutaneous transluminal coronary angioplasty and the findings were compared with SPECT imaging detection of restenosis in symptomatic patients. The value of exercise electrocardiography (ECG) and the amount of ischemic myocardium in symptomatic and asymptomatic patients were determined. Forty-one patients were asymptomatic after angioplasty; 77% of these had chest pain before angioplasty. Seventy-five patients had chest pain after angioplasty; 99% of these had chest pain before angioplasty.

To compare the accuracy of supine bicycle stress echocardiography (SBSE), a new technique for evaluating coronary disease during peak exercise, with tomographic thallium-201 exercise imaging (SPECT), 71 patients were evaluated by SBSE, SPECT, and coronary arteriography: Twenty patients had normal coronary vessels; 22 had single-vessel, 14 had double-vessel, and 15 had triple-vessel disease. There were no differences in sensitivity (90% vs 92%), specificity (80% vs 65%), and accuracy (87% vs 85%) between SBSE and SPECT for the group of 71 patients. The results were similar in patients with and without prior myocardial infarction and with single-, double-, or triple-vessel disease. There were no differences between SBSE and SPECT for disease detection for the group of 213 individual vessels in sensitivity (88% vs 80%), specificity (87% vs 84%), and accuracy (88% vs 82%), but SBSE was more sensitive for the left anterior descending artery (97% vs 82%, p< 0.005) and for arteries involved in triple-vessel disease (93% vs 69%, p< 0.01) and more specific for the right coronary artery (88% vs 66%, p< 0.01). Supine bicycle exercise was associated with significantly lower maximal heart rates than treadmill exercise but with significantly higher systolic and diastolic blood pressures. There were no differences in heart rate × systolic blood pressure. We conclude that SBSE and SPECT are equally reliable for coronary disease detection in patients and for evaluation of disease in specific arteries with the exception of SBSE's higher sensitivity for the left anterior descending artery and arteries involved in triple-vessel disease and higher specificity for the right coronary artery.

The author takes a personal view of the 60-year history of coronary angioplasty and discusses the conditions that dictate its use today.

Coronary angioplasty as a treatment modality has become an often used modality for multivessel coronary disease. The authors have been not only the pioneers of percutaneous transluminal coronary angioplasty (PTCA), but also the individuals who have continued to push the procedure to its limits. They clearlyoutline that in carefully selected patients, a high initial success rate and low incidence of complications canbe achieved. A schema for the triage of multivessels disease patients is presented.

Objectives. The aim of this study was to assess the utility of percutaneous transluminal coronary rotational ablation in the treatment of coronary artery disease.

Cardiac death consequent to acute vessel closure after coronary angioplasty occurred in 13 of 294 closures from 8,207 consecutive procedures performed at two centers since 1981 (0.16% cardiac mortality rate). To determine the predictors of cardiac death after acute coronary closure, 50 clinical, angiographic and procedural variables were analyzed by an observer unaware of the clinical outcome for each of the 13 patients who died and also 190 patients randomly chosen, in whom vessel closure after angioplasty did not result in death during hospitalization. Univariate analysis found female gender (p < 0.0001), collateral channels from the vessel dilated (p < 0.0001), use of balloon counterpulsation (p < 0.0002), pre- and postprocedural hypotension (p = 0.0003 and p = 0.003, respectively), jeopardy score ≥2.5 (p = 0.003), left ventricular hypertrophy (p = 0.013), hypertension (p = 0.02), diabetes (p = 0.02) and multivessel disease (p = 0.03) to be predictive of death. Multivariate analysis found collateral vessels, female gender and multivessel disease to be independent predictors of death.

One hundred and twenty-two consecutive ante mortem patients with proven severe aortic valve disease are presented with their electrocardiographic, radiologic, and hemodynamic findings. Atrial fibrillation was noted in only one patient who had evidence of associated severe coronary arterial insufficiency resulting in an acute myocardial infarction. The rarity of atrial fibrillation in a series of patients with pure aortic valve disease is doubtless related to its poor prognostic implication and markedly shortened life span and explains why the incidence of atrial fibrillation is much lower in this report than in previous postmortem series. Other findings in this series are consistent with earlier observations with the exception of systemic arterial hypertension which was noted in only 4.7% of the patients with aortic stenosis, an observation lower than in previous reports.

The first deaths from mushroom toxicity in the United States were reported in 1871 by Cheney 1 in Chico, Calif. Cases of fatal mushroom poisoning are seen fairly frequently in Central Europe2,3; the incidence in the United States, however, is low. The United States National Registry of Death recorded only 21 deaths from mycetism from 1957 to 1962. Although fatalities are rare, the admission of a patient with mushroom poisoning to the hospital calls for immediate and knowledgeable care, and the use of special techniques such as peritoneal dialysis or hemodialysis may be required to prevent death.Two patients with mushroom poisoning were recently referred to the University of California Medical Center, where they were treated by intermittent peritoneal dialysis. The first case, a typical example of severe mushroom toxicity, ended in the patient's death. The second case is unique, in that renal tissue obtained by biopsy was examined

To characterize the longterm outcome in patients who had successful coronary angioplasty (PTCA) and those who had an unsuccessful, uncomplicated procedure followed by elective bypass surgery (BYPASS) between 3/78 and 6/81, late followup was obtained in 196 (140 PTCA and 56 BYPASS) patients. Mean time to followup was 12 years (range = 13–16). There was no difference between the groups in survival (PTCA – 84.8%; BYPASS – 88.9%), late myocardial infarction (PTCA – 11.3%; BYPASS – 13.0%) or freedom from angina at latest contact (PTCA – 84.1 %; BYPASS – 87.0%). In the PTCA group, 110 (78.6%) were definitively treated with one or more PTCA procedures. In the BYPASS group, 46 (82.1%) were definitively treated with one or more bypass surgeries. Twenty (14.3%) of the PTCA group crossed over to BYPASS and 8 (14.3%) of the BYPASS group crossed over to PTCA. In conclusion, PTCA and BYPASS strategies yield comparable longterm results. Crossover rates between the two therapeutic procedures are similar. It appears that repeat procedures and crossovers are important in sustaining the beneficial results for both procedures over very long periods of time.