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Introduction: Until the development of drug-eluting stents (DES), diffuse in-stent restenosis (ISR) was the main limitation of bare-metal stents in percutaneous coronary intervention (PCI). Among the different treatments available, intracoronary brachytherapy (BT) emerged as one of the most promising, although it was almost abandoned with the increasing use of DES., Objective: To assess the Portuguese experience with 90Sr/90Y beta brachytherapy for the treatment of diffuse ISR regarding long-term (>10 years) major adverse cardiac events (MACE) and angiographic restenosis., Methods: This single-center, retrospective, observational study included 12 consecutive patients treated between January and June 2001, mean age 58.6±9.9 years (range 43-77 years), 11 male. All had chronic stable angina, 75% had dyslipidemia, 58% had hypertension, 50% had peripheral arterial disease, 42% had diabetes and 50% had multivessel disease. Recurrent ISR was present in half of the patients and 11 had normal left ventricular function. After balloon dilatation, BT was performed using an Sr90/Y90 (Novoste Beta-CathTM) beta radiation source. All patients remained under dual antiplatelet therapy until scheduled nine-month follow-up angiography. Patients were followed for the occurrence of death (all-cause and cardiovascular), non-fatal myocardial infarction (MI), revascularization, stent thrombosis and angiographic restenosis. MACE were defined as the combined incidence of cardiac death, MI and urgent target vessel revascularization., Results: In all cases there was both clinical and angiographic success. In a mean follow-up of 10.9±2.5 years, 19 events occurred in seven patients: death in three (25%), only one cardiac (8.3%); ST-elevation MI in one (related to a non-target vessel) (8.3%); and 15 revascularizations in five (42%), of which nine were of the target vessel (mainly in the first two years). There was only one case of probable stent thrombosis. Angiographic restenosis at nine months was 27% (three out of 11 patients), of which two were total occlusions. Ten-year MACE-free survival was 42% (5 patients)., Conclusions: Intracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious, with no late adverse events related to intracoronary radiation., (Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Aims: To characterize a population with stable coronary artery disease (CAD) in an outpatient setting and to evaluate the importance of resting heart rate (HR), a recently recognized prognostic risk factor., Type of Study: A prospective and observational registry of patients with stable CAD followed mainly by cardiologists in private outpatient clinics., Methods: Patients were selected by at least one of the following inclusion criteria: coronary angiography with at least one significant stenosis; positive stress test; previous myocardial infarction; or revascularization by angioplasty or surgery. Demographics, concomitant diseases, HR, blood pressure (BP), presence of angina and medical therapy were all recorded. Data compilation and statistical analysis were performed by a CRO independent of the sponsor and the investigators., Results: Between May and October 2009, 3477 consecutive patients were included by 186 doctors. Mean age was 66.6 +/- 10.1 years and 26.3% were female, 76% had arterial hypertension, 34% diabetes, 47% previous infarction, 42% angioplasty and 25% coronary surgery. Of concomitant diseases, 13% of patients had peripheral vascular disease or erectile dysfunction. Medical therapy included antiplatelet agents (97%), lipid-lowering agents (92%), beta-blockers (72%), ACEIs (54%), nitrates (39%), calcium blockers (36%), ARBs (28%), ivabradine (24%) and trimetazidine (17%). Mean HR was 67 +/- 12 bpm and 67% of patients had HR > 60 bpm. Mean systolic BP was 134 +/- 18 mmHg and mean diastolic BP was 76 +/- 10 mmHg. Angina was present in 31.3% of patients and 53.4% had class II angina. The population with angina was more severe, 74% had HR > 60 bpm and 68% were taking beta-blockers. In patients with angina and HR > 60 bpm, beta-blocker use was only 64%., Conclusion: In an outpatient population with stable CAD of whom a third had angina, there was an increased number of patients with HR > 60 bpm and decreased use of beta-blockers with increasing disease severity. These findings support increased use of newly developed drugs for the treatment of stable CAD and angina.

Background: In previous randomized studies levosimendan improved hemodynamics and clinical course, with a still unclear effect on prognosis. There are, however, few data regarding its effects when used in daily practice., Aims: We evaluated the clinical effectiveness and safety of levosimendan in the treatment of acute systolic heart failure (SHF) in daily practice conditions., Methods: In this prospective, multicenter, nonrandomized trial, a continuous infusion of levosimendan (0.05 microg/kg/min-0.2 microg/kg/min) was administered for 24 hours. An optional loading dose of 12 microg/kg over 10 minutes was used. The primary combined endpoint of clinical effectiveness (as defined by a eight-variable clinical score) and safety (defined by the absence of serious adverse events) was assessed at 24 hours after the beginning of treatment; a second similar primary combined endpoint was assessed at 5 days., Results: One hundred and twenty-nine consecutive patients requiring inotropes despite optimal oral background heart failure therapy were recruited. The primary endpoint was reached in 80.6% at 24 hours and in 79.7% at 5 days. During the six months before levosimendan the number of patient days of hospitalization for heart failure was 14.9 +/- 14.6 versus 3.1 +/- 7.6 during the six months following levosimendan (p < 0.001)., Conclusions: In daily practice, levosimendan was clinically effective and safe in 80.6% and 79.7% of patients with acute SHF at 24 hours and 5 days respectively after the beginning of treatment. A marked reduction in the number of days of hospitalization for heart failure was also seen during the subsequent six months.

Background: Atherothrombotic coronary artery disease is increasingly recognized as part of a systemic metabolic disorder. However, little is known about the significance of metabolic dysfunction in the setting of acute coronary syndrome., Objective: Our aim was to assess the prognostic implications of markers of metabolic dysfunction at hospital admission obesity (BMI > 30), previous history of hypertension, admission glucose > 128 mg/dl, triglycerides > 150 mg/dl, and HDL cholesterol < 40 mg/dl for men, or < 50 mg for women--in patients with non-ST elevation acute coronary syndromes (ACS)., Methods: A total of 303 consecutive patients admitted to the CCU with ACS were included in the study. Mean age was 63 +/- 10 years, and 86% were male. The primary end-point was a composite of death or non-fatal acute myocardial infarction (MI) at one-year follow-up. Each marker was assigned one point, and a metabolic score (MetScore) was calculated for each individual patient by adding together the number of markers present at hospital admission. Three groups were considered: group 1 (MetScore 0) with 0 markers (n = 30); group 2 (MetScore 1 to 3) with 1 to 3 markers (n = 222); and group 3 (MetScore 4 to 5) with 4 to 5 markers (n = 51)., Results: The cumulative incidence of death or MI was 14.5%. We found a statistically significant relation between MetScore and outcome at one-year follow-up. The event rate was 3.3% in the MetScore 0 group, 13.9% in the MetScore 1 to 3 group and 23.5% in the MetScore 4 to 5 group (p = 0.0114). MetScore was an independent predictor of death or MI at one year, with a 2.3-fold risk increase (95% CI: 1.32-4.01; p = 0.003) from one group to the next. Other variables identified as independent predictors of outcome were advanced age, Killip class, ST-segment depression and previous CABG. The incidence of the primary end-point in diabetic patients without significant metabolic dysfunction and non-diabetic patients with SMD was similar (21.2% vs. 22.7%; p = NS)., Conclusion: Assessment of markers of metabolic dysfunction on admission in patients with non-ST elevation acute coronary syndromes, adds important prognostic information to conventional clinical, ECG and risk stratification markers and could prove useful in establishing secondary prevention strategies.

Background: There is disagreement concerning the prognostic value of a prior history of percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation acute coronary syndromes (ACS). This study characterizes these patients and investigates the impact of prior PCI on their prognosis., Methods: 448 consecutive patients admitted due to ACS between 1998 and 2000 were evaluated. Patients with prior PCI were compared to the others with regard to baseline demographic and clinical features. The study endpoint was death or myocardial infarction at one-year follow-up. The impact of prior PCI on the outcome was analyzed. In patients with prior PCI, the prognostic value of the time interval between PCI and current admission was assessed. In those patients who underwent coronary angiography during the index hospitalization, the culprit lesion features were evaluated., Results: 134 patients (30%) with prior PCI were identified. Overall ACS patients had an event rate of 19% at one year. A history of prior PCI was not an independent predictor of outcome, but in the 44 patients with PCI performed during the 117 days before the index hospitalization, the event rate was significantly higher (30% versus 13%). Prior PCI in the previous 117 days was an independent risk predictor (adjusted OR 4.81; 95% CI, 1.57-14.71; p = 0.006). In these patients restenosis was the most frequent culprit lesion (60% versus 30%; p = 0.003)., Conclusions: In ACS patients, a history of PCI in the previous four months is an independent predictor of adverse outcome at one-year follow-up.

Introduction: Patients with coronary heart disease and left ventricular dysfunction are at increased risk for the development of ventricular tachycardia (VT) related to areas of myocardial fibrosis. Although the mechanism and the circuit of this arrhythmia are well understood, little is known about the triggers that precipitate VT episodes. Purkinje fiber potentials may be responsible for idiopathic VT, and recent studies have related them to polymorphic VT and ventricular fibrillation., Methods: Between January 2002 and December 2003, we performed ablation in 10 patients with coronary heart disease, left ventricular systolic dysfunction and VT refractory to pharmacological therapy. All patients had implantable cardioverter-defibrillators. Electroanatomical activation and voltage mapping (CARTO) and electrophysiological criteria (premature activation during VT, pace mapping, and presence of diastolic potentials) were used to define scar regions, slow conduction areas and the reentry circuit isthmuses., Results: Spike potentials were recorded in the scars of three patients. These potentials were almost fused with the ventricular electrogram during sinus rhythm, and were more premature during VT, probably reflecting local activation of Purkinje fibers. During ablation, we were able to dissociate the spike from the ventricular electrogram, thus terminating the VT. In the cases with conduction recovery, ventricular; ectopic beats recurred, preceded by a spike and degenerating into short runs of VT. The ablation strategy was not modified since persistence of the VT required the isthmus., Conclusion: The results suggest that residual Purkinje fibers may be present in scar regions and that the activity of these fibers may trigger VT in pre-established circuits.

Background: The exercise test has a recognized lower risk of complications when used in the general population and in coronary artery diseased patients, but from a theoretical point of view should have a higher rate of complications when performed in patients with chronic heart failure (CHF)., Aims: To characterize and assess the type and incidence of complications during cardiopulmonary stress test (CPX) in patients with depressed left ventricular systolic function in comparison with a group of patients and individuals with normal function., Methods: Retrospective analysis of the 334 consecutive CPX performed for risk stratification in 198 patients with a left ventricular ejection fraction below 40% (Group A) and 180 consecutive CPX performed in 78 subjects with normal function (Group B). The two groups were compared with respect to demographic data, CPX parameters and specific complications., Results: Major complications during the tests occurred only in 14 tests of Group A (4.2%, p = 0.012). Non-sustained ventricular tachycardia, <6 beats, occurred in 7 group A and 2 group B tests. The absence of coronary artery disease was the only independent predictor for complications., Conclusions: Major CPX complications occurred only in patients with impaired left ventricular systolic function. Heart failure patients showed a low probability (around 4%) for complications during CPX, significantly higher and more severe than the risk in the group of patients with normal ventricular function, allowing us to recommend that CPX in patients with heart failure should be performed in a hospital setting under the supervision of a physician with specific training.

Introduction: The LIDO and RUSSLAN trials showed that levosimendan was well tolerated and had a stronger hemodynamic effect than dobutamine and a positive impact on prognosis. There are, however, few data regarding its effectiveness and safety when used in an everyday clinical setting., Objective: To test the hypothesis that in day-to-day practice conditions levosimendan is both effective and safe for the treatment of decompensated heart failure (HF). This primary combined endpoint of effectiveness and safety was evaluated at 24 hours and 5 days after the beginning of the treatment., Design: Prospective, multicenter, nonrandomized clinical trial with evaluations at baseline, 24 hours, 5 days, and 3 and 6 months. Follow-up for 6 months., Setting: The intensive care units of 15 cardiology or internal medicine departments., Patients: 129 consecutive patients requiring inotropes due to decompensated systolic HF despite maximally tolerated oral therapy., Intervention: 24-hour infusion of levosimendan via a central or peripheral vein. MEASUREMENTS AND EVALUATION OF RESULTS: 1. Monitoring: Continuous ECG monitoring, non-invasive blood pressure, urinary output, oximetry. Invasive monitoring was not required. 2. Follow-up. Baseline evaluation: history, physical examination, ECG, 2D echocardiogram, hemogram, ionogram, liver and kidney function. 24-hour and 5-day evaluations: symptoms, physical examination, recording of medical therapy and previous 24-hour urinary output, ECG, hemogram, ionogram, liver and kidney function, and evaluation of arrhythmic episodes and heart rate and blood pressure trends in previous 24 hours. 3- and 6-month evaluations: number of hospital admissions and length of hospital stay due to HF, and mortality. 3. Evaluation of primary endpoint., Effectiveness: assessed by a clinical score including 2 subjective parameters (1. NYHA functional class, 2. patient self-evaluation symptom class) and 6 objective parameters (3. body weight, 4. pulmonary congestion, 5. previous 24-hour diuresis, 6. serum creatinine, 7. oral HF medication, 8. intravenous HF medication). Definition of clinical effectiveness: improvement in > or = 1 subjective parameters plus improvement in > or = 1 objective parameters, with all other parameters unchanged., Safety: The therapy was judged safe in the absence of any serious adverse event with a probable or undetermined causal relationship with levosimendan. Primary endpoint evaluation: Patients reached the primary endpoint when levosimendan was both effective and safe according to the above definitions.

Background: Ablation of typical atrial flutter relies on the suppression of electrical conduction along the cavo-tricuspid isthmus. Bidirectional isthmus block is a criterion of successful ablation and is associated with the presence of different activation times on each side of the ablation line., Objective: The aim of this study was to determine whether the difference in isthmic activation times correlates with the length of the atrial flutter cycle., Population and Methods: We studied 31 patients with typical atrial flutter (93.6% male, mean age 66 +/- 9 years) who underwent successful ablation during tachycardia. CARTO electroanatomic mapping was used to confirm diagnosis of isthmus-dependent atrial flutter, guide the ablation line creation and assess its efficacy. At the end of the procedure, a three-dimensional activation map of the right atrium was constructed, under pacing from the coronary sinus ostium (with a 500 ms cycle). Activation times on the lateral (right) and septal (left) sides of the ablation line were measured. The difference between these two activation times was termed the difference in isthmic activation times (delta IAT), and was compared to the flutter cycle length., Results: Mean activation times were 173.7 +/- 34.3 ms on the lateral border of the ablation line and 19.1 +/- 12.5 ms on the septal border. Mean delta IAT was 154.6 +/- 27.8 ms and mean atrial flutter cycle length was 257.5 +/- 30.6 ms. delta IAT and flutter cycle length were significantly correlated (r = 0.503, p = 0.0039). The linear regression equation that best described this result was: delta IAT = 37 + (0.46 x flutter cycle)., Conclusion: After atrial flutter ablation, a difference in isthmic activation times of more than half the flutter cycle length was associated with isthmus conduction block.

The development of surgical and percutaneous techniques for treatment or palliation of congenital heart disease has prolonged survival in these patients and has increased late complications, particularly arrhythmias. Such arrhythmias are more frequently refractory to medical therapy, requiring percutaneous ablation. We present the clinical case of a 14-year-old child with complex congenital heart disease (double outlet right ventricle) who underwent two corrective surgeries (Rastelli operation and subsequent replacement of the homograft in the conduit connecting the right ventricle to the pulmonary artery; ventricular septal defect closure and tricuspid valve repair). After the second surgery the patient presented with wide complex syncopal tachycardia, refractory to medical therapy. Electrophysiologic study (EPS) identified an isthmus-dependent atrial flutter that was successfully treated by radiofrequency (RF) ablation (a linear block was created along the cavo-tricuspid isthmus). Three months later a new episode of tachycardia occurred, but without syncope. The second EPS revealed an atrial tachycardia originating from the lateral wall of the right atrium, which was treated by ablation with focal application of RF energy. Four months after the last EPS the child remains free of arrhythmic symptoms, under no anti-arrhythmic therapy.

Primary malignant cardiac tumors, particularly lymphoma, are rare entities. Cardiac involvement or metastization of the heart from neoplasia located elsewhere are more frequently found. We present the case of a 79-year-old patient admitted with heart failure symptoms with a 3-week evolution. Evaluation led to the identification of a cardiac tumor with unusual clinical presentation and with a rapid and fatal evolution. Pathologic analysis identified a B-cell non-Hodgkin lymphoma.

Introduction: The growing use of abciximab during coronary angioplasty, with 12 hours of intravenous perfusion, prolongs hospital stay and increases the risk of hemorrhage after sheath removal at the puncture site. Femoral percutaneous closure devices can reduce immobilization time, but their safety in the presence of abciximab in respect to hemorrhage has not been clearly determined., Objectives: To evaluate the safety and efficacy of the Perclose system in patients undergoing angioplasty with abciximab., Population and Methods: The Perclose system was used in 79 patients undergoing angioplasty, with abciximab in 31 patients (58.6 +/- 12.2 years, 90% male, p = NS)--Group 1, and 48 pts without abciximab (61.8 +/- 10.9 years, 79% male, p = NS)--Group 2. We compared heparin dose, sheath diameters, primary success rate, coronary care unit admissions and minor and major complications. One patient was previously anticoagulated with warfarin and all the others were on oral antiplatelet therapy before and after angioplasty., Results: Primary success with the use of the Perclose system was 78%. We found no significant statistical differences between groups in respect to the presence of diabetes, sheath diameter or referral for intervention. Heparin dosage was slightly higher in group 2 (p = 0.09) and ACT was also higher in group 2 (p = 0.01). More patients in group 1 had delayed ambulation (p = 0.04) due to abciximab perfusion. In 7 patients in group 1 and 9 in group 2, additional manual/mechanical compression was needed for moderate bleeding in the first hours (p = NS). One rupture of the femoral artery with need for surgical repair (primary failure) and another delayed rupture (48 hours) occurred in group 1 (both with an associated infection), and 1 pseudoaneurysm in a patient from group 2, without abciximab but taking warfarin (p = NS). None of the variables analyzed determined the occurrence of complications. Only oral anticoagulation determined the occurrence of major complications., Conclusions: User of the Perclose system for percutaneous closure of the femoral artery in patients undergoing coronary angioplasty with simultaneous use of abciximab was not associated with greater morbidity than in patients without glycoprotein IIb/IIIa receptor antagonists.

Background: The association between atrial fibrillation (AF) and mitral valve disease is frequent. Isolation of the pulmonary veins by radiofrequency energy applications performed intraoperatively has been proposed for patients with AF in whom mitral valve surgery has been indicated. Balloon mitral valvuloplasty is currently the preferred procedure for patients with mitral stenosis and a favorable valve anatomy., Aim: To evaluate the short- and long-term results of percutaneous pulmonary vein isolation for the treatment of AF in patients with mitral stenosis undergoing balloon mitral valvuloplasty., Methods: Five patients (four male and one female, age 43 +/- 4 years) underwent balloon mitral valvuloplasty concomitant with pulmonary vein isolation between August 1996 and February 1997. These patients had permanent AF, diagnosed 31 +/- 12 months previously; their mitral valve area was 1.0 +/- 0.25 cm2 and their left atria measured 54 +/- 5 mm. Balloon mitral valvuloplasty was performed via a transseptal approach, and then four ablation lines were created in the left atrial posterior wall to encircle all four pulmonary veins. Radiofrequency applications lasted 45 seconds each, and aimed at a maximum preset temperature of 65 degrees C. Electrical cardioversion was performed at the end of the procedure., Results: Mitral valve area increased 1.0 +/- 0.3 cm2 after valvuloplasty. The number of radiofrequency applications per patient was 37 +/- 3, and the average duration of the entire treatment was 131 +/- 28 minutes. Fluoroscopy time averaged 32 +/- 12 minutes. All patients were discharged in sinus rhythm, and mitral flow Doppler evaluation at one month showed a biphasic pattern in all cases, with the A wave measuring 70 +/- 15 cm/sec. Three patients maintained sinus rhythm at five-year follow-up. Of these patients, one had developed a left atrial flutter at four-year follow-up and underwent ablation. The remaining two patients presented AF at five year follow-up., Conclusions: Percutaneous isolation of the pulmonary veins concomitant with balloon mitral valvuloplasty had suppressed AF in 60% of patients by five-year follow-up.

Unlabelled: Eight patients (pts; 2 female, 58 +/- 12 yrs) with paroxysmal atrial fibrillation (AF) (duration 39 +/- 20 months) underwent AF surgery, with concomitant myocardial revascularization in 2 pts and myomectomy in 1 (HOCM). AF was idiopathic in the remaining 5 pts. AF surgery consisted of bilateral isolation of the pulmonary veins (PV) using radiofrequency (RF) energy applied epicardially by a heptapolar catheter (Thermaline) in 5 pts and by a new system (Atricure) in 3 pts. For the former, each set of 7 simultaneous applications aimed at a maximum duration of 2 + 2 min., preset temperature 80 degrees C and output 150 watts. With the new system, bipolar applications were carried out; energy delivery was controlled by impedance monitoring and applications were ended after abrupt, sustained elevation of impedance. Epicardial bipolar voltage mapping (CARTO) was performed before and after each RF procedure. Using the navigator catheter, points were recorded at the insertion of each PV and at the non-isolated left atrial posterior wall. The amplitude of the local electrograms (LE) was measured before and after RF applications. If the LE amplitude inside the isolated zone was not 0.1 mV and not reduced by > 80%, a second application was performed. A maximum of 2 epicardial applications were carried out in each pt and if the final result was unsatisfactory, further endocardial applications were performed., Results: Baseline LE amplitudes were > 1 mV in all cases. Successful isolation of right PVs was achieved in 7 pts, after one set of applications in 5 and a second set in 2. Left PV isolation required 2 sets of epicardial applications in all pts, being successful in only 2; 4 pts (one with associated myomectomy and 3 with idiopathic AF) received endocardial applications. Overall, bilateral PV isolation was achieved in 5 pts., Conclusions: CARTO bipolar voltage mapping is a fast, simple means for evaluation of epicardial PV isolation.

Objective: There are currently two techniques for percutaneous electrical isolation of the pulmonary veins (PV): anatomical isolation and electrical disconnection. The aim of the present study was to assess the continuity and circumferential extension of the radiofrequency applications necessary for PV electrical disconnection in order to evaluate the differences between this technique and anatomical isolation., Methods: We studied 9 patients with paroxysmal atrial fibrillation who underwent PV electrical disconnection. The electrophysiologic study was performed with a decapolar circular catheter (Lasso) introduced in the PV ostia and a mapping and ablation catheter (CARTO). Ablation was performed following the activation sequence of PV potentials. Using the CARTO system we evaluated the number of applications, their distribution in quadrants, and the maximum distance between contiguous and opposite RF applications. We assessed the number of veins with circumferential applications. The number of applications and maximum distance between contiguous applications were compared to the maximum distance between opposite applications., Result: A total of 26 PV were isolated, including 9 right superior, 5 right inferior, 6 left superior and 6 left inferior. On average more than 10 applications were necessary, with a heterogeneous distribution. In 80.8% of the PVs the maximum distance between contiguous application was less than 1 cm and maximum distance between opposite application were highest in the right superior PV and lowest in the right inferior PV. The applications were circumferential in 80.8% of the disconnections. The number of RF applications was significantly higher in PVs with greater distances between opposite applications (correlation coefficient 0.51; p=0.008). No relation was found between maximum distances in contiguous and opposite applications (correlation coefficient r=0.13; p=NS)., Conclusion: Electrical disconnection was achieved in the great majority of cases with circumferential applications, similarly to anatomical isolation. However, the heterogeneous distribution of the applications implies the existence of areas that need a greater number of applications and that can only be identified during electrophysiologic study. Therefore, rather than two aspects of the same treatment for atrial fibrillation, electrical disconnection and anatomical isolation complement each other in the achievement of effective PV isolation.

Background: Several studies relate cytomegalovirus (CMV) infection to the development of atherosclerosis. Its influence in triggering acute coronary syndromes (ACS) is not known., Objectives: We set out to identify a relationship between CMV infection, occurrence of ACS and prognosis., Methods: Serologic markers (IgM and IgG) for CMV were tested prospectively at admission and at 30 days, in patients (pts) admitted to our CCU for ACS. Serologic markers for CMV were also tested in a group of pts with stable coronary artery disease admitted for elective coronary angiography. A greater than two-fold elevation of IgG titer at 30 days was defined as reactivation/reinfection. At 30 days and six months, the composite endpoint of death, myocardial (re)infarction and re-admission for unstable angina was evaluated., Results: There were 60 pts with ACS in the study group (age 63 +/- 10 years, 75% male) and 31 pts in the control group (age 64 +/- 10 years, 71% male). On admission, 95% of the pts with ACS and 81% in the control group presented a positive IgG (p = 0.029). In the study group, at 30 days, the only pt with a 3-fold titer elevation had an endpoint. The percentage was 17% for the group with a > or = 2- and < 3-fold elevation and 11% in the group without reactivation (p = 0.034). At six months, 50% of the patients with a greater than 2-fold titer elevation and 15% of the remaining patients had an endpoint (p = 0.017). In the control group, at 30 days, 3 pts (10%) had a significant elevation in IgG titer, > or = 2- and < 3-fold, without endpoint., Conclusions: In pts with ACS, we found a higher prevalence of serologic markers for CMV than in pts with stable coronary disease. An elevation in IgG titer for CMV was associated with a worse outcome at 30 days and six months.

Aims: Ectopies from the pulmonary veins may cause paroxysmal atrial fibrillation and their discrete ablation may be curative. In the absence of focal activity during the procedure, identification of target sites with conventional techniques is difficult. We investigated the feasibility of non-contact mapping (EnSite) for identification and successful ablation of pulmonary vein foci in such cases., Methods and Results: We studied 7 patients with idiopathic paroxysmal atrial fibrillation referred for percutaneous ablation and not presenting spontaneous or inducible atrial premature beats during the procedure. An EnSite balloon catheter and an ablation catheter (NaviStar) were placed inside the left atrium. The ablation catheter was also used for electroanatomic mapping (CARTO) of specific sites. Multiphasic pulmonary vein potentials were detected on virtual electrograms and tagged on the non-contact map and confirmed with conventional mapping. The procedural endpoint was elimination or dissociation of the multiphasic potential. Non-contact mapping identified 13 foci of multiphasic potentials in the seven patients (5 foci were initially identified by EnSite), and discrete ablation suppressed 9 of them (69%). Six months later, 4 of the 5 patients in whom all foci were suppressed remain asymptomatic, in sinus rhythm, under no medication., Conclusion: In patients with paroxysmal atrial fibrillation and no ectopic activity during electrophysiological study virtual electrograms may complement conventional techniques in detecting hidden pulmonary vein foci and may be used to evaluate ablation efficacy.

Background: After an acute myocardial infarction, women have a higher risk of death or reinfarction. In unstable angina, female gender seems to be protective. On the other hand, studies suggest that women are less frequently given coronary angiography., Objectives: To evaluate, in our population of patients admitted for non-ST-elevation acute coronary syndrome (ACS), the influence of gender in prognosis and in the use of invasive procedures., Population and Methods: We studied 387 consecutive patients, 20% female, admitted to our ICU for non-ST-segment elevation ACS. We compared demographic and clinical variables, the use of coronary angiography and myocardial revascularization procedures, according to gender. We analyzed the combined endpoint of death or (re)infarction at 30 days and for the total follow-up period of 420 +/- 322 days., Results: The women were older (65 +/- 10 vs. 62 +/- 11 years, p = 0.05), and more frequently had a history of hypertension (p = 0.005), diabetes mellitus (p = 0.07), previous surgical myocardial revascularization (p = 0.048) and higher heart rate on admission (p = 0.048). Smoking was more frequent in men (p < 0.001). The most frequent diagnosis was unstable angina; 76% for women vs. 66% in men (p = 0.12). Coronary angiography was performed during hospitalization in 87%, in both genders. Myocardial revascularization was performed in 62% of the women and 69% of the men (p = 0.26). At 30 days, the frequency of death or (re)infarction was 11% for women and 10% for men (log-rank, p = 0.79). By multivariate analysis (Cox regression), the independent predictors of outcome at 30 days were previous myocardial revascularization and heart failure on admission. For the total follow-up, we did not find differences in the occurrence of the combined endpoint, and the independent predictors of outcome were previous surgical myocardial revascularization, heart failure on admission, ST segment depression on the admission ECG and surgical myocardial revascularization., Conclusions: In non-ST-elevation ACS, women present some differences in their demographic and clinical profile. We did not find differences in the use of invasive procedures or prognosis in the short and medium term.

Background: Comparing the prognostic value of peak oxygen uptake (VO2max) in absolute values and percentage of predicted VO2max (%PredVO2) in terms of prognostic stratification, contradictory references are found in the medical literature. In theory, the measurement of VO2max relative to a normal subject should improve its predictive capacity, because VO2max is influenced by gender, weight, physical activity and age., Objectives: To compare the prognostic value of VO2max and %PredVO2 (Jones equation) in an adult population (> or = 20 years) of patients with left ventricular systolic dysfunction and to study the influence of age on these parameters., Population and Methods: We review data from the first cardiopulmonary stress test performed in 295 consecutive patients with left ventricular systolic dysfunction (ejection fraction < or = 40%); mean age was 52 +/- 10 years, 81% were male, and 76 aged > or = 60 years. In 52%, the etiology was ischemic. We evaluated demographic and clinical variables, the baseline ECG and the medication used before the test. We compared VO2max (ml/kg/min) and %PredVO2 in terms of prognostic stratification for the combined endpoint (death and/or heart transplant) for 2 years of follow-up., Results: We detected 60 patients with events (42 deaths and 18 transplants). ROC curve analysis was used to determine the best cut-off value for VO2max and %PredVO2 to identify patients with events. The best cut-off for VO2max was < or = 19 ml/kg/min and < or = 49% for %PredVO2 in the total population, and in the event-free survival analysis, by log-rank test, we obtained p < 0.001 for both cut-offs. Considering the two extreme age groups (20-40 years and > or = 60 years), we found different cut-off values. In the youngest group we obtained VO2max of < or = 23 ml/kg/min and %PredVO2 of < or = 59%, and in the elderly < or = 12.5 ml/kg/min and < or = 64% respectively. For the intermediate group, the cut-off values were the same as for the total population. In the youngest patients, the new cut-offs did not offer an improvement in accuracy. In the elderly, for VO2max, we obtained an improvement in specificity from 28 to 86% and a reduction in sensitivity from 95 to 50%, with an improvement in accuracy from 46.8 to 75.9% (p = 0.05). With regard to %PredVO2, specificity fell from 86 to 61% and sensitivity increased from 50 to 82%, with similar accuracy (75.9 to 67%, p = 0.78)., Conclusions: In the extreme age groups, we obtained different cut-off values, but only for the elderly (VO2max < or = 12.5 ml/kg/min and %PredVO2 < or = 64%). A benefit in terms of accuracy was only obtained in respect of VO2max, because for %PredVO2, there is already a correction for age through the Jones equation.

Background: Myocardial perfusion SPECT is often used to exclude late restenosis or disease progression after coronary angioplasty (PTCA), but few studies have been published regarding the prognostic value of a negative study., Aim: To examine the long-term prognostic value of a non-ischemic SPECT result after successful PTCA., Methods: We retrospectively reviewed 783 patients (pts) who underwent scintigraphy 3 months to 3 years after successful PTCA. In 118 no significant myocardial ischemia (moderate or severe) was observed. There was a history of myocardial infarction (MI) in 38.1%, multivessel disease in 36.8% and LVEF < 50% in 15.3%. Referral for SPECT was chronic angina in 50.5% and acute coronary syndrome in 32.2%. SPECT was performed using a treadmill exercise test in 72%, adenosine in 21%, dipyridamole in 3% and dobutamine in 4%. Fifty-three percent of pts were under anti-ischemic medication. Patients were divided into two groups according to the SPECT result: group A pts (n = 70) had mild or no ischemia and group B pts (n = 48) had non-reversible defects of small or moderate size. The endpoint was the combined occurrence of death, MI, unstable angina (UA) and repeated revascularization., Results: There were one MI, 2 UA episodes and 4 repeated PTCAs (1 for UA). Event-free survival rate at two-year follow-up was slightly lower in patients from group B compared with group A, respectively 91.7% versus 97.1% (p = 0.16, log rank test)., Conclusions: This study suggests an excellent prognosis for patients with no or mild ischemia as assessed by SPECT performed more than 3 months after coronary angioplasty. Those patients with mild persistent defects did not present a significantly worse outcome.

Objective: To evaluate electrophysiological changes after bilateral pulmonary vein isolation in patients undergoing mitral valve surgery and to relate the clinical outcome at 1-year follow-up with the results of the postoperative electrophysiological study., Methods: Prospective study of patients with atrial fibrillation undergoing bilateral pulmonary vein isolation using radiofrequency energy and concomitant mitral valve surgery. Pulmonary vein isolation was performed with a heptapolar catheter. Each set of up to 7 simultaneous applications aimed at a maximal duration of one minute and a maximal preset temperature of 70 degrees C. Energy delivery (< 150 watts) was controlled by thermosensors located on each electrode. Before hospital discharge, all patients presenting sinus rhythm underwent an electrophysiological study, using epicardial pacing wires placed during surgery. Isolated areas were compared to the non-isolated left atrium with respect to electrogram amplitudes and atrial capture thresholds. At one-year follow up, cardiac rhythm was assessed in all patients and correlated with the results of the postoperative electrophysioloical study., Results: The study population consisted of 20 patients with mitral valve disease (mean age 59 +/- 11 years), chronic atrial fibrillation present for 0.5 to 18 years and dilated left atria (55 +/- 11 mm assessed by M-mode echocardiography). The radiofrequency procedure added, on average, 7 minutes (3 to 17) to the duration of the mitral valve surgery. No patient died or suffered surgical complications. Eleven patients presented sinus rhythm before hospital discharge. The electrogram amplitude inside the isolated zones was less than 25% of that in nonisolated areas (0.3 +/- 0.2 mV versus 2.1 +/- 1.7 mV, p = 0.002). Atrial capture thresholds were significantly higher for the isolated areas (13.5 +/- 9.3 mA versus 8.5 +/- 4.0 mA; p < 0.05). At one-year follow-up, nine patients maintained atrial fibrillation, nine remained in sinus rhythm and two lost sinus rhythm to atrial fibrillation. In both these patients, the reduction in electrogram amplitude inside the isolated zones was similar to that of the remaining patients discharged in sinus rhythm. However, postoperative electrophysiological studies in these patients showed that atrial capture thresholds for isolated areas had not increased significantly (8 mA and 6 mA, respectively)., Conclusion: Rhythm at discharge after bilateral pulmonary vein isolation tends to remain at one-year follow up. Radiofrequency-induced modifications in electrogram amplitudes may be less important than increases in pacing thresholds of isolated zones with respect to maintenance of sinus rhythm.

Background: The pathogenesis of atrial fibrillation (AF) is not completely understood. The role of pulmonary veins (PV) in AF initiation is documented, and the recent demonstration of persistent fibrillatory activity in an isolated PV suggests that the PV play a role in the maintenance of AF., Objective: Since AF is facilitated by multiple reentry circuits in atrial tissue with short effective refractory periods (ERP) and prolonged conduction times, we investigated whether PV have shorter ERP compared with the left atrium (LA)., Population and Methods: The study population consisted of five male patients, between 45 and 78 years of age, with normal sized LA; three had coronary artery bypass surgery (and no previous history of atrial arrhythmias) and two had paroxysmal lone AF refractory to antiarrhythmic drugs and were referred for percutaneous ablation with radiofrequency energy. In the surgical patients, epicardial bipolar pacing wires were inserted in the PV ostia and LA roof at the end of the procedure. Post-operatively, the pacing wires were used to determine atrial thresholds and ERP in the PV ostia and LA roof. In the AF patients, atrial thresholds and ERP at these locations were obtained with the mapping/ablation catheter before and after PV isolation. ERP were determined with a basic pacing cycle length of 500 ms and a single extrastimulus with an initial coupling interval of 350 ms, gradually decreased (10 ms at a time) until atrial capture failure or AF induction., Results: ERP in the LA roof were longer than 210 ms. The shortest ERP was always obtained in a PV ostium, with the shortest in the left PV ostia. The ERP values of the right inferior PV most resembled those of the LA roof. In patients referred for ablation, AF was induced when PV ostia with ERP shorter than 200 ms were stimulated., Conclusion: In the present study, the ERP of PV ostia were shorter than LA ERP, possibly explaining not only the presence of ectopic foci in the PV ostia, but also sustained fibrillatory activity in isolated PV, despite conversion of the atria to sinus rhythm. This fact may also explain the higher success rate and the preference for PV isolation in AF ablation.

Introduction: The prognostic value of peak oxygen uptake (peak VO2) in patients with left ventricular systolic dysfunction is currently recognized and accepted. Some studies have shown that other cardiopulmonary exercise test (CPET) parameters have additional value., Objectives: To evaluate whether our population of patients with left ventricular dysfunction had similar results to those found by other investigators who showed that a slow normalization of oxygen uptake (VO2) during the recovery period of a CPET has prognostic value, and whether the recovery phase parameters have additional prognostic value to peak VO2 in these patients., Methods: We studied 292 consecutive adult patients (81.5% male; mean age 52.4 +/- 10.6 years) with an ejection fraction below 40% (mean 23.6 +/- 8.8%) given their first symptom-limited CPET between 03/1993 and 08/2000. The etiology was ischemic heart disease in 154, idiopathic cardiomyopathy in 130 and other in 8 patients. NYHA class was I in 7%, II in 50.6% and III in 42.4% of the patients. Two years was defined as the maximum follow-up time; it was 551.5 +/- 242.2 days on average, and 62 events (death or cardiac transplantation) occurred. The following parameters were analyzed: peak VO2 (l/min and ml/kg/min), percent predicted peak VO2 (pred VO2) (l/min and ml/kg/min), VO2 every 15 seconds (sec) of the first 3 minutes of recovery (the difference between peak VO2/kg and VO2/kg every 15 sec in the recovery period (dif VO2), expressed in ml/kg/min, and also the time (sec) to reach 50% of peak VO2 (T1/2). It was considered that a combined end-point was reached if patients died or underwent cardiac transplantation., Results: ROC curves of these parameters showed the following as cut-off values (area under the curve > 0.7) for the occurrence of events: peak VO2 < 60% of pred VO2, dif VO2 at 60 sec (< 3 ml/kg/min), 90 sec (< 5), 120 sec (< 8), 150 sec (< 8.6) and 180 sec (< 10.5) of the recovery and T1/2 > 115 sec. Survival analysis was performed considering pred VO2 < 60%, dif VO2 at 150 sec (the largest area under the curve) and T1/2 > 115 sec. In the survival analysis, when the decrease in VO2 at 150 sec was less than 8.6 ml/kg/min the number of patients with events increased from 9.2% to 43.5% (p < 0.001; log-rank), and when T1/2 was less than 115 sec the number of events increased from 12.3 to 34.2% (p < 0.001; log-rank). When the criteria of T1/2 and dif VO2 at 150 sec were considered together with pred VO2 < 60%, mortality increased from 31 to 54% and from 33 to 51%, respectively (p < 0.001, for both parameters; chi-square)., Conclusions: A slow VO2 kinetics in the recovery period of the CPET by itself identified groups of patients with poor prognosis. The association of these parameters with peak VO2 enhanced the identification of groups at greater risk for events. A global evaluation of the CPET should be performed, considering other parameters besides peak VO2, particularly those related to VO2 kinetics in recovery (T1/2 and dif VO2 at 150 sec) as identified in this study.

Objectives: To evaluate the influence of prior medication on mode of presentation and short-term prognosis of acute coronary syndromes (ACS)., Design: Prospective study., Setting: Coronary intensive care unit in Santa Cruz Hospital., Population: We included 425 consecutive patients admitted for ACS., Methods: Prior medication with anti-platelet agents, beta-blockers, nitrates, calcium channel blockers, statins and angiotensin-converting enzyme (ACE) inhibitors was recorded on admission. Medication introduced in the last 7 days was excluded. Using a multivariate analysis model we examined the impact of baseline characteristics and previous medication on mode of presentation of ACS. We also evaluated their influence on short-term prognosis (death or non-fatal myocardial (re)infarction in the first 30 days)., Results: Of the 425 patients studied 228 (53.6%) presented with unstable angina (UA), the remainder with acute myocardial infarction (AMI) (24.7% with ST elevation). Medication prior to admission included anti-platelet agents in 53.7% of patients, beta-blockers in 44.2%, nitrates in 48.2%, calcium channel blockers in 36.9%, statins in 28.9% and ACE inhibitors in 38.6%. During the first 30 days, 14 deaths (3.3%) and 37 (re)infarctions (8.7%) occurred. The combined occurrence of death or (re)infarction was 10.8%. Variables with significant and independent influence on mode of presentation of ACS were male gender, presence of known coronary artery disease and previous medication with anti-platelet agents and beta-blockers. Male gender was a predictor of AMI as mode of presentation, whereas a previous history of coronary artery disease and medication with anti-platelet agents or beta-blockers predicted UA. Short-term prognosis was influenced by heart failure symptoms on admission, but not by previous medication., Conclusion: Previous medication with anti-platelet agents and beta-blockers was associated with an increased frequency of UA as mode of presentation of ACS. No relation between previous medication and short-term prognosis was observed in the present study.

We describe a 33-years-old male patient, presenting with progressive right heart failure. After evaluation, the hypothesis of effusive-constrictive pericarditis was considered. Medical therapy was initiated with no clinical benefit. On the 15th day after admission he was proposed for surgical intervention. The intraoperatory examination revealed a thick pericardium adhering to the epicardium without a clear separation between them. Complete resection was technically impossible. The postoperative course evolved with worsening heart failure and development of renal failure requiring hemodialysis. A diagnosis of primary pericardial mesothelioma was made after histological evaluation. The patient died 8 days after surgery despite all efforts at hemodynamic compensation. Despite its rarity, this diagnosis should be considered in cases with rapid evolution of constrictive or effusive-constrictive pericarditis. The prognosis for pericardial mesothelioma is poor due to its late diagnosis, the difficulty of surgical excision and poor response to radio- or chemotherapy.

The authors report a case study of a 73-year-old male, with signs of right-sided heart failure with 6 months of evolution. It was constrictive pericarditis, without radiologic, echocardiographic and magnetic resonance imaging manifestations, diagnosed on the basis of the clinical situation and hemodynamic evaluation during cardiac catheterization. The authors suggest that the lack of imagiologic manifestations might have been the result of an early diagnosis, before the development of the classic picture. Pericardiectomy, performed with success, was followed by resolution of the heart failure. It was not possible, histologically, to draw conclusions about the etiology. The development of mitral regurgitation after pericardiectomy has enriched this case with an unusual, but previously described, complication of this type of surgery.

Objectives: The introduction of the implantable cardioverter-defibrillator was a very important advance in the treatment of malignant ventricular arrhythmias. However, its use is associated with some possible adverse events, which should be taken into consideration when a patient is proposed for implantation. These complications may occur early after implantation and be associated with the procedure itself, or they may be late complications, usually associated with the device or the arrhythmia. It was our objective to assess the incidence of these complications in our population of patients., Population and Methods: We describe the complications found in 98 patients (55.9 +/- 13.9 years, 89% male) with an implantable cardioverter-defibrillator and compare our results with the incidence of complications described by other authors., Results: We found complications associated with the presence of the implantable cardioverter-defibrillator in 32% of patients. The most frequent complication was inappropriate shocks in 13%. The presence of infection was detected in 4%, lead insulation faults in 5%, need for lead extraction in 2%, repositioning in 1% and re-establishment of the connection with the generator in 2%. In 5% of patients, there was inefficacy of the device, 3% due to non-detected ventricular tachycardias (slow tachycardias) and 2% due to electrical storms. There was syncope in 2% of patients. The total mortality in a 2.9 +/- 1.9 year follow-up was 13% (sudden death in 3%)., Conclusions: Major complications associated with implantable cardioverter-defibrillators were in our experience relatively rare, our results agreeing with those of other centers.

Introduction: The restenosis rate of stents implanted into small coronary arteries is considered higher than that of stents in arteries > or = 3 mm, but could be influenced by clinical parameters and by the type and length of the stents., Objective: To assess the incidence of angiographic restenosis at 6 months after implantation of 2.5 mm ACS RX Multi-Link (ML) stents, 15 and 25 mm length, in de novo coronary stenosis., Design: Angiographic substudy of the Portuguese Multi-Link 2.5 Registry, which included Interventional Cardiology centers with facilities for coronary angiographic recordings allowing quantitative analysis., Population: Between April 7 and November 20 1998 and in the 5 hospitals that agreed to participate, 61 patients were enrolled and 40 selected as having procedural and 6-month angiographies of sufficient quality for quantitative analysis. The only significant differences in the demographic, clinical and angiographic characteristics of the patients relative to those of the Registry were the lower prevalence of unstable angina and smoking in the angiographic substudy. There were 43 lesions and 46 ML stents were implanted. In 37% the lesions were located in the LAD, in 37% in the LCx and 26% in the RCA. 29 stents of 15 mm length and 17 stents of 25 mm were used., Methods: The morphologic characteristics of the lesions were analyzed subjectively using the AHA/ACC classification. Quantitative coronary analysis (QCA) was performed, in an independent laboratory using the CAAS 2 system, for reference vessel diameter, lesion length, percentage of stenosis, minimum lumen diameter (MLD) and related parameters. Restenosis was defined as > or = 50% lumen obstruction at 6-month angiography., Results: In the subjective analysis, 2 lesions were type B1, 27 type B2 and 14 type C. The overall restenosis rate was 32.6%. Restenosis was 27.7% for 15 mm stents and 36% for 25 mm stents (p = 0.4). For the QCA parameters analyzed, only MLD at the end of stent implantation was a predictor of 6-month restenosis (2.19 +/- 0.30 without vs. 2.03 +/- 0.18 with restenosis, p = 0.048)., Conclusions: The restenosis rate of the Multi-Link 2.5 mm stents, of 15 and 25 mm length, was similar to that described with other types of stents in small coronary arteries. Minimum lumen diameter after stenting was found to be the best predictor of 6-month restenosis.

Introduction: Stents are being used with increasing frequency in percutaneous transluminal coronary angioplasty (PTCA) but their use in small vessels is still controversial, due to the possibility of excessively high rates of adverse events and restenosis., Objective: To assess the safety and clinical efficacy of ACS RX Multi-Link (ML) 2.5 mm stents, in "de novo" coronary stenosis., Design: Prospective Registry, with 6 months clinical follow-up, involving all Portuguese centers of Interventional Cardiology., Population: Between April 7 and November 20 1998, 102 patients were enrolled, 82 male and with ages ranging from 30 to 86 years (average 58 +/- 11). Clinical presentation for PTCA was stable angina in 53%, unstable angina in 36% and silent ischemia in 11%. There was a history of previous myocardial infarction in 29% of patients. The main risk factors were hypertension (58%), hyperlipidemia (57%), smoking (25%) and diabetes (20%). Multivessel coronary artery disease was present in 46% of patients and left ventricular function was normal in 89%. Of the 217 existing lesions, 188 (87%) were treated: 35 with balloon angioplasty and 153 with stent implantation, 114 of which were ML 2.5 mm: 79 of 15 mm in length and 35 of 25 mm., Methods: Angiographic success with ML stent implantation and major adverse cardiac events (MACE)--myocardial infarction (MI), coronary artery bypass graft (CABG), new target vessel revascularizations and death--were evaluated during hospital stay, and at 1 and 6 months clinical follow-up., Results: Angiographic success was 97.4%. In one patient it was not possible to cross the lesion, in another there was stent migration and in a third distal coronary flow after stenting was TIMI grade 1. Clinical success was 96.1% and there were no cases of death, Q-wave MI or urgent CABG. Two patients had non-Q wave MI and two required urgent repeat angioplasty. Subacute stent thrombosis occurred in 1 patient. There were no additional MACE at 1 month follow-up. At 6-month follow-up (in 97% of patients) MACE had occurred in 14.1%: 2 deaths (one non-cardiac), 3 MI (one non-Q) and 14 new PTCA (one in a non-ML stent). There was no need for CABG in any patient. Six-month survival rate was 97.9%, 94.9% were free of infarction and 84.8% were free of infarction and new revascularization., Conclusions: Multi-Link 2.5 mm stent implantation appears to be safe and efficient with a low incidence of immediate and 6-month adverse events in the range of centers and operators of the Registry.

Aim: After ST elevation myocardial infarction, ST segment and T wave changes generally resolve, but in some patients T waves keep their negative components for a long time. The aim of this study is to evaluate the pathophysiological implications of persistent negative T waves and restored positive T waves in the chronic stage of Q wave myocardial infarction., Methods: We studied 30 patients with a previous anterior wall ST elevation myocardial infarction (more than one year follow-up) and presenting Q waves in at least three consecutive precordial leads in the standard 12-lead electrocardiogram at rest. Patients were divided into two groups according to the T wave pattern in leads with Q waves: positive T group consisting of patients in whom all T wave components showed an upright configuration; and a negative T group consisting of patients in whom T waves were are least partly inverted. We used echocardiography to measure systolic thickening of the interventricular septum within the infarction area. Systolic thickening was considered significant when end-systolic thickness was greater than end-diastolic thickness by > 25% in proportion and > 1 mm in absolute value., Results: Significant systolic thickening was demonstrated in 14 (74%) of the 19 positive T patients and in one (9%) of the 11 negative T patients (odds ratio 8.1; 95% CI, 1.2 to 53.5; p = 0.002)., Conclusion: In the chronic stage of a myocardial infarction, restored T wave positivity predicts preserved systolic thickening, suggesting the presence of viable and normally contracting myocytes within the infarction area. Further studies are needed to establish the prognostic value of T wave characteristics in patients with a past history of myocardial infarction.

The initial experience with percutaneous transluminal coronary angioplasty (PTCA) at Santa Cruz Hospital is presented. Between May and November 1984, ten patients with single significant (> 75%) coronary artery obstructions, 8 of the left anterior descending (LAD), 1 of the circumflex (Cx) and one of the right coronary artery (RCA), underwent coronary angioplasty using Gruentzig's technique and steerable catheters. Five patients were cases of chronic stable angina and 5 patients were cases of unstable angina, one of them of acute coronary insufficiency previously treated with intracoronary streptokinase. In every case was possible to cross the lesions which were proximal in 9 cases (7 of the LAD, 1 of the Cx and 1 of the RCA) and distal (LAD) in one case. Primary failure to dilate was seen in 2 cases of unstable angina due to pain and reversible ECG changes. In only 1 case there was occlusion at 9 hours after angioplasty which required emergency bypass operation. Although with a short follow-up, six patients are well and free of symptoms and in only 1 case there was recurrence of angina at four and a half months after PTCA. These results which represent the beginning of the learning curve are considered satisfactory and rewarding.

Background: Cardiac Troponins (cTn) are useful in unstable angina (UA). Moreover the different elevation patterns that can be observed in this condition seem to have different prognostic implications., Aim: To study cTn kinetics and cTn nadir in patients with UA, defined as angina at rest within the last 24 hours before admission accompanied by ischemic ECG changes and no myocardial infarction (MI) enzymatic criteria., Population and Methods: Samples were collected from 156 patients for cardiac enzymes and cTnI at admission and at 6, 12, 18 and 24 hours. The chemilluminescence method (Access/Sanofi Pasteur) was used for cTnI. The primary end-point at 30 days was the combined occurrence of death, MI and recurrent ischemia., Results: All determinations were below 0.10 ng/ml (group N) in 114 patients and the other 42 pts (group P) had at least one value equal to or above 0.10 ng/ml. The primary endpoint was observed in 24.6% of group N pts compared with 45.2% of group P pts (p = 0.02). Three different patterns of cTnI kinetics were observed. This enabled the identification of a subgroup--group N pts with increasing cTnI values within the first 12 hours and a total differential value > or = 0.03 ng/ml--with an increased risk (50.0% versus 21.4%--p = 0.02--Kaplan-Meier test)., Conclusion: Besides the prognostic value conferred by cTnI elevation, cTnI kinetics analysis established another sub-group of patients with an adverse prognosis at 30 days follow-up, despite having a negative cTnI.

Unlabelled: Coronary angioplasty (PCI) of chronic total occlusions (CTO), even when successful, are associated to less favourable long term results. The recent use of coronary stents has improved the long term outcome of those interventions., Purpose: To evaluate the short term results and long term occurrence of major adverse coronary events (MACE): death, MI, urgent revascularization and the need for a new target vessel revascularization (TVR) in patients with CTO who had previously been submitted to a PCI with excimer laser for plaque debulking followed by a provisional stent., Population: From our database, we selected 19 patients with a mean age of 51 +/- 13 years (18 male) submitted to PCI between 1994 and 1998. Of those patients, 10 had had of a previous MI. Hypertension, smoking habits and hypercholesterolemia were present in 9 patients (42%). Two patients had diabetes. The main reason for PCI was stable angina in 16 patients (84%) and unstable in 3 patients (16%). Single-vessel disease was present in 18 patients (94%) and multiple-vessel in 1 patient (6%); left ventricular ejection fraction was preserved in 18 patients (94%). Single vessel PCI was performed in 16 patients (84%) and double vessel in 3 patients. Plaque debulking with excimer laser was performed in all patients, followed by 23 stents (Multilink--8; Gianturco Roubin--5; Palmaz Schatz--4; others--6). The mean clinical follow-up was 19 months., Results: There were no major short-term clinical events (death, MI or urgent revascularization). During follow-up, TVR was only required in 5 patients (26%), all of them in the first 7 months after PCI., Conclusions: In the highly selected population, PCI for chronic total occlusion, with excimer laser plaque debulking followed by provisional stents, was a safe procedure with a very acceptable rate of new target vessel revascularization in the follow-up period.