Search

Background: The transradial approach to coronary interventions has been accepted as a safe and effective alternative to the femoral approach due to fewer access site complications and improved patient comfort. In the present study we aimed to investigate the safety and efficacy of transradial procedure in the elderly., Methods: We analyzed 850 patients who underwent transradial coronary angiography and/or angioplasty. All patients were divided into two groups, according to age. The first group consisted of patients < 70 years (600; 70.5%) and the second group consisted of patients greater than or equal to 70 years (250; 29.5%)., Results: Baseline characteristics did not differ between the two groups, except for diabetes mellitus which affected more patients greater than or equal to 70 years of age. Procedure duration, X-ray time and number of catheters used were similar in the two groups. No deaths or acute myocardial infarctions occurred. There were some vascular complications in both groups, with no statistically significant difference between groups. In Group 2 (the older group) 2 TIAs and 1 stroke occurred, whereas in Group 1, there was 1 TIA (p = 0.08)., Conclusions: From our experience, we conclude that the transradial catheterization is a safe and effective technique in the elderly, with a reduced risk of local vascular complications and a noteworthy increase in patient comfort, especially in view of the age-related diseases that frequently affect older patients.

Background: Coronary angioplasty and coronary artery bypass grafting (CABG) are both major techniques for the management of coronary artery disease, but CABG is associated with a lower incidence of repeat revascularization. Recent studies comparing angioplasty with stenting vs CABG have yielded conflicting results, with some suggesting improved survival with stenting, and others the opposite. We thus undertook a systematic overview of the randomized trials comparing stenting vs CABG in coronary artery disease., Methods: MEDLINE (January 1986-February 2003), ISI Current Contents, the Cochrane Controlled Trial Register, LILACS and the American Heart Association, American College of Cardiology, European Society of Cardiology, and Transcatheter Cardiovascular Therapeutics conference proceedings were among the databases we searched. Abstraction was performed in a non-blinded manner on pre-specified forms. The random-effect odds ratios for death, myocardial infarction, stroke, repeat revascularization, and symptomatic angina were computed for the longest available follow-up., Results: Nine randomized trials (3283 patients, representing only 6% of all screened subjects) with an average follow-up of 28 months were included in the analysis, while four studies were excluded because they were still unpublished, ongoing, or with non-systematic stenting. No study used drug-eluting stents. The odds ratios for stenting vs CABG were 0.82 (95% confidence interval-CI 0.57-1.18, p = 0.3) for the occurrence of death, non-fatal myocardial infarction or stroke, 4.6 (95% CI 3.5-5.9, p < 0.00001) for repeat revascularization, and 2.3 (95% CI 1.8-2.8, p < 0.00001) for symptomatic angina. Heterogeneity tests were not statistically significant. The results of sensitivity analysis were similar even after stratification for single vessel, off-pump, single center or high-quality studies., Conclusions: Overall and event-free survival after conventional stenting for coronary artery disease are similar to those after CABG, but surgery is still associated with a significantly lower incidence of repeat revascularization and symptoms. The role of next-generation drug-eluting stents in widening the indications for stenting and overcoming restenosis will need to be assessed in future observational and randomized studies comparing stenting vs CABG.

Background: Recent studies have reported that adequate perfusion of the infarct-related artery improves survival in patients with myocardial infarction, independently of left ventricular pump function. However, it is not known whether or not this reduction in mortality is independent of myocardial viability within the infarct zone. The aim of this study was to evaluate the prognostic value of the patency of the infarct artery and the presence of myocardial viability in akinetic regions in patients with myocardial infarction., Methods: Low-dose dobutamine echocardiography was performed in 154 patients with recent or previous myocardial infarction and known coronary anatomy. In each patient three vascular regions were defined. Each akinetic region was considered viable if function improved during dobutamine echocardiography, and irrorated by a not stenotic akinetic area-related artery if the supplying vessel had a stenosis < 75% or had been successfully revascularized within 1 month of dobutamine echocardiography., Results: At follow-up of 34 +/- 14 months, 19 patients died of cardiac death. At univariate Cox analysis end-diastolic and end-systolic volumes, ejection fraction, previous myocardial infarction, regional wall motion score index, and stenosis of the akinetic area-related artery were related to mortality. At multivariate analysis, stenosis of the akinetic area-related artery remained a significant predictor of mortality (p = 0.04), with higher mortality (13/66 vs 6/88, p = 0.02) in patients with a stenotic akinetic area-related artery, without differences in ejection fraction (35 +/- 9 vs 34 +/- 10%). Mortality was lower in patients with myocardial viability if they had a not stenotic akinetic area-related artery (1/43 vs 4/21, p = 0.02), while no difference was found among non-viable patients, with or without stenosis of the akinetic area-related artery (5/45 vs 9/45)., Conclusions: The present study confirms the prognostic role of the patency of the infarct-related artery. However, it suggests that the lower mortality in patients with a patent artery supplying akinetic infarcted regions is related to the presence of myocardial viability in these regions.

To assess the contribution of residual muscle perfusion in the infarcted territory to prevent ventricular remodeling, 24 patients with 1-vessel disease underwent coronary angiography and angioplasty of a critical left anterior descending coronary stenosis 18+/-11 days after a first anterior myocardial infarction. The degree of stenosis was assessed using biplane quantitative angiography, whereas ventricular volumes, together with regional wall motion, were computed from single-plane ventriculography. Patients were reevaluated at 6 months after they had been subdivided according to the videointensity of the territory of the culprit vessel, as assessed from images obtained during main stem dye contrast injections before and immediately after angioplasty using a subtraction technique (group A, increased intensity [n= 15]; group B, no change [n=9]), assuming that higher peak intensities reflect greater myocardial blood volume. There was a significant time group interaction for ventricular volumes (diastolic, -13+/-12% for group A vs +20+/-24% for group B, p=0.008; systolic, -15+/-19% for group A vs +18+/-36% for group B, p=0.017), although no interaction was evident for the degree of resolution of coronary stenosis or the extent of recovery of regional dysfunction. The effects on volumes were paralleled by changes in ventricular end-diastolic pressure (-3+/-7 mm Hg in group A vs +5+/-6 mm Hg in group B, p=0.006), although baseline clinical characteristics and medical regimen over the 6-month period were quite comparable between the 2 groups. In conclusion, despite late angioplasty of the culprit vessel, ventricular remodeling is prevented mainly when the procedure guarantees improved perfusion at the muscular level. The result is not necessarily mediated by recovery of regional systolic function.

Nine patients with syndrome X were compared with 2 groups of patients known to have coronary artery disease (CAD) (8 patients who developed regional wall motion abnormalities [group ECHO+] and 6 patients who showed only ST depression at echo-pacing [group ECG+]) and with 6 healthy volunteer control subjects. Left ventricular function at rest was normal in all patients. End-diastolic and end-systolic volumes (ml/m2) and ejection fraction were calculated at baseline and at peak of echo-pacing using a Simpson's biplane method. No regional wall motion abnormalities were observed during the echo-pacing in patients with syndrome X or in the volunteers. End-diastolic volume decreased in patients with syndrome X, in the volunteers (from 47 +/- 11 to 30 +/- 12 and from 72 +/- 7 to 38 +/- 6, respectively, p <0.01 for both), and in ECG+ patients (from 48 +/- 10 to 33 +/- 6, p <0.05), whereas it did not change in ECHO+ patients. End-systolic volume decreased in patients with syndrome X and in the volunteers (from 17 +/- 5 to 11 +/- 4 and from 28 +/- 6 to 16 +/- 4, respectively, p <0.01 for both), whereas it did not change or else slightly increased in patients with CAD (from 18 +/- 10 to 16 +/- 5 for ECG+ patients and from 19 +/- 5 to 24 +/- 9 for ECHO+ patients, p = NS for both), regardless of whether regional wall motion abnormalities appeared. Ejection fraction decreased in ECG+ and ECHO+ patients (from 64 +/- 12 to 52 +/- 11 and from 62 +/- 9 to 44 +/- 13, respectively, p <0.01 for both), whereas it did not change in patients with syndrome X and in the volunteers (from 64 +/- 8 to 61 +/- 8 and from 61 +/- 7 to 58 +/- 7, respectively, p = NS for both). During echo-pacing in syndrome X patients no regional wall motion was detected. Left ventricular volumes and ejection fraction showed the same patterns of variation in these patients as they did in the healthy control subjects, in contrast with those patients with CAD, whether or not regional wall motion abnormalities appeared in the latter.

In the assessment of the acute results of percutaneous transluminal coronary angioplasty (PTCA), myocardial perfusion at maximal vasodilatation theoretically has fewer limitations than the coronary flow reserve measurements and quantitative coronary angiography. The purpose of this study was to compare the myocardial perfusion to the measurements of the severity of the lesion (minimal luminal diameter and percent area stenosis) and to relate it to the changes of left ventricular function after PTCA. Regional myocardial perfusion was assessed during intracoronary papaverine, using the inverse mean transit time of contrast medium (1/Tmn), before, 15 min after, 18-24 hr after, and 6 months after successful single-vessel PTCA in 14 patients with stable angina. Left ventricular angiography (before angioplasty, 18-24 hr after, and 6 months later) was analysed by area-length and centerline methods. Immediately after PTCA, 1/Tmn increased from 0.14 +/- 0.07 sec-1 to 0.21 +/- 0.09 sec-1 (P = .001). Maximal myocardial perfusion remained higher than the pre-PTCA value the day after angioplasty (1/Tmn of 0.23 +/- 0.09 sec-1), while it reduced to near pre-PTCA values at follow-up (1/Tmn of 0.16 +/- 0.05 sec-1). Before PTCA, three out of ten patients had ejection fraction of < 65%, and seven had mild-to-moderate hypokinesis. The day after PTCA the ejection fraction and the regional dysfunction improved significantly. The change in ejection fraction 18-24 hr after PTCA did not correlate with minimal luminal diameter and percent area stenosis and correlated slightly with the improvement of perfusion (r = 0.54, P = .10). At follow-up left ventricular function deteriorated in the whole group, despite the persistence of angiographic success of PTCA, possibly because of changes in the loading condition. Coronary artery stenosis measurements and 1/Tmn failed to correlate with the left ventricular function. Given the difficulties in routine application of the analysis of time-density curves, the measurement of minimal luminal diameter remains a more practical assessment of the results of the intervention. However, the improvement of myocardial perfusion may give more information than coronary artery dimensions of the early recovery of left ventricular function.

Short-term outcome after coronary angioplasty is mainly determined by restenosis, while long-term outcome is determined by new events due to incomplete revascularization, by atherosclerosis progression and by late-restenosis. The aim of this study is to assess if correctly treated coronary risk factors are predictors of poor prognosis after coronary angioplasty. Two-hundred and twenty six patients (209 males, 17 females, mean age 56 +/- 9 years) with successful coronary angioplasty were treated for coronary risk factors. New events (death, myocardial infarction, repeat angioplasty, bypass surgery) were recorded. Ischemia was evaluated by serial exercise tests. The mean follow-up was 31 +/- 12 months. Survival was 99.5% at 1 year and 97.4% after 5 years; "event free survival" was 84.6% at 1 year and 65.9% after 5 years; "ischemia free survival" was 84.6% at 1 year and 44.8% after 5 years. "Ischemia free survival" was higher in patients with single coronary angioplasty and in patients with infarct-related vessel angioplasty. Smoke addiction, diabetes, hypercholesterolemia and hypertension were not significantly correlated with "ischemia free survival". Smokers and diabetics had a trend towards a less favorable 5 year outcome, but without statistical differences. In conclusion, this study shows that correctly treated coronary risk factors do not worsen prognosis after coronary angioplasty.

Coronary stenting is a technique complementary to coronary angioplasty, because it is successful in the management of the two major limitations of conventional balloon dilation, i.e. the acute or threatened closure and the restenosis. The currently available intracoronary stents are far from being ideal, mainly for their thrombogenicity. During abrupt closure, the bailout stenting has, in most of the cases, offered a valuable alternative to emergency coronary artery bypass surgery. The major complications after stent insertion are the result of an inadequate stent placement, of persistence of intra and/or poststent obstruction and of the ineffective anticoagulant therapy. The mechanical support (scaffolding) provided by the stent after dilation significantly reduces the amount of elastic recoil, and, improving laminar flow, eliminates arterial wall shear stress that may contribute to an increase in intimal thickening. Moreover, the reduction of arterial cyclical stretching may reduce the rate of neointimal proliferation. By sealing the exposed subintimal spaces, stents may minimise the formation of local thrombi, and thus also limit their later organization and fibrous conversion into part of the restenotic lesion: two recently completed randomized trials (STRESS and BENESTENT) confirm the lower rate of restenosis in patients treated with single stent placement in de-novo lesions as compared with standard balloon angioplasty. The mechanism of stent benefit in reducing restenosis rate seems to be the wider initial lumen, which can accommodate a greater degree of intimal hyperplasia. In the near future, the improvements of the blood and tissue compatibility of the stents, may allow easier management.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients with ischemic heart disease are often affected by a mixed hyperlipoproteinemia, where a hypercholesterolemia of various severity is accompanied by slight or moderate hypertriglyceridemia (type IIb dyslipidemia). Current epidemiologic evidence suggests that hypertriglyceridemia has not to be disregarded, particularly in certain subgroups of patients. We evaluated the effect of the association of simvastatin 10 mg/day [an hydroxymethyl-glutaryl-CoA (HMG-CoA) reductase inhibitor] and omega-3 polyunsaturated fatty acids (n3-PUFA) in comparison with simvastatin 10 mg/day alone. The subjects undergoing the study were affected by coronary artery disease and showed hypercholesterolemia (LDL-cholesterol > 160 mg/dl) and moderate hypertriglyceridemia (serum triglycerides 200-400 mg/dl) after 2 months of moderate dietary therapy for hyperlipidemia (Step 1 of the National Cholesterol Education Program [NCEP]). Thirty-nine patients were randomized to have 1 of 2 scheduled treatments. At the same time the patients underwent severe dietary therapy for hyperlipidemia (Step 2 of the NCEP). After 3 months of treatment, total-cholesterol, LDL-cholesterol, and triglycerides were significantly lower than basal values in both groups (p < 0.05). Total-cholesterol, LDL-cholesterol, and triglycerides were lower in the group treated with n3-PUFA and simvastatin compared to simvastatin alone. However, only for triglycerides was the difference significant (-39.99% in patients treated with n3-PUFA and simvastatin versus -25.65% in patients treated with simvastatin alone, particularly in the first group of 35.85%; p < 0.05). With regard to HDL-cholesterol, the differences between the basal values and the 2 groups of treatments were non significant. Remarkable side effects were not observed in the 2 groups.(ABSTRACT TRUNCATED AT 250 WORDS)

In 24 patients 2 leads Holter monitoring was performed during percutaneous transluminal coronary angioplasty (PTCA) of left anterior descending (17 patients), right coronary artery (6 patients), left circumflex (1 patient). In 20 patients (83%) significant ST segment deviations were recorded in the lead CM2 or RV. The following characteristics of ST segment deviation were analyzed during 7 +/- 3 successive occlusions: time to onset, maximal ST shift, slope to development, time to onset and slope of ST segment normalization. In 17 patients with successful PTCA the slope of ST segment normalization increased progressively from the first to the third-fifth inflation and then was constant. The improvement in ST segment normalization velocity was correlated (p less than 0.01) with the reduction of the diameter and with improvement of sectional area of the dilated vessel. The maximal ST segment normalization slope was correlated (p less than 0.01) with the diameter and the area of the residual stenosis. Continuous electrocardiographic recording, during PTCA, for evaluation of ST segment normalization velocity is a promising approach for monitoring the immediate result of coronary angioplasty.

In order to evaluate perioperative electrical cardiac disturbances and ST segment changes, 42 patients (38 M, 4 F, aged 57 +/- 6 ys) were studied using 24-hour Holter monitoring before, during and after coronary bypass surgery. In the 4-6 hours before cardioplegic arrest, 38% of patients had ST segment changes. No patient and malignant arrhythmias. The injection of cold cardioplegic solution was followed by bradycardia, ventricular tachycardia, ventricular fibrillation and isoelectric line within 2-4 minutes. After aortic declamping, 30 patients were defibrillated. Impulse formation and conduction disturbances, found in 55% of patients, solved themselves in 1 to 60 minutes. Bundle branch block continued in just 4 cases. A total of 59% of patients had ST segment elevation for 14 +/- 14 minutes and 19% had ST segment depression for 19 +/- 20 minutes. Successive transient ST segment changes were detected in 38% of patients. Sustained ventricular tachycardia occurred during 2 ischemic episodes. Impulse formation and conduction disturbances were not related to the duration of cardiac arrest or ventricular fibrillation, but were more frequent and lasted longer in patients with incomplete revascularization. Transient ST segment depression far from aortic declamping correlated with preclamping ischemia. Transient ST segment elevation correlated with incomplete revascularization. We concluded that ECG signs of intraoperative damage were reversible. Moreover, perioperative transitory ischemia was frequent but could be prevented by coronary active drug administration. On the other hand incomplete revascularization was associated with electrical disturbances and ischemia.

Despite the fact that numerous studies have been published regarding the possible presence in plasma of an endogenous Na-K pump inhibitor with a digitalis-like structure in essential hypertension, very little is known about this factor in heart disease in general, and in situations characterized by low cardiac output. We measured the ability of plasma obtained from the femoral vein to inhibit a human renal Na(+)-K+ ATPase before and immediately after percutaneous transluminal coronary angioplasty (PTCA) in 6 patients suffering from angina pectoris and severe coronary stenosis. Intraerythrocyte sodium and potassium concentrations were also measured simultaneously. Na(+)-K+ ATPase inhibition proved significantly greater after angioplasty as compared to basal activity (percentage inhibition: 31.5 +/- 7.8 vs 16.1 +/- 12.2). No significant changes in intraerythrocyte sodium and potassium were detected. Though we are not in a position to define the mechanism underlying the increase in the digitalis-like factor, a plausible hypothesis may be that the reduction in cardiac output during PTCA by raising cardiac pressures may stimulate the production of a factor of compensatory inotropic significance.

Five coronary arterial aneurysms were found in 4 of 80 (5%) patients who underwent elective coronary arteriography 6 months after successful percutaneous transluminal coronary angioplasty. None of them was present immediately after dilatation. All patients had been suffering from stable angina before angioplasty, while no case had recurrent angina or definite angiographic restenosis at the 6-month follow-up. Quantitative coronary angiography was performed in all angiograms. The coronary aneurysms only developed in the dilated portions (4 in left anterior descending and 1 in an intermediate branch of the left coronary artery): their diameter ranged from 3.1 to 4.4 mm, and their length from 2.2 to 4.9 mm. The ratio between the aneurysm diameter and the coronary arterial diameter (aneurysm: artery ratio) varied from 1.15 to 1.91 (mean 1.47). No significant clinical or technical differences were found between patients who developed aneurysm after angioplasty, and patients who did not. On the other hand, 4 of the 5 patients who developed aneurysm had angiographic evidence of "non-pathologic" dissection immediately after balloon dilatation. Moreover, the ratio between the measured angiographic diameters of the balloon (at maximal inflating pressure) and of the coronary artery selected for the procedure showed that the balloon was mildly oversized (balloon: artery ratio ranging from 1.10 to 1.37, mean 1.28) in all cases with aneurysm except the only 1 in whom dissection did not occur. In conclusion, aneurysm formation after coronary angioplasty is not infrequent in our experience: balloon size and wall dissection seem to be the major factors related to this event.

Chronic total coronary occlusion is a growing indication to percutaneous transluminal coronary angioplasty. Since primary success of balloon angioplasty in this condition is usually limited by the difficulty of crossing the occlusion, different techniques have been described for this purpose, such as use of stiff guidewires, coronary infusion catheters, guidewires with an olive-shaped tip, or new developing methods (atherectomy, laser), in association with balloon dilatation. Here, we describe our initial experience with a thick (0.035 in) and relatively stiff open-ended guidewire, which has an inner (0.018 in diameter) lumen provided with a core wire. Several advantages are considered. The core wire yields a perfect means of steerability of the whole system, while pushability of a thicker guidewire is much greater. Moreover, the core wire can be removed, and contrast injections beyond the occlusion through the inner lumen can assure proper intraluminal location. Finally, position across the occlusion can be kept easily, since an exchange wire for conventional balloon catheters can be inserted in the inner lumen of the open-ended guidewire.

In 354 patients with coronary artery disease (9 with greater than or equal to 90%, 42 with 50-75% and 303 with no left main (LM) stenosis, prevalence of ergometric criteria of severe disease was considered. In patients with LM stenosis were more frequent: work load less than or equal to 75 watt (p less than 0,001); ST depression greater than 2 mm (p less than 0,01); 3 or more leads involved (p less than 0,05); no increment of heart rate (p less than 0,01) or of blood pressure (p less than 0.01). Work load had the best predictive value (30%) of LM stenosis, associated with a reasonable sensitivity (55%). Combination ST depression + heart rate or work load + blood pressure had a predictive value of 100%, but minimal sensitivity (8%). In detecting greater than or equal to 90% LM stenosis heart rate had the best predictive value (13%), associated with high sensitivity (78%). Presence of 2 any criteria could detect all greater than or equal to 90% LM stenosis (sensitivity 100%, predictive value 11%). ST depression + heart rate had a predictive value of 100% and a sensitivity of 44%. It is concluded that no single or associated exercise variable has both high sensitivity and high predictive value of LM stenosis.

It has been recently shown that preload reduction affects the pattern of left ventricular (LV) filling in a way that mimics those Doppler changes that have been associated with impaired LV diastolic function. In order to better relate changes of mitral flow velocity profile to changes of the diastolic properties of the ventricle, in 11 ischemic patients diastolic pressure-volume relations from micromanometer LV pressure and LV volume derived from Doppler and 2D-echocardiography were constructed before and after TNT (0.2 mg iv). TNT induced a significant reduction in LV peak pressure (% change: -13 +/- 7%, p: 0.0003), end-diastolic pressure (EDP) (-62 +/- 45%, p: 0.0006), and constant of isovolumic pressure decay (T) (-8.4 +/- 6.6%, p: 0.012). The left atrial pressure at the time of mitral valve opening (PCO: defined as the pressure at the time of initial transvalvular flow assessed by Doppler) decreased 5.3 +/- 9.6 mmHg (p: 0.11). The early filling E wave of the Doppler velocity profile was significantly reduced by TNT (-20.1 +/- 12.7%, p: 0.0003), while the atrial contribution to total filling increased by 21.3 +/- 29.7% (p: 0.03). The E/A ratio decreased from 0.87 +/- 0.31 to 0.66 +/- 0.22 (p: 0.016), and the change correlated with changes in EDP (p less than 0.05) and PCO (p less than 0.01). The diastolic pressure-volume relationship was displaced downward (p: 0.0007) and minimally leftward (p: 0.45), suggesting relief of external constraint.(ABSTRACT TRUNCATED AT 250 WORDS)

266 male p., with chest pain and without previous myocardial infarction were studied by exercise test and coronary arteriography. 17 had no coronary disease (group C-0), 22 had less than or equal to 50% coronary stenosis (C-1), 65 had severe 1 vessel disease (C-2), 73 had 2 vessel disease (C-3), 89 had 3 vessel disease (C-4). 95 had normal ventricular function (group V-0), 111 had hypokinetic ventricular segments (V-1) and 60 had akinetic ventricular segments (V-2). 11 exercise test variables were stepwise selected to discriminate the C-groups and the V-groups. For C-groups significant variables were: test result, heart rate increment, number of leads, work load, rate-pressure product, systolic pressure increment. By 4 discriminant functions, 41% p. were correctly classified. For V-groups significant variables were: hear rate increment, test result, effort angina, rate-pressure product, number of leads, ST depression, ST configuration, age. By 2 discriminant functions 53% p. were correctly classified.

The article presents a case study of a 39-year-old woman who was admitted after resuscitation from cardiac arrest caused by left coronary artery dissection.