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The periprocedural events and myocardial function during nonocclusive coronary atherectomy by Rotablator or transluminal extraction catheter (TEC) may differ from events during balloon angioplasty. This may have important clinical consequences and needs to be defined further. Therefore, 17 patients undergoing Rotablator and 18 undergoing TEC atherectomy were assessed by clinical, hemodynamic and electrocardiographic monitoring and simultaneous transesophageal echocardiography. The findings were compared with similar parameters during subsequent balloon angioplasty performed in 16 of 17 patients undergoing Rotablator and 14 of 18 undergoing TEC atherectomy. Chest pain occurred more frequently during balloon inflation than during either atherectomy (p less than 0.02), whereas ST-segment and T-wave electrocardiographic changes were equally frequent. Transient second- or third-degree atrioventricular block occurred in 6 patients during Rotablator but in none during TEC atherectomy or balloon inflation (p less than 0.01 for each). Hemodynamic parameters and global left ventricular function remained unchanged during atherectomy. Regional myocardial function in the distribution of the target coronary artery, assessed by a wall motion score, was not affected during Rotablator, but deteriorated slightly during TEC atherectomy and more significantly during balloon inflation (score from 0.3 +/- 0.5 to 1.0 +/- 0.7 during TEC and 2.0 +/- 0.6 during balloon inflation, p less than 0.005 for both). Thus, chest pain is infrequent, whereas hemodynamics and global left ventricular function are preserved during Rotablator and TEC atherectomy. Transient atrioventricular block during Rotablator and regional myocardial dysfunction during TEC atherectomy may occur without significant consequences. These data suggest that these techniques may be preferable to balloon angioplasty for preserving intraprocedural left ventricular function.

The increasing complexity of coronary intervention and the limitations of hemodynamic and electrocardiographic monitoring have facilitated the introduction of new imaging techniques in the cardiac catheterization laboratory. Transesophageal echocardiography (TEE) has proved valuable for left ventricular (LV) monitoring during high-risk surgery, but its reported use in the cardiac catheterization laboratory has been limited. Accordingly, we assessed the feasibility and value of TEE during complex or high-risk coronary intervention in the catheterization laboratory. The TEE probe was successfully introduced in 53 of 54 (98%) attempted cases. The primary imaging goals were LV monitoring in 39 (74%), left main coronary artery (LMCA) imaging in 9 (17%) and both in 5 (9%) cases. LV monitoring was successful in 43 of the 44 (98%) attempted cases. In 25 (58%) of these, additional important observations were made by TEE that were not apparent by symptoms, or hemodynamic, electrocardiographic or radiographic monitoring. These included unexpected changes in regional myocardial function (n = 20), alteration in LV size (n = 2), exclusion of considered pericardial tamponade (n = 2) and detection of unsuspected mitral regurgitation (n = 1). Management of the interventional procedure was directly influenced by the findings of TEE in 11 of the 43 (26%) monitored cases. The LMCA was successfully visualized in 13 of the 14 (93%) attempted cases. In 11 of these, measurement of the stenotic lesion diameter by TEE correlated well with quantitative angiography both before (r = 0.83, standard error of the estimate = 0.01, p less than 0.002) and after (r = 0.80, standard error of the estimate = 0.03, p less than 0.005) intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Although cardiopulmonary bypass support has been increasingly used for high risk coronary angioplasty, few data exist regarding its effects on left ventricular function. Accordingly, in 20 patients changes in left ventricular size, afterload and myocardial function were assessed by continuous hemodynamic monitoring and simultaneous two-dimensional echocardiography during cardiopulmonary bypass-supported high risk angioplasty. The cross-sectional left ventricular area during bypass support remained unchanged during diastole, whereas during systole it decreased (from 29.6 +/- 11.4 to 27.6 +/- 10.4 cm2, p less than 0.05). Global left ventricular function expressed as fractional area change remained unchanged from baseline to bypass support but decreased during balloon inflation (from 0.27 +/- 0.11 to 0.17 +/- 0.09, p less than 0.001). The end-systolic meridional wall stress decreased during bypass support (from 141 +/- 75 to 110 +/- 58 x 10(3) dynes/cm2, p less than 0.02). Regional myocardial function was assessed by a wall motion score (0 = normal, 1 = hypokinesia, 2 = akinesia and 3 = dyskinesia). Regions supplied by a stenotic (greater than or equal to 50% diameter) vessel deteriorated during bypass support (score from 0.9 +/- 0.8 to 1.06 +/- 0.8, p less than 0.01), whereas regions supplied by a nonstenotic vessel did not. Regions supplied by the target vessel deteriorated further during balloon inflation (score from 0.7 +/- 0.6 to 1.7 +/- 0.75, p less than 0.001). Thus, although left ventricular size and global function remain unchanged and afterload decreases during bypass support, myocardial dysfunction in regions supplied by a stenotic vessel may occur. Furthermore, regional and global left ventricular dysfunction still occur with angioplasty balloon inflation during cardiopulmonary bypass support.