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Background: The role of the MitraClip implantation in treatment of critically ill patients with heart failure and severe functional mitral regurgitation is undetermined.Methods: We screened...

Background The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that for patients with diabetes mellitus (DM) and multivessel coronary disease (MVD), coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention with drug-eluting stents (PCI-DES) in reducing the rate of major adverse cardiovascular and cerebrovascular events after a median follow-up of 3.8 years. It is not known, however, whether CABG confers a survival benefit after an extended follow-up period. Objectives The purpose of this study was to evaluate the long-term survival of DM patients with MVD undergoing coronary revascularization in the FREEDOM trial. Methods The FREEDOM trial randomized 1,900 patients with DM and MVD to undergo either PCI with sirolimus-eluting or paclitaxel-eluting stents or CABG on a background of optimal medical therapy. After completion of the trial, enrolling centers and patients were invited to participate in the FREEDOM Follow-On study. Survival was evaluated using Kaplan-Meier analysis, and Cox proportional hazards models were used for subgroup and multivariate analyses. Results A total of 25 centers (of 140 original centers) agreed to participate in the FREEDOM Follow-On study and contributed a total of 943 patients (49.6% of the original cohort) with a median follow-up of 7.5 years (range 0 to 13.2 years). Of the 1,900 patients, there were 314 deaths during the entire follow-up period (204 deaths in the original trial and 110 deaths in the FREEDOM Follow-On). The all-cause mortality rate was significantly higher in the PCI-DES group than in the CABG group (24.3% [159 deaths] vs. 18.3% [112 deaths]; hazard ratio: 1.36; 95% confidence interval: 1.07 to 1.74; p = 0.01). Of the 943 patients with extended follow-up, the all-cause mortality rate was 23.7% (99 deaths) in the PCI-DES group and 18.7% (72 deaths) in the CABG group (hazard ratio: 1.32; 95% confidence interval: 0.97 to 1.78; p = 0.076). Conclusions In patients with DM and MVD, coronary revascularization with CABG leads to lower all-cause mortality than with PCI-DES in long-term follow-up. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450)

Acute myocarditis carries a variable prognosis. We evaluated the morbidity and mortality rates in patients with acute myocarditis and admission electrocardiographic predictors of outcome.Patients admitted to a tertiary hospital with a clinical diagnosis of acute myocarditis were evaluated; 193 patients were included. Median follow-up was 5.7 years, 82% were male, and overal median age was 30 years (range 21-39). The most common clinical presentations were chest pain (77%) and fever (53%). The 30-day survival rate was 98.9%. Overall survival during follow-up was 94.3%. The most common abnormalities observed on electrocardiography were T-wave changes (36%) and ST-segment changes (32%). Less frequent changes included abnormal T-wave axis (105° or -15°; 16%), abnormal QRS axis (12%), QTc460 ms (11%), and QRS interval ≥120 ms (5%). Wide QRS-T angle (≥100°) was demonstrated in 13% of the patients and was associated with an increased mortality rate compared with patients with a narrow QRS-T angle (20% vs 4%; P = .007). The rate of heart failure among patients with a wide QRS-T angle was significantly higher (36% vs 10%; P = .001). Cox regression analysis demonstrated that a wide QRS-T angle (≥100°) was a significant independent predictor of heart failure (hazard ratio [HR] 3.20, 95% confidence interval [CI] 1.35-7.59; P .01) and of the combined end point of death or heart failure (HR 2.56, 95% CI 1.14-5.75; P .05).QRS-T angle is a predictor of increased morbidity and mortality in acute myocarditis.

Many patients with heart failure need anticoagulants, including warfarin. Good control is particularly challenging in heart failure patients, with60% of international normalized ratio (INR) measurements in the therapeutic range, thereby increasing the risk of complications. This study aimed to evaluate the effect of a patient-specific tailored intervention on anticoagulation control in patients with heart failure.Patients with heart failure taking warfarin therapy (n = 145) were randomized to either standard care or a 1-time intervention assessing potential risk factors for lability of INR, in which they received patient-specific instructions. Time in therapeutic range (TTR) using Rosendaal's linear model was assessed 3 months before and after the intervention.The patient-tailored intervention significantly increased anticoagulation control. The median TTR levels before intervention were suboptimal in the interventional and control groups (53% vs 45%, P = .14). After intervention the median TTR increased significantly in the interventional group compared with the control group (80% [interquartile range, 62%-93%] vs 44% [29%-61%], P.0001). The intervention resulted in a significant improvement in the interventional group before versus after intervention (53% vs 80%, P.0001) but not in the control group (45% vs 44%, P = .95). The percentage of patients with a TTR ≥60%, considered therapeutic, was substantially higher in the interventional group: 79% versus 25% (P .0001). The INR variability (standard deviation of each patient's INR measurements) decreased significantly in the interventional group, from 0.53 to 0.32 (P.0001) after intervention but not in the control group.Patient-specific tailored intervention significantly improves anticoagulation therapy in patients with heart failure.

Background The developmental origin of the c-kit expressing progenitor cell pool in the adult heart has remained elusive. Recently, it has been discovered that the injured heart is enriched with c-kit + cells, which also express the hematopoietic marker CD45. Methods and results In this study, we characterize the phenotype and transcriptome of the c-kit+/CD45+/CD11b+/Flk-1+/Sca-1±(B-type) cell population, originating from the left atrial appendage. These cells are defined as cardiac macrophage progenitors. We also demonstrate that the CD45+ progenitor cell population activates heart development, neural crest and pluripotency-associated pathways in vitro, in conjunction with CD45 down-regulation, and acquire a c-kit+/CD45−/CD11b−/Flk-1−/Sca-1+ (A-type) phenotype through cell fusion and asymmetric division. This putative spontaneous reprogramming evolves into a highly proliferative, partially myogenic phenotype (C-type). Conclusions Our data suggests that A-type cells and cardiac macrophage precursor cells (B-type) have a common lineage origin, possibly resolving some current conundrums in the field of cardiac regeneration.

Introduction Prevention of acute decompensated heart failure (ADHF) hospitalizations has both medical and economic implications, yet remains an unmet need. Increases in pulmonary and perhaps upper airway fluid content may be detectable remotely by voice analysis. The Cordio HearO™ system is a mobile application with cloud-based computing, designed to identify distinct speech measures (SM) in standard audio recordings which may be indicative of HF clinical status and provide early warning of impending decompensation. Hypothesis Cordio HearO™ speech analysis can identify clinical worsening of heart failure (HF) patients prior to hospitalization. Methods In this ongoing multicenter, observational study, we recruited 173 New York Heart Association Class II-III, stable stage C chronic heart failure patients. The patients recorded five sentences (2-5 sec each) each day in their native language (English, Hebrew, Arabic or Russian), using Cordio HearO™ operating on standard smartphone devices. Patients have been followed for 3 to 23 months. The current analysis explored the association between different SM parameters and episodes of HF decompensation requiring hospitalization. Results A total of 196,610 recordings, collected over 47,376 patient days of follow up were analyzed during which 13 patients required hospitalization for ADHF. 10 (76.9%) (95% CI: 54.02% - 99.83%) of these episodes were detected by Cordio HearO™ software an average of 12.2 (range 8 to 17 days) days prior to admission. The estimated false-positive event rate per year was 1.47 (95% CI: 1.28 - 1.68). Conclusions Cordio HearO™ novel speech analysis technology may be a useful tool in remote monitoring of HF patients, providing an early warning of impending episodes of decompensation, thus having the potential to reduce ADHF hospitalizations and improve patient quality of life and economic outcomes. Ongoing and future studies will continue to define the role of speech measures in the management of heart failure patients.

Large thrombus burden negatively affects the results of percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI). We investigated the impact of thrombus burden in patients with STEMI undergoing primary PCI with the mesh-covered MGuard stent (InspireMD Ltd., Tel Aviv, Israel) versus a control bare-metal or drug-eluting stent. In 433 patients with STEMI randomized to the MGuard stent versus a control stent, angiographically visible thrombus was identified in 383 patients (88.5%), with median thrombus area 30.15 mm(2) (22.70, 41.93). Lesions with large thrombus (areamedian) were treated with more frequent use of manual aspiration (80.8% vs 65.8%, p = 0.0009) and longer (22.1 ± 5.9 vs 19.4 ± 5.4 mm, p0.0001) and larger (3.46 ± 0.40 vs 3.29 ± 0.36 mm, p0.0001) stents. PCI of lesions with large thrombus burden had more thrombotic complications (30.6% vs 15.9%, p = 0.0007) and reduced angiographic success (80.3% vs 91.1%, p = 0.003). In large thrombus lesions, the MGuard stent was more effective than control stents in achieving Thrombolysis In Myocardial Infarction-3 flow (87.9% vs 74.5%, p = 0.02) and tended to result in less slow flow or no reflow (8.8% vs 17.6%, p = 0.07). ST-segment resolution was improved with the MGuard, and clinical outcomes were favorable in both stent groups, regardless of thrombus burden. In conclusion, reperfusion success is reduced after primary PCI in lesions with large thrombus burden, an outcome that may be modified by the MGuard stent.

Background The effects of electromagnetic fields (EMFs) on cardiovascular calcification is unknown. We sought to evaluate the effects of EMF on vascular calcification in normal rats and in rats with chronic kidney disease (CKD) – a condition which promotes calcification. Methods We used four groups of rats: group 1 – exposed to EMF, group 2 – not exposed to EMF, group 3 – rats with CKD exposed to EMF, group 4 – rats with CKD not exposed to EMF. In order to induce CKD, groups 3 and 4 rats were fed with a uremia-inducing diet. Groups 1 and 3 rats were continuously exposed to EMF using a system similar to an electrical transformer, which consists of a primary coil, a ferrite ring, and a secondary coil. The system transmitter emitted a series of exponentially decaying electromagnetic sine waves (continuous exposure with pulsed peaks) in randomly selected frequencies between 150 and 155 kHz, with random exposure intensities between 4 and 7 mG. Clinical investigations included multislice computed tomography of the aortic roots. Pathological examinations of the aortas included histological characterization, and antigen expression analyses. Results No calcification was found in either group of rats with normal kidney function. Aortic root calcification was significantly higher in rats exposed to EMF (group 3) compared with group 4 rats – with a mean Agatston score of 138±25 vs. 80±20 respectively (p

Sensitivity, specificity, and precision of the various commercially available troponin assays vary considerably. The purpose of this study was to evaluate the diagnostic performance of a novel point-of-care rapid assay (Sens-A-Heart) that qualitatively determine the presence of cardiac biomarkers

Objectives This study sought to investigate the blood pressure (BP) response after transcatheter aortic valve implantation (TAVI) and its correlation with short- and mid-term clinical outcomes. Background TAVI is an emerging therapy for aortic stenosis patients at high surgical risk. The acute hemodynamic sequelae of this procedure and their clinical relevance are yet unclear. Methods Consecutive patients who underwent TAVI in a single center were prospectively monitored for BP response during 5 post-procedural days. Clinical parameters, adverse events, and medical treatment were recorded during hospitalization, at 30 days, and at 12 months after the procedure. Patients were divided according to their post-procedural BP response into 2 groups: increased BP and stable BP. Results One hundred and five patients were analyzed. Overall, systolic BP increased immediately after TAVI in the entire cohort by an average of 15 ± 31 mm Hg. This rise was sustained and led to intensification of antihypertensive treatment in 53 patients (51%); these patients were designated as the increased BP group. The increase in systolic BP after TAVI was associated with an increase in stroke volume and cardiac output and was not related to age, baseline cardiac function, or procedural outcomes. Patients with increased BP after TAVI had a significantly better prognosis with fewer adverse events in the hospital (21% vs. 62%, p Conclusions After TAVI, a substantial number of patients have a significant rise in systolic BP necessitating long-term treatment. This increase in BP is associated with an increase in cardiac output and predicts a better clinical outcome.

The risk of death in heart failure (HF) is high. The electrocardiographic spatial QRS-T angle reflects changes in the direction of the repolarization sequence and predicts death in the general population. The frontal QRS-T angle is simple to measure but has not been evaluated in a large chronic HF cohort. We examined the significance of the frontal QRS-T angle in predicting the clinical outcome in a large cohort of patients with HF. The QRS-T angle was calculated from the frontal QRS and T axis of the baseline 12-lead surface electrocardiogram. The patients were followed for cardiac-related hospitalizations and death; 5,038 patients with HF were evaluated. The mean follow-up period was 576 days; 51% were men. Overall survival during the follow-up period was 83%. Cox regression analysis after adjustment for significant predictors, including age, gender, ischemic heart disease, hypertension, atrial fibrillation, body mass index, pulse, serum hemoglobin, sodium, estimated glomerular filtration rate, and urea levels, demonstrated that the QRS-T angle was an incremental predictor of increased mortality in both genders. For women, a QRS-T angle of ≥60° had a hazard ratio of 1.35 (95% confidence interval 1.04 to 1.75; p

Background Heart failure is increasing in prevalence and carries a very poor prognosis. Heart failure centers (HFC) with specialized management programs have been proposed to improve treatment adherence, improve functional capacity and reduce mortality. Objective To evaluate the effect of the HFC in Beit Shemesh on clinical outcome and heath service utilization. Methods Retrospective cohort study. Data was retrieved from Clalit Health Service records for all heart failure patients in Beit Shemesh area for 2013–2014. Patients treated in the HFC were compared with heart failure patients not treated by the center. Results The cohort included 429 patients, 82 (19%) were treated in the HFC. Basic patients’ characteristics were similar in both groups. Patients who were treated at the HFC visited their family physician more often than patients who did not visit the center (62.4 visits vs. 38.5 P Fig. 1 ). Adjustment for various confounders did not change the result. Conclusion Treatment in the heart failure center in addition to standard care was associated with a higher health service utilization rate but a much lower mortality rate.

High adenine phosphate (HAP) diet serves as an animal model of chronic renal failure (RF). Induction of RF and establishment of end organ damage require long exposure periods to this diet. Previously, we have shown that RF is reversible after diet cessation even after protracted administration. In this study, we explored the underlying renal changes and cellular pathways occurring during administration and after cessation of the diet. Kidneys were obtained from rats fed HAP diet for 7 weeks, and from rats fed HAP diet followed a 10 week recovery period on normal diet. The kidneys of HAP diet group were significantly enlarged due to tubular injury characterized by massive cystic dilatation and crystal deposition. Kidney injury was associated with markers of apoptosis as well as with activation of apoptosis related pathways. Diet cessation was associated with a significant reduction in kidney size, tubules diameter, and crystals deposition. The recovery from renal injury was coupled with regression of apoptotic features. This is the first study showing the potential reversibility of long standing RF model, allowing optimal evaluation of uremia-chronic effects.

Aims The renin–angiotensin system (RAS) plays a key role in heat acclimation, a process which induces adaptive changes in cardiac function. These changes are mediated in part by reduced thyroid hormone activity and improve myocardial function during and following exposure to various (non-heat) stresses such as ischemia. The aim of this study was to examine the role of RAS in the development of the heat acclimated protected heart. Main methods Three treatment groups were used: (1) C, controls; (2) AC, heat acclimated rats (1 mo 34 °C,); and (3) HAEL, heat acclimated euthyroid rats treated with 3 ng/ml of eltroxine. A Langendorff perfusion apparatus was used to measure hemodynamic parameters at baseline and following administration of angiotensin-II, losartan and PD123319 in isolated hearts. Protein and mRNA levels of angiotensin receptors were measured. Key findings Both C and HAEL animals showed increased contractility and a drop in coronary flow during angiotensin II exposure whereas AC animals did not have an inotropic response or vasoconstriction. Significantly different patterns of AT1 and AT2 receptor densities (a 50% reduction and a 30% increase in outer cell membrane AT1 and AT2 receptors respectively) were observed in AC animals compared to the other two groups. AT receptor mRNA levels were similar in all treatment groups. Significance The attenuated response of heat acclimated hearts to angiotensin is mediated by reduced thyroxine levels and is associated with a shift in AT1 receptors from the outer to the inner membrane. This shift appears to be caused by modified posttranslational trafficking of AT receptors.

Objectives The E-Five registry was designed to evaluate the safety and effectiveness of the Endeavor zotarolimus-eluting stent (ZES) (Medtronic CardioVascular, Santa Rosa, California) for the treatment of coronary artery stenosis across a wide range of patients treated in real-world clinical practice settings. Background Early clinical trials with the Endeavor ZES have demonstrated low rates of target lesion revascularization with a favorable safety profile including low late stent thrombosis with up to 4 years of follow-up. A clinical registry was designed to complement controlled trial data by examining a large patient population, including high-risk patient subsets. Methods The E-Five registry is a prospective, nonrandomized, multicenter global registry conducted at 188 centers worldwide. Adult patients (n = 8,314) with coronary artery disease who underwent single-vessel or multivessel percutaneous coronary intervention were enrolled. The primary end point was the rate of major adverse cardiac events (MACE) at 12 months. A secondary analysis stratified patients by standard versus extended-use clinical and lesion characteristics. Results Overall 12-month outcome rates were MACE 7.5%; cardiac death 1.7%; myocardial infarction (all) 1.6%; target lesion revascularization 4.5%; and stent thrombosis (Academic Research Consortium definite and probable) 1.1%. The 12-month MACE rates were 4.3% and 8.6% for standard- and extended-use patients, respectively (p Conclusions This large, international multicenter registry provides important information regarding the long-term safety and efficacy of the Endeavor ZES across standard and extended-use patients in the real-world setting. Rates of MACE and measures of safety including cardiac death, myocardial infarction, and stent thrombosis were low and consistent with pooled results of clinical trials. (E-Five Registry: A World-Wide Registry With The Endeavor Zotarolimus Eluting Coronary Stent [eFive Registry]; NCT00623441 )

Summary. Aim: C-reactive protein (CRP) is a risk marker and a potential modulator of vascular disease. Previous studies support a prothrombotic activity of CRP, with impaired thromboregulation. The present study examined the antithrombotic effect of aspirin in mice transgenic for human CRP (CRPtg mice). Mechanistic investigations further elucidated the effect of CRP on prostanoid metabolism in vivo and in vitro. Methods and Results: Administration of aspirin (30 mg kg−1 day−1) to CRPtg mice slowed the accelerated thrombosis after photochemical injury to the carotid (99 ± 32 vs. 45 ± 24 min and 75 ± 23 vs. 82 ± 26 min in wild-type mice vs. CRPtg mice, without and following aspirin treatment, respectively). Vascular injury modulated the expression of key pathways in prostanoid metabolism differently in CRPtg mice and wild-type mice. Suppression of cyclo-oxygenase 2 (COX-2)-derived metabolism with suppression of prostaglandin I2 (PGI2) synthase and PGI2 metabolism was recorded in the injured artery with increased thromboxane receptor expression. Aspirin therapy reduced the difference in PGI2 biosynthesis between CRPtg mice and wild-type mice. In vitro studies in human-derived cells further supported these findings. Incubation of human umbilical vein endothelial cells (HUVECs) with human recombinant CRP (5 μg mL−1) suppressed PGI2 synthase expression and significantly increased thromboxane receptor levels. Incubation of smooth muscle cells with CRP did not affect prostanoid expression. Conclusions: CRP modulates prostanoid metabolism to favor vascular occlusion. Elevated CRP levels might predispose to the cardiovascular hazard conferred by selective COX-2 inhibitors, and the risk mediated by CRP may be limited by aspirin.

Elevated CRP levels predict increased incidence of cardiovascular events and poor outcomes following interventions. There is the suggestion that CRP is also a mediator of vascular injury. Transgenic mice carrying the human CRP gene (CRPtg) are predisposed to arterial thrombosis post-injury. We examined whether CRP similarly modulates the proliferative and hyperplastic phases of vascular repair in CRPtg when thrombosis is controlled with daily aspirin and heparin at the time of trans-femoral arterial wire-injury.Complete thrombotic arterial occlusion at 28 days was comparable for wild-type and CRPtg mice (14 and 19%, respectively). Neointimal area at 28d was 2.5 fold lower in CRPtg (4190+/-3134 microm(2), n=12) compared to wild-types (10,157+/-8890 microm(2), n=11, p0.05). Likewise, neointimal/media area ratio was 1.10+/-0.87 in wild-types and 0.45+/-0.24 in CRPtg (p0.05). Seven days post-injury, cellular proliferation and apoptotic cell number in the intima were both less pronounced in CRPtg than wild-type. No differences were seen in leukocyte infiltration or endothelial coverage. CRPtg mice had significantly reduced p38 MAPK signaling pathway activation following injury.The pro-thrombotic phenotype of CRPtg mice was suppressed by aspirin/heparin, revealing CRP's influence on neointimal growth after trans-femoral arterial wire-injury. Signaling pathway activation, cellular proliferation, and neointimal formation were all reduced in CRPtg following vascular injury. Increasingly we are aware of CRP multipotent effects. Once considered only a risk factor, and recently a harmful agent, CRP is a far more complex regulator of vascular biology.

Background Contrast-induced nephropathy (CIN) is a major complication of percutaneous coronary interventions with currently limited preventive measures. Objectives To prevent CIN, we assessed the safety and feasibility of contrast removal from the coronary sinus (CS) during coronary angiography. Methods We attempted contrast removal on seven patients undergoing coronary angiography with preexisting renal insufficiency (mean serum creatinine=262±56 mg%). Results In four patients, a balloon catheter could not be successfully deployed in the CS. In three patients, a balloon catheter with distal side holes was positioned in the CS orifice. The balloon was inflated to occlude the CS concurrent with coronary injections, and 12–16 ml of blood was aspirated after each injection. The procedure appeared to be safe, without adverse events and elevations of serum creatinine levels. Contrast media were effectively withdrawn (44%±8%) as assessed by fluoroscopy and dilution of blood. The increased venous pressure at the time of injection reduced coronary flow, allowing for small volumes of administered contrast. Conclusions Occlusion of the CS during coronary angiography with aspiration of contrast media is safe and effective in reducing contrast load during coronary interventions. This procedure may reduce the risk for CIN in prone patients.

The E-Five is a prospective, nonrandomized, multicenter global registry of patients receiving the Endeavor zotarolimus-eluting stent (ZES; Medtronic Vascular, Santa Rosa, CA) for the treatment of coronary artery stenosis. All consecutive procedures were included in the registry, without any specific anatomic or clinical exclusion criteria. Since October 2005, 8,318 patients have been enrolled in the E-Five Registry at 188 hospitals in Europe, South America, Australia, New Zealand, and Asia, and 10,343 lesions have been treated. The primary end point is the rate of major adverse cardiac events (MACE) at 1 year. Of the lesions treated, 60.3% were American College of Cardiology (ACC) and American Heart Association (AHA) type B2 or C lesions, and 16.5% were bifurcation stenoses. The average lesion length was 18.50 +/- 10.60 mm, and 50.6% of the lesions wereor =16 mm long. Clinical data have been analyzed for 1,989 of the patients (23.9%) receiving the Endeavor ZES in this registry, with 30-day clinical outcomes available for 1,985 of these 1,989 patients (99.8%). The acute procedure success rate in these patients was 98.6%, comparable with procedure success rates observed in previous Endeavor ZES clinical trials. The 30-day rate of MACE in these patients was just 1.7%, comparable with 30-day rates of MACE observed in previous ENDEAVOR clinical trials. In an early analysis of a subgroup of patients enrolled in the E-Five Registry, the Endeavor ZES demonstrated encouraging acute and 30-day outcomes in a real-world population of patients who underwent single-vessel or multivessel percutaneous coronary intervention.

Background: Five to 15% of the population have allergy to nickel, chromium, or molybdenum, which is a potential cause for in-stent restenosis. The Titan stent is made of stainless steel and is coated with titanium-nitride oxide (TiNOX), which completely prevents the discharge of metal elements. We performed a real-life multicenter registry to assess the short- and long-term characteristics of the Titan stent. Methods and results: A total of 103 Titan stents was implanted in 100 patients. Patients were 61.4F12.6 years old (81 men). Risk factors included hypercholesterolemia (63%), hypertension (53%), diabetes mellitus (DM; 35%), and current smoking (23%). Indications for PCI (percutaneous coronary intervention) were acute coronary syndromes (ACS) in 68% [acute ST elevation myocardial infarction (MI) in 8%], stable AP (angina pectoris) in 25%, and silent ischemia in 7% of the patients. Fifty-two percent of the treated lesions were of Type B2 or C. Lesion length was 14.3F2.9 mm and stent diameter was 3.06F0.36 mm. Indications for stenting were prevention of restenosis in 66%, residual stenosis in 33%, dissection in 13%, acute MI in 13%, and in-stent restenosis in 7% of the patients. Procedural success was 100%, with no complications. At 30 days, there were no major adverse cardiac events (MACE), including death, MI, and revascularization. At 180 days, only three patients had TVR (target vessel revascularization); two had TLR (target lesion revascularization) (one PCI and one CABG [coronary artery bypass grafting]), and one patient had a new narrowing proximal to the stent and underwent CABG due to multivessel disease. Conclusions: The Titan stent has a remarkable safety profile in high-risk patients and complex coronary lesions and excellent short- and long-term outcome with a very low clinical TLR rate. D 2005 Elsevier Inc. All rights reserved.

Background the diagnosis of infected protheses in patients with long standing fever is difficult, challenging and has major impact on the management. Aim Since 18-Fluo Desoxyglucose positron emission tomography performed together with computerized tomography (FDG PET-CT) has a role in the diagnosis and localization of infection; we evaluated its value in the diagnosis of infected prostheses, correlating its results with medical workup, echo-cardiogram and dedicated CT. Patients: Fourteen patients (pts) with cardiovascular prostheses (seven with a pacemaker, four with vascular grafts, two with pulmonary stent and one with mitral valve prosthesis were hospitalized for prolonged fever. Methods All pts received antibiotics and underwent repeated medical workup. Eight of the 14 pts had a proven bacteriemia. Transthoracic and transoesophagial echocardiogram was performed as well as CT, for most of them. FDG PET-CT was performed in all of them, following injection of 370 MBq of F-18 FDG. All patients were normoglycemic at the time of injection. Results of the FDG PET-CT were compared with other diagnostic modalities and clinical follow up. Results In the 7 pts with pacemaker, FDG PET-CT was positive in 4, echo in 2/4. IN 3/4 the device was removed. A new pacemaker was implanted for two patients after few weeks. FEG PET-CT was negative in 3/7 pts with 1 positive, 1 negative and 1 intermediate results. All patients with vascular graft had positive FDG PET-CT scan and only one had a positive echocardiogram. This patient had a surgical proven abscess. Two pts with pulmonary stent had a positive FDG PET-CT scan and 1 positive echo. In this patient the stent extracted was infected. FDG PET-CT and echo was negative in the patient with mitral prosthesis.Conventional CT was positive in only 1 patient. Twelve pts return to normal including all the patients after prostheses extraction except one who died during graft replacement. Conclusion FDG PET -CT is a useful tool for the diagnosis of infected cardiovascular prosthesis and is more accurate than stand alone CT. Correlation of the clinical, echo and FDG PET CT findings is crucial for the therapeutic decision.

The study sought to determine the 6-month clinical outcome of patients who underwent implantation of very long coronary stents to treat diffuse disease and/or long dissections and to compare the findings with those reported in the literature for patients who underwent implantation of multiple short coronary stents.New designs of flexible stents enable the implantation of long stents rather than multiple short, older design stents. The initial experience is very promising but the long-term outcome has not been described yet.Fifty-seven consecutive patients in whom 67 long stents (/=30 mm) were successfully deployed were included in this study. Six-month clinical and angiographic follow-up was prospectively collected. Patients with recurrent angina underwent coronary angiography without further testing. Patients who remained asymptomatic at the 6-month follow-up visit underwent positron emission tomographic imaging, and those with results suggestive of ischemia underwent coronary angiography. A combined study end point was defined as death, myocardial infarction, and the need for target vessel revascularization.Only 1 patient (2%) reached a study end point at hospital discharge. An additional 20 patients (total 21 patients [37%]) reached an end point by 6 months. The outcome was not influenced by the clinical presentation (stable or unstable angina) or by the indication for stenting (elective or emergency). Predictors for adverse outcome were multiple stents per narrowing (63% vs 29%, P. 04), and stents smaller than 3.5 mm (49% vs 22%). Narrowing and stent length were not predictive of a study end point in narrowings that were successfully treated by a single long stent.Elective stenting provides an effective solution for patients with diffuse coronary disease provided that a single long stent (usually40 mm) can cover the full length of the narrowing. The results are better when vessels larger than 3 mm are treated. Compared with multiple short stents, implantation of a single long stent is probably at least as effective, and the procedure is quicker and cheaper and thus should be the preferred approach.

Background the association of severe aortic stenosis and mitral regurgitation (MR) is not rare in patients undergoing transcatheter aortic valve implantation (TAVI). The effect of TAVI on MR and its impact on outcome was evaluated. Methods All patients undergoing TAVI in our center were evaluated. Patients with paravalvular leak or residual stenosis after TAVI were excluded. Ninety out of 166 patients undergoing TAVI had follow-up data on post-procedural MR and constituted the patient population. Mitral regurgitation was graded on a 0-4 scale and divided into two categories for survival analysis, minimal (none/mild MR [grade 0-1/4]) and significant MR (moderate /severe MR [grade 2-4/4]). Patients were followed for a median of 427 days for death and development of heart failure (HF). Results Average age was 81±6; 49% were male and the average Euroscore was 22±15. Mitral regurgitation before TAVI was minimal in 52 pts (58%) and significant in 38 pts (42%). Post TAVI, MR was minimal in 56 pts (62%) and significant in 34 pts (38%). Sixteen pts (18%)developed worsening MR with an increase of at least one MR grade post TAVI, 25 pts (28%) has an improvement in the MR (MR grade was less) and 49 pts (54%) no change occurred in the MR. Development of significant MR post successful TAVI was a strong predictor of the development of HF (49±9% vs 70±6%, respectively, p=0.02) as well as the combined end point of death and HF (event free survival 46%±9% versus 64%±7%). Conclusions MR post TAVI without aortic regurgitation or residual stenosis is a commmon issue and predicts the developemnt of HF and death.

Objectives. We sought to compare the angiographic outcome of diabetic patients (treated with insulin or oral hypoglycemic agents) after successful coronary angioplasty with that in nondiabetic patients. The analysis included the outcome of the dilated (restenosis) and nondilated narrowings (disease progression). Background. Recent data have confirmed that diabetes mellitus is an important risk factor for long-term adverse events. These adverse events are more common after balloon angioplasty than after bypass surgery (Bypass Angioplasty Revascularization Investigation [BARI]). Methods. We examined retrospectively 353 coronary angiograms of 248 patients (55 diabetic, 193 nondiabetic) who were referred for diagnostic angiography >1 month after successful angioplasty (1.4 ± 0.6 [mean ± SD] repeat angiograms/patient). Restenosis and disease progression/regression were compared between groups by means of quantitative angiography. Results. Baseline clinical and angiographic characteristics were similar in both groups. There was a nonsignificant trend for a higher restenosis rate of dilated narrowings in diabetic patients. There were no significant changes between diabetic and nondiabetic patients in the rates of progression and regression of narrowings that were not dilated during the initial angioplasty. The main difference was in the rate of appearance of new narrowings: There was a 22% increase in the number of narrowings on the follow-up angiogram in diabetic patients (38 new, 174 preexisting narrowings) compared with 12% (86 new, 734 preexisting narrowings) in nondiabetic patients (p Conclusions. The combination of diabetes mellitus and an artery that was instrumented during balloon angioplasty is additive and increases the risk of formation of new narrowing in that artery. This finding may explain the high adverse event rates observed in diabetic patients in the angioplasty arm of the BARI study, most of whom had angioplasty performed in at least two arteries.

We investigated the diameter of epicardial coronary arteries in 12 patients (ten men) with dilated cardiomyopathy, and compared to 21 normal persons (14 men). Dilated cardiomyopathy patients were younger than controls with no difference in height, weight and body surface area. Ejection fraction was lower in dilated cardiomyopathy compared to normals (31+/-10% and 73+/-7%, respectively, P0.001). Left ventricular mass was significantly larger (P=0.04). The sum of diameters of the proximal left anterior descending, circumflex and right coronary arteries (Total Coronary Diameter) in the dilated cardiomyopathy and controls was 13.4+/-2.7 and 10.5+/-1.5 mm (P0.001). Absolute diameters of the left main, left anterior descending, circumflex, proximal right coronary artery and the right ventricular branch in dilated cardiomyopathy were also significantly larger as was Total Coronary Diameter adjusted for body surface area. Total Coronary Diameter adjusted for left ventricular mass, was significantly smaller (103.42+/-30.38, 146.00+/-41.59 mm/mg, respectively, P0.03). Specific arteries in the dilated cardiomyopathy adjusted for left ventricular mass were significantly smaller, or had a tendency for smaller diameter compared to normals. There was no correlation between age and coronary diameter in each group. After adjusting for left ventricular mass there was no difference in coronary artery diameter between men and women. Thus, coronary arteries of patients with dilated cardiomyopathy have increased absolute diameter compared to normals, but decreased diameter when adjusted for left ventricular mass. This may contribute to patients' complaints and to the natural history of the disease.

Acute myocardial infarction occurs when a ruptured coronary artery plaque causes sudden thrombotic occlusion of a coronary artery and cessation of coronary artery blood flow. This paper reviews the underlying coronary pathology in progressive coronary atherosclerosis, mechanisms of plaque rupture and arterial occlusion and the time relationship between coronary occlusion and myocardial necrosis. Reperfusion can be achieved by chemical thrombolysis with different thrombolytic agents. Early lysis is achieved best by prehospital administration, a transtelephonic monitor, a mobile intensive care unit, active general practitioner treatment or by warning the emergency room of impending arrival of a patient. Thrombolytic therapy may be unsuccessful and not achieve Grade III TIMI flow in less than 4 h (or even 2 h) due to inadequate or intermittent perfusion or reocclusion. Adjuvant therapy includes aspirin and platelet receptor antagonists. Bleeding is a constant danger. Direct percutaneous transluminal coronary angioplasty (PTCA) may be as effective or better than chemical thrombolysis. Reperfusion protects the myocardium and salvages viable tissue. It also improves mechanical remodelling of the ventricle. Long-term follow-up has shown that quantum leaps of fresh coronary occlusion causes step-wise progression in patient disability and that further early, prompt reperfusion can salvage myocardium and prevent this inexorable progress of the disease.

PURPOSE: The aim of this study was to determine the proportion of patients with acute myocardial infarction (AMI) excluded from thrombolytic therapy on a national basis and to evaluate the prognosis of these patients by reasons of ineligibility and according to the alternative therapies that they received during hospitalization. PATIENTS AND METHODS: During a national survey, 1,014 consecutive patients with AMI were hospitalized in all the 25 coronary care units operating in Israel. RESULTS: Three hundred and eighty-three patients (38%) were treated with a thrombolytic agent and included in the GUSTO study. Ineligible patients for GUSTO were treated: (1) without any reperfusion therapy (n = 449), (2) by mechanical revascularization (n = 97), or (3) given 1.5 million units of streptokinase (n = 85) outside of the GUSTO protocol. The in-hospital and 1-year post-discharge mortality rates were 6% and 2% in patients included in the GUSTO study; 6% and 5% in those mechanically reperfused; 15% and 10% in those treated with thromoblysis despite ineligibility for the GUSTO trial, and 15% and 13% among patients not treated with any reperfusion therapy. CONCLUSIONS: Ineligibility for thrombolysis among patients with AMI remains high. Patients ineligible for thrombolysis according to the GUSTO criteria, but nevertheless treated with a thrombolytic agent were exposed to an increased risk.

This study examines the effect of coronary angioplasty on the progression and appearance of new disease in sites of the coronary tree that were not dilated by the balloon. We examined 355 pairs of coronary angiograms from 252 patients. The study consisted of consecutive patients who were referred for catheterization1 month after successful angioplasty. Progression/regression and the appearance of new narrowings at sites not dilated by angioplasty were determined. The life-table method was used to determine outcome, and any event (progression, regression, and new narrowing) was analyzed according to the time of occurrence. The angioplasty artery was compared with the non-angioplasty artery and the effect of restenosis was determined by comparing arteries with and without restenosis. Progression/regression rates were not significantly different in angioplasty and non-angioplasty arteries. More new narrowings were identified in the angioplasty artery (p0.01). With regard to narrowings located in the angioplasty artery, progression was more common, regression less common, and the appearance of new narrowings more common in arteries with restenosis than in non-angioplasty arteries or arteries without restenosis. We believe that mechanical trauma to the artery during angioplasty could accelerate disease progression and the appearance of new narrowings in angioplasty arteries, whereas normalization of flow rate and pattern, especially in arteries without restenosis, attenuates the rate of progression and the appearance of new narrowings in these arteries. The final outcome depends on the balance between these factors.

The angiographic appearance of the coronary arteries were examined in 302 patients with stable angina pectoris and compared to 308 patients with acute myocardial infarction, who received high-dose intravenous thrombolytic therapy, in order to elucidate the underlying angiopathological picture in the two diseases. In each group coronary lesions were present in proximal segments of the arteries and were closely related to bifurcations. Lesions were more extensively distributed in the coronary tree in patients with stable angina and they had an average of 5.4 lesions per patient, compared to the acute myocardial infarction group who had only 2.4 lesions. Also, in the acute myocardial infarction patients, four-fifths of the culprit arteries were patent, 104 (34%) had a ruptured plaque, 22 (7%) had an ulcerated plaque and in 190 (62%) the lesions were eccentric. The study shows that patients with myocardial infarction who are suitable for thrombolysis have a unique coronary angiographic picture and the acute episode is caused by sudden rupture of a localized atheromatous plaque which initiates an obstructive thrombotic cascade.

To compare the long-term prognosis of a group of patients treated by an early invasive approach after a non-Q-wave anterior wall acute myocardial infarction (AMI) with a similar group treated conservatively, data from 110 consecutive patients with non-Q-wave AMI were retrospectively obtained from 3 different hospitals: (1) a hospital with coronary angioplasty and coronary bypass facilities favoring on early invasive approach, (2) a hospital with a catheterization laboratory and no coronary angioplasty or coronary bypass facilities, and (3) a community hospital without a catheterization laboratory. Patients were divided according to the presence or absence of an early invasive approach: those who had undergone in-hospital catheterization and revascularization (n = 55) and those with a conservative approach (n = 55). The early invasive approach resulted in a significant decrease in major events. The rate of recurrent myocardial infarction was 29% in the conservative group versus 7.2% in the invasive group (p = 0.025). Survival rate curves at 3-year follow-up showed significant differences in mortality (p = 0.001), recurrent myocardial infarction (p = 0.002), recurrent angina pectoris (p = 0.001), and development of congestive heart failure (p = 0.05). Multivariate analysis disclosed the early invasive approach to be an independent predictor for decreasing the likelihood of recurrent infarction by 86% (odds ratio 0.14, confidence intervals 0.04 to 0.48, p = 0.0006), and for decreasing the likelihood of recurrent angina by 66% (odds ratio 0.34, confidence intervals 0.18 to 0.63, p0.005). The early invasive strategy may result in an improved outcome in the treatment of patients with non-Q-wave anterior wall AMI compared with patients treated conservatively.

Many patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) have mitral regurgitation (MR). It is suggested that MR affects echocardiographic and clinical outcomes. High risk or inoperable patients who underwent balloon or self-expanding TAVR for AS at two

The combination of diagnostic angiography and angioplasty as a single procedure is becoming common practice in many institutions, but the feasibility and safety of this strategy have not been reported. This report describes 2,069 patients who underwent coronary angioplasty over a 3-year period at an institution where combined angiography and angioplasty is the norm. All patients were prepared before angiography for potential immediate angioplasty. In 1,719 patients, angioplasty was performed immediately after the diagnostic angiogram, while separate procedures were performed in 350 patients. Of those 350 patients, 254 were referred for angioplasty after diagnostic angiography at other hospitals. One thousand one hundred ninety-seven patients were admitted electively for treatment of stable angina pectoris, and 872 underwent procedures during hospitalization for unstable angina or acute myocardial infarction. One thousand nine hundred seven patients (92.2%) had successful angioplasties; in 130 patients (6.3%) the lesion could not be dilated, but no complication occurred, and in 32 patients (1.5%) angioplasty ended with a major complication (0.8% death, 1.0% Q-wave myocardial infarction, 0.5% emergency coronary artery bypass surgery). There was no difference between the combined and staged groups with regard to success, major and minor complication rates or in length of hospitalization after angioplasty. We conclude that routine combined strategy for angiography and angioplasty is feasible, safe, easier for the patient, and more cost-effective than 2 separate procedures.

A national study was performed in early 1992 in the 25 operating coronary care units in Israel, which enabled the assessment of whether the therapeutic management of patients with acute myocardial infarction was affected by patient gender. During a 2-month period, 1,014 consecutive patients with acute myocardial infarction were hospitalized. Thrombolytic therapy was given to 47% of men (362 of 769), and 43% of women (106 of 245) (p = NS). After adjustment for age, no gender differences in the administration of thrombolytic therapy were noted (odds ratio 0.95; 95% confidence interval 0.73–1.23). Coronary angiography was more frequently performed in men (22%) than in women (16%) (p

The angiographic appearance of the coronary arteries was examined in 308 patients with acute myocardial infarction (AMI) who received highdose intravenous thrombolytic therapy. Coronary angiography was performed on day 7 after admission to the hospital. Patients had an average of 2.4 discrete arterial narrowings or obstructions. The narrowings were proximal and related to bifurcations. Four fifths of the culprit arteries were patent; 104 (34%) had a ruptured plaque, 22 (7%) had an ulcerated plaque, and in 190 (62%) the lesions were eccentric. Patients differed from a comparable, previously studied, control series of 302 patients with chronic stable angina pectoris who had more extensive disease. They had 5.7 narrowings/patient, also located proximally and at bifurcations, but more widely distributed in the coronary tree. Patients with AMI who are suitable for thrombolysis have a unique coronary angiographic picture. The data confirm that AMI is caused by sudden rupture of a localized atheromatous plaque that initiates an obstructive thrombotic cascade.

Conduction disturbances after coronary artery bypass grafting may result from compromised septal blood flow. To examine this hypothesis we reviewed the preoperative coronary angiography of 55 consecutive patients undergoing coronary artery bypass grafting. Thirty-five patients had either no lesion or a discrete lesion in the left anterior descending coronary artery that did not include the septal perforator (type I anatomy). Twenty patients had a lesion of the left anterior descending coronary artery at the origin of the first septal branch, a lesion of the first septal artery, or a pair of lesions in the left anterior descending coronary artery that straddled the origin of the first septal artery; all lesions were proximal to the graft site (type II anatomy). None of the patients with type I anatomy had a major conduction disturbance after coronary artery bypass grafting. Eleven of the patients with type II anatomy had major conduction disturbances after coronary artery bypass grafting; right bundle-branch block in 1, right bundle-branch block and left anterior hemiblock in 2, left bundle-branch block in 5, and complete atrioventricular block that required pacemaker implantation in 3 (p less than 0.001). In the 20 patients with type II anatomy, the appearance of conduction disturbances correlated well with the absence of retrograde flow to the septal branches from the right coronary artery (p less than 0.01). Pathological lesions in the left anterior descending coronary artery that compromise flow in the first perforator and that do not provide an adequate circulation produce localized damage and conduction disturbances after coronary artery bypass grafting. This can be predicted from the preoperative angiographic anatomy.

Management of chronic aortic regurgitation remains a challenge. Of many unresolved issues, the major issue remains when to recommend aortic valve replacement.1-3 The syndrome of chronic aortic regurgitation involves both the aortic valve and the myocardium, with complex changes in ultrastructure, geometry, and function of the left ventricle. The latter changes determine the natural history and outcome after valve surgery, and it is these changes, therefore, that need careful assessmenk4 The literature contains numerous reports on approaches using preoperative assessment by clinical, ECG, and chest x-ray examination, cardiac catheterization, and nuclear and echocardiographic techniques to predict outcome after aortic valve replacemenL5-I3 While virtually all of the proposed criteria are of some value, no single criterion is sufficient or reliable. Nuclear magnetic resonance (NMR) imaging is the newest of the noninvasive methods and has the potential to contribute substantially to the evaluation of aortic regurgitation. The technology cari evaluate morphology, function, flow dynamics, and metabolism.‘4’15 Some of the information derived from NMR studies might be acquired using a variety of the less costly approaches. However, because of its unique properties, NMR may provide superior information and offer new insights into the disease complex. There are many excellent papers that review the physical basis and technical aspects of NMR imaging.16’17 While many naturally occurring elements (sodium, phosphorous, hydrogen, fluorine, and others) have nuclei that exhibit nuclear magnetic resonance, it is the hydrogen nucleus, or the proton, that provides the basis for highresolution imaging approaches. Both the proton and the nuclei of several other elements have the potential to provide metabolic information that ultimately may have some potential to characterize the status of the myocardium in aortic regurgitation. Such approaches are presently under development and early investigation.l’, I9

Balloon aortic valvuloplasty (BAV) first introduced by Cribier in 1985 [1] promptly enlarges the aortic valve orifice, reduces the transvalvular gradient and alleviates symptoms. The early interest in BAV declined quickly mainly because its immediate hemodynamic and symptomatic gains are not durable. Transcatheter Aortic Valve Implantation (TAVI) provides a more durable alternative to patients with severe AS and poor surgical candidacy. BAV became an integral initial part of TAVI. BAV is also associated with procedural complications and is thus reserved for the extremely sick and frail patients [2]. Serious adverse events were reported in 16%, with very poor long term survival and mortality up to 50% within six months of follow-up [3]. Procedural mortality rate range from 1% to 3% [4] and severe aortic insufficiency has ranged from 1% to 2% [5,6]. The present case series describes the incidence of acute aortic regurgitation (AR) and its clinical presentation and discusses the diagnostic and therapeutic modalities. We reviewed our database of all consecutive patients who underwent BAV as an isolated procedure or as an initial step in TAVI during a five year period (January 2008 to January 2013), for the occurrence of acute procedural AR manifested as hemodynamic collapse immediately after BAV. Hemodynamic collapse was defined as acute deterioration of blood pressure that warranted prompt cardiopulmonary resuscitation. The clinical records and all preprocedural and procedural imaging studies were thoroughly reviewed, searching for predicting factors as well as for diagnostic and therapeutic clues. There were 219 consecutive patients that underwent BAV as part of TAVI (n = 152) or BAV as an isolated procedure (n = 67). There was no difference in age or co-existent morbidities between the two groups, but the BAV suffered from higher rate of LV dysfunction (83% vs. 68%) and all its patients were in NYHA class III or IV. Three patients that suffered immediate hemodynamic collapse following BAV were detected and in all of them, acute AR was the presumed diagnosis. In all three cases BAV was performed as part of TAVI. The procedure was performed under conscious sedation with rapid ventricular pacing (180–200 bpm) via a temporary lead placed in right ventricle. In all three cases BAV was performed by transfemoral artery approach, with an 18 Fr sheath already in place. A major support to the diagnosis in all cases was the floating of the pigtail catheter between the aorta and the left ventricle following BAV (Fig. 1). All three patients underwent resuscitation with intubation, mechanical ventilation, cardiac massage and inotropes followed by prompt valve deployment which resulted in immediate recovery and no mortality at 30 days (Table 1). The differential diagnosis of acute hemodynamic deterioration in a patient undergoing BAV includes in addition to acute AR, bleeding to the pericardium and tamponade due to either the stiff wire in the left International Journal of Cardiology 171 (2014) 88–100

Microphthalmia transcription factor (MITF) is critical in differentiation and proliferation of several cell types, including neural crest and mast cells. We have previously shown that MITF is expressed in the adult heart, with a prominent role in hypertrophy and stress response. We grew, defined and

Objectives The study determines whether treatment of coronary disease by percutaneous coronary intervention (PCI) in the presence of severe aortic stenosis (AS) is feasible and defines which patients might benefit most. Background Severe symptomatic AS is considered a class I indication for aortic valve replacement (AVR). Many patients with AS have concomitant coronary artery disease (CAD), and the true reason for symptoms is often unclear. It is common practice to combine AVR with coronary artery bypass grafting. However, in some cases PCI alone might improve symptoms and allow surgery to be deferred. Methods We analyzed 38 consecutive patients who underwent PCI for CAD in the presence of significant AS between 1989 and 2004. Data included demographic factors, clinical features, angiographic, and echocardiographic information. Events during follow-up included PCI complications, improvement post-PCI, AVR, and death. Statistical analysis was used to assess the impact of PCI on outcome and survival. Results The mean age of the study group was 71 ± 9.3 years, and the mean aortic valve area was 0.84 ± 0.28 (0.4–1.2) cm 2 . Reasons for choosing PCI over surgery were patients' preference, high surgical risk, and cardiologist recommendation. Thirty-five patients (92.1%) reported symptomatic improvement after PCI, and no major PCI-related complications were recorded. Significant predictors for long-term event-free survival were good functional class ( P = .006) and single-vessel coronary disease ( P = .017). Conclusion PCI in patients with severe AS and significant CAD is safe, offers relief of symptoms in most cases, and has good long-term outcome in a subset of patients who have mild CAD and good functional class. This therapeutic approach should be considered in such patients and in those with high surgical risk.

C oronary stents were introduced in an attempt to overcome 2 main limitations of balloon angioplasty: acute occlusion and restenosis. Numerous reports showed that different stent designs are useful.1-3 The main problem of currently available metallic stents is the tendency for thrombotic occlusion. This is a serious complication that can cause acute myocardial infarction and death.4 Chronic anticoagulation decreases the occlusion rate but causes complications at the puncture site and increases the length of hospitalization and cost of the procedure.5 Recent abstracts have suggested that anticoagulation might not be necessary when stents are deployed with high-pressure balloon inflation with or without intravascular ultrasound proof of optimal deployment.6,7 This report will describe our initial experience with PalmazSchatz stents with emphasis on the risk of thrombotic occlusion. . . . Coronary stents were successfully deployed in 50 of 52 patients (96%). In the 2 patients in whom the stent was not deployed, the procedure was successfully completed with balloon dilatation. The mean age was 60 + 11 years, most patients (45) were men, and the indication for cardiac catheterization was stable angina in 29 and unstable or postmyocardial infarction angina in 21 patients. Twenty-seven stents were implanted to overcome acute closure or severe dissection that would have otherwise required emergency bypass surgery, 14 were implanted in lesions with previous restenosis, and in 11 patients stents were implanted electively as the initial therapy (mainly in saphenous vein grafts). Thirty-nine stents were implanted in native coronary vessels and 13 in saphenous vein grafts. Stents were deployed after target lesion predilatation using a balloon that matched the size of the normal artery. Stents were manually crimped on a balloon (usually 0.5 mm larger than the original balloon) and were deployed using 30-second inflation to 6 to 8 atm. Patients were treated with intravenous dextran for 24 hours and a combination of aspirin and dipyridamole. Treatment with warfarin was begun on the day of the procedure and was continued for 3 months, with a target international normalized ratio of 3 to 4. Heparin infusion was maintained with a target partial thromboplastin time of 80 to 100 seconds for >5 days, and for 1 day after target prothrombin level was achieved. Sheaths were removed from the femoral artery the morning after the