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Routine aspiration thrombectomy (AT) in percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI) has not proved effective in randomized trials. However, in patients undergoing primary percutaneous coronary intervention with severely reduced flow or visible thrombus, AT remains an intuitively attractive option. The use of adjunctive AT in a high-risk cohort of 158 consecutive patients with STEMI and Thrombolysis In Myocardial Infarction (TIMI) 0 to 1 flow or visible thrombus on baseline angiography was examined. Of these, 80 patients underwent AT as an adjunct to primary percutaneous coronary intervention, and 78 underwent percutaneous coronary intervention without AT (non-AT). TIMI 3 flow rates, residual thrombus after percutaneous coronary intervention, and major adverse cardiac events (mortality and nonfatal Q-wave myocardial infarction) at 30 days, 6 months, and 1 year were compared. Baseline characteristics were similar between groups. The AT group more frequently achieved TIMI 3 flow after the intervention (91.3% AT vs 67.9% non-AT; p <0.001) and had less residual thrombus (7.5% AT vs 19.2% non-AT; p = 0.03). AT was associated with reduced major adverse cardiac events at 6 months (6.8% AT vs 24.0% non-AT; p = 0.004) and 1 year (16.6% AT vs 29.2% non-AT; p = 0.009), and decreased mortality rates in the AT group at 6 months (5.4% AT vs 21.3% non-AT; p = 0.004) and 1 year (7.7% AT vs 26.2% non-AT; p = 0.005). In conclusion, for patients with STEMI and TIMI 0 or 1 flow or visible thrombus on baseline angiography, AT was associated with increased TIMI 3 flow rates, decreased residual thrombus, and decreased clinical events, including mortality.

Half the patients who survive ST-segment elevation anterior myocardial infarction continue to have ST elevation (STE) 6 months after the event. The mechanism for this and its clinical significance are unclear. There are data to suggest that larger infarcts are more likely to have persistent changes in the ST segment. This study is designed to test this association further using a novel means of assessing the presence and magnitude of myocardial scar using cardiac magnetic resonance imaging (MRI). Delayed imaging by MRI after injection of gadolinium is commonly used to detect myocardial scar through the appearance of delayed contrast hyperenhancement. Consecutive patients referred for myocardial viability imaging were reviewed. The volume of scar as a percentage of anterior wall volume was calculated, and the 26 patients with scar involving >or=10% of the anterior wall were selected for inclusion. All had an electrocardiogram recorded within 15 days of MRI, and none had an intervening cardiac event. Observers unaware of MRI findings independently measured ST-segment changes. Nine patients had STE >1 mm and 17 did not. Mean anterior scar volume in the group without STE was 31.9 +/- 17.1% of the anterior wall volume compared with 50.3 +/- 15.9% in the group with STE >1 mm (p = 0.01). The larger the myocardial scar, the more likely STE was to be present. Only 1 of 10 patients (10%) with scar in the anterior wall <30% had such an elevation compared with 3 of 9 (33%) with scar size of 30% to 49% and 5 of 7 (78%) with scars >or=50%. In conclusion, persistent anterior STE is associated with the size of myocardial scar detected using MRI.

Coronary perforation is a particularly feared complication of percutaneous coronary intervention. The optimal management and predictors of adverse outcomes for these patients remain to be defined. Advances in management such as the use of polytetrafluoroethylene-covered stents have not been critically examined in terms of efficacy. We analyzed a cohort of patients who sustained coronary perforation during percutaneous coronary intervention at our institution during a 9-year period to examine the trends in incidence, management, and outcomes. The patient medical records were reviewed, and detailed angiographic analysis was undertaken to identify the predictors of adverse outcomes, including the development of tamponade, the requirement for emergency coronary artery bypass grafting, and in-hospital death. One year of follow-up was attempted for all patients. Seventy-two cases of coronary perforation were identified, with an overall incidence of 0.19%. The perforation grade and presence of chronic renal insufficiency were the only predictors of mortality on multivariate regression analysis. The use of polytetrafluoroethylene-covered stents to manage perforations was not associated with any reduction in adverse outcomes, such as the development of tamponade, the need for emergency coronary artery bypass grafting, or in-hospital death. In conclusion, coronary perforation remains a feared complication in the contemporary interventional era with significant in-hospital mortality. Emphasis should be placed on preventing this complication whenever possible, including exercising particular caution in patients with chronic renal insufficiency. The treatment of such patients should be tailored to the severity of the perforation. The optimal treatment of these patients needs to be defined, and the efficacy of covered stents needs to be studied prospectively.

We have analyzed the incidence, management, and outcome of 84 cases of coronary artery perforation in patients who underwent percutaneous coronary intervention at our institution. This complication was more frequent in female patients and in patients who underwent lesion modification with atheroablative devices. A total of 8 patients (9.5%) died after the procedure. They were usually older and had a higher incidence of cardiac tamponade; a larger percentage of these patients underwent emergency surgery than those who survived.

Transesophageal echocardiographic findings and their effect on disease management were evaluated in 216 patients with suspected cardiovascular source of emboli. Clinical and transesophageal echocardiographic findings were useful in defining pretest probability for finding a probable cardiovascular source of emboli on transesophageal echocardiography.

Preangioplasty intravascular ultrasound in 81 patients showed that adaptive remodeling occurred in 35% and constrictive remodeling in 34%. Multivariate analysis showed that smoking and fibrocalcific plaques were associated with constrictive remodeling, whereas small vessel size and hypercholesterolemia were associated with adaptive remodeling.

The clinical and treatment characteristics of 71 patients who had acute myocardial infarction complicated by ventricular septal rupture were assessed retrospectively. A history of hypertension was strongly associated with "early" septal rupture (p < 0.001); other clinical and treatment characteristics, including the use and timing of thrombolytic therapy, were not.

A multicenter study was performed to compare the diagnostic accuracy of a new technique, seismocardiography, with that of electrocardiography for physiologically and anatomically significant ischemic coronary artery disease (CAD) during exercise stress testing. Five participating centers enrolled 129 patients who had simultaneous seismocardiograms and 12-lead electrocardiograms at the time of their exercise treadmill stress tests. Two different definitions of CAD were used: anatomic and physiologically significant disease. The presence of anatomically significant CAD (> or = 50% diameter stenosis) was documented by coronary angiography. Physiologically significant CAD was defined as present in the same 129 patients when coronary arteriography (> or = 50% diameter stenosis) and thallium-201 scintigraphy (defect on initial postexercise images) were both abnormal. Seismocardiography had a significantly better sensitivity for detecting anatomic CAD than did electrocardiography (73 vs 48%; p < 0.001), without loss of specificity (78 vs 80%; p = NS). Exercise seismocardiography added significant incremental diagnostic information beyond that provided by exercise electrocardiography. Seismocardiography was more sensitive (without less specificity) in women and in patients who did not achieve maximal predicted heart rate. In patients with physiologically significant CAD, the seismocardiogram was also significantly more sensitive (78%) than was the electrocardiogram (55%) (p < 0.02), without loss of specificity (84 vs 74%). Seismocardiography significantly improved sensitivity for the detection of anatomic and physiologic CAD. It is easy to perform and may be a clinically useful adjunct in exercise stress testing.

Left ventricular (LV) filling patterns in 26 elderly (mean age 81 years) patients with severe aortic stenosis (AS) were evaluated using pulsed-wave Doppler echocardiography. Parameters of LV filling, including the ratio of the peak atrial velocity to the peak early diastolic velocity (A/E ratio) and the percent contribution of active atrial filling to total LV filling (%A), of these patients with AS (group I) were compared with 2 groups presumed to have abnormal LV filling: elderly patients (group II) and hypertensives with increased LV mass (group III), as well as with normal volunteers (group IV). The patients with AS had a broad range of LV inflow velocity patterns (A/E = 0.91 +/- 0.56, range 0.20 to 1.91; %A = 34.3 +/- 16.4, range 3.0 to 65), as compared with the consistently low A/E ratio (0.48 +/- 0.13) and %A (25 +/- 7) in the normal volunteers and the high A/E ratio and %A in the elderly (A/E = 1.48 +/- 0.28, %A = 49 +/- 11) and hypertensive (A/E = 1.41 +/- 0.32, %A = 49 +/- 8) groups. When comparing the data obtained by Doppler with hemodynamics at catheterization, the patients with AS and a high A/E ratio (A/E ratio greater than 1, n = 11) had lower LV mid-diastolic pressures (7 vs 18 mm Hg, p less than 0.001), lower pulmonary artery systolic pressures (33 vs 49 mm Hg, p less than 0.05) and less symptomatic heart failure than those patients with AS and a low A/E ratio (A/E less than 1). The aortic valve area was similar in these 2 subgroups (0.40 vs 0.37 cm2).(ABSTRACT TRUNCATED AT 250 WORDS)

The ability of heart rate (HR) correction of exercise-induced ST-segment depression (the delta ST/HR index) to reduce the number of false positive exercise electrocardiograms during initial screening for occult coronary artery disease (CAD) was examined in active, asymptomatic men from the Army Reserve. Among 606 consecutive men given treadmill tests, 62 asymptomatic subjects with normal results on resting electrocardiograms but abnormal outcomes on standard exercise electrocardiograms underwent rest and exercise radionuclide cineangiography, and the 10 subjects with abnormal radionuclide findings then underwent coronary angiography. A previously established delta ST/HR index less than 1.6 microV/beat/min correctly identified 34 of 52 subjects (65%) who, despite abnormal standard exercise electrocardiographic findings, had no rest or exercise radionuclide abnormalities. A delta ST/HR index greater than or equal to 1.6 microV/beta/min detected 7 of 7 subjects with abnormal radionuclide cineangiograms who had CAD at cardiac catheterization, but also identified 2 of 3 subjects with an abnormal radionuclide test who had no CAD. In contrast to the 7 of 62 subjects (11%) with abnormal standard exercise test criteria who had radionuclide and angiographic evidence of CAD, a delta ST/HR index partition of 1.6 microV/beat/min separated subjects into subgroups with 0% (0 of 35) vs 26% (7 of 27) prevalences of CAD by serial diagnostic evaluation (p less than 0.01). Thus, among asymptomatic subjects with abnormal electrocardiographic responses to exercise, simple HR correction of the magnitude of ST-segment depression reduced by 56% the number of subjects with standard exercise test criteria leading to referral for additional diagnostic evaluation, without loss of sensitivity for angiographically proven CAD and with accurate negative predictive value.(ABSTRACT TRUNCATED AT 250 WORDS)

The initial results of percutaneous transluminal coronary angioplasty (PTCA) in this institution were described previously and were comparable with national statistics despite the comparatively small number of cases performed by individual physicians. Two years later, the number and complexity of cases have increased significantly. In the present study, the experience of 3 physicians (group 1) who performed greater than 100 PTCAs (143 +/- 35, mean +/- standard deviation) was compared with that of 14 physicians (group 2) who performed less than 100 PTCAs (25 +/- 16) during a recent 12-month period. Group 1 and group 2 performed 430 and 351 PTCAs, with a 91 and 84% success rate, respectively (p less than 0.01). Group 1 and group 2 attempted dilatation of 595 and 444 narrowings with an 85 and 81% success rate, respectively (p less than 0.025). The differences reflect outcomes with "complex lesions," with which group 1 had a higher success rate than group 2 (81 vs 69%, p less than 0.05) and a lower complication rate (3.1 vs 7.5%, difference not significant). Outcomes with "simple lesions" were similar for the 2 groups (93 vs 90%). As a result, the conclusions of the previous study should be modified. The present data suggest that while low frequency operators can perform PTCA of "simple lesions" with quite satisfactory results in the setting of an institution in which large numbers of PTCAs are performed and in which an expert team is available for support, outcomes with "complex lesions" are likely to be better in more experienced hands.

There are few data evaluating electrocardiographic diagnosis of left ventricular (LV) hypertrophy in the presence of right bundle branch block (BBB). This study assesses the relative value of multiple electrocardiographic variables for detecting LV hypertrophy in patients with right BBB. LV hypertrophy was defined as LV mass greater than or equal to 215 g calculated from the Penn method using standard M-mode echo measurements. Sixty-two patients were evaluated (ages 41 to 94) and 35 had LV hypertrophy. None of the electrocardiographic criteria was sensitive; the best was mean QRS axis less than or equal to -30 degrees (sensitivity) 52%) and excessive negative P terminal force (sensitivity 28%). Several electrocardiographic variables were specific: Sokolow index greater than or equal to 35 mm (100%), RV5 or RV6 greater than or equal to 25 mm (96.3%), RI + SIII greater than or equal to 25 mm (92.6%) and intrinsicoid deflection greater than or equal to 0.05 seconds (88.5%). Conventional electrocardiographic criteria do not reliably detect LV hypertrophy in the presence of right BBB, but several criteria are relatively specific for LV hypertrophy.

This study assesses the effect of dietary supplements with high dose omega-3 fatty acid (N3FA) on the frequency of clinical restenosis during the 6 months after successful percutaneous transluminal coronary angioplasty (PTCA). One hundred ninety-four patients (214 significant coronary narrowings) were randomized after successful PTCA to receive conventional medical therapy or to an identical regimen supplemented by high dose N3FA (4.5 g/day). Enrollment required angina pectoris and successful dilatation of all significant coronary narrowings. The subjects were randomly assigned to either no N3FA (control, n = 99) or N3FA supplementation (n = 95). After a 1-week trial period, 11 (group 2) declined further treatment because of side effects. The remaining 84 subjects (group 1) continued N3FA throughout the 6-month period. Monthly clinical follow-up was obtained in all patients. Ninety-two percent of patients had cardiac testing for evaluation of recurrent ischemia. Except for a greater percentage of women in the group refusing N3FA supplementation (group 2), the 3 groups were similar in demographic data, medical history, dietary habits, history of previous PTCA and angiographic characteristics. Of the 194 subjects, 56 had clinical restenosis (45 by cardiac catheterization, 8 by exercise testing and 3 by symptoms alone [refused further clinical testing]). Reocclusion rates were: group 1 19%, group 2 46%, and control 35%. Analysis both in accordance with the principle of intention to treat and for subjects who actually received N3FA revealed a significant effect of N3FA on preventing clinical restenosis (p less than 0.04 and p = 0.008, respectively). These data suggest that high dose N3FA supplements reduce the clinical restenosis rate after successful PTCA.

A patient with a pheochromocytoma presented with profound hypertension and the clinical syndrome of coronary artery spasm after the initiation of beta blockade therapy. It is postulated that intense unopposed alpha receptor stimulation can precipitate coronary artery spasm in susceptible persons with this tumor.

Acute illness characterized by fever, cough, chest pain and pulmonary infiltrates on chest film is characteristic of patients witb sickle cell anemia and with sickle-C disease. The underlying hemoglobinopathy is usually recognized in the former, but because patients with sickle-C disease as a rule have less severe anemia and fewer, less severe crises their abnormal hemoglobin may not be detected until adolescence or adulthood. Acute pulmonary illness in such patients may therefore present a diagnostic dilemma for the unwary. Two cases are presented to highlight this point. Pulmonary angiographic findings in patients with sickle cell states might add information about the pathogenesis of this disorder since vascular occlusion appears to play a major role. Pulmonary angiograms in the two patients we describe documented the presence of localized abnormalities of perfusion. In one, the presence of filling defects in medium-sized arteries suggests intravascular thromboembolism.

Persistent ST elevation after healing of myocardial infarction (MI) is often cited as an electrocardiographic sign of left ventricular (LV) aneurysm. This sign is rare in patients with coronary artery disease who have normal or only mildly deranged LV function and is most often associated with QRS patterns indicative of large MI, especially anterior wall MI. To determine whether ST elevation identifies a distinctive abnormality of LV function that might be labeled LV aneurysm, global and regional LV function in 12 patients with QRS patterns of anterior MI and ST elevation were compared with that in 12 patients with similar QRS abnormalities but without ST elevation by means of radionuclide ventriculography. All measured parameters of ventricular function were similar in the 2 groups. ST elevation could not be demonstrated to predict a distinctive abnormality that might be labeled LV aneurysm.