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Objective: We sought to determine the effects of open (O) and closed (C) cell stents on the size and number of embolic particles generated during carotid artery stenting (CAS) and assess the impact on outcome., Methods: Embolic debris from carotid filters after CAS was analyzed using photomicroscopy and imaging software. Patient comorbidities, preoperative cerebrovascular symptoms, stent type, and outcomes (perioperative major adverse events) were examined., Results: Carotid filters from 173 consecutive CAS procedures (O, 125 and C, 48) were reviewed. The mean age was 70.9 ± 9.2 years; 58% were men. Mean stenosis was 88.2% ± 8.1%; 36.6% had neurological symptoms preprocedurally. There was no difference in preoperative symptoms between the two groups (O, 38.7% vs C, 31.3%; P = not significant [NS]). However, closed cell stent use was associated with higher degree of stenosis (O, 87.2% ± 8.0% vs C, 90.6% ± 7.8%; P = .01), an older age (O, 70.0 ± 8.6 years vs C, 73.4 ± 10.2 years; P = .03), and peripheral arterial disease (21.1% vs 43.5%; P = .01). A larger mean particle size was observed in patients treated with open cell stents compared to closed cell stents (O, 416.5 ± 335.7 μm vs C, 301.1 ± 251.3 μm; P = .03). There was no significant difference in the total number of particles (O, 13.8 ± 21.5 vs C, 17.6 ± 19.9; P = NS), periprocedural stroke (P = NS), and major adverse events between the two groups (P = NS)., Conclusions: Open cell stents are associated with a larger mean particle size compared to closed cell stents. No impact on procedural outcomes based on stent type was observed., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: We evaluated the impact of the everolimus-eluting stent (EES) on the frequency of stent thrombosis (ST), target vessel revascularization (TVR), myocardial infarction (MI), and cardiac death in randomized controlled trials comparing the EES to non-everolimus-eluting drug-eluting stents (EE-DES)., Background: Whether or not the unique properties of the EES translate into reductions in ST remains unknown., Methods: We searched MEDLINE, Scopus, the Cochrane Library, and Internet sources for articles comparing outcomes between EES and non-EE-DES without language or date restriction. Randomized controlled trials reporting the frequency of ST were included. Variables relating to patient and study characteristics and clinical endpoints were extracted., Results: We identified 13 randomized trials (n = 17,101) with a weighted mean follow-up of 21.7 months. Compared with non-EE-DES, the EES significantly reduced ST (relative risk [RR]: 0.55; 95% confidence interval [CI]: 0.38 to 0.78; p = 0.001), TVR (RR: 0.77; 95% CI: 0.64 to 0.92; p = 0.004), and MI (RR: 0.78; 95% CI: 0.64 to 0.96; p = 0.02). There was no difference in cardiac mortality between the groups (RR: 0.92; 95% CI: 0.74 to 1.16; p = 0.38). The treatment effect was consistent by different follow-up times and duration of clopidogrel use. The treatment effects increased with higher baseline risks of the respective control groups with the strongest correlation observed for ST (R(2) = 0.89, p < 0.001)., Conclusions: Intracoronary implantation of the EES is associated with highly significant reductions in ST with concordant reductions in TVR and MI compared to non-EE-DES. Whether these effects apply to different patient subgroups and DES types merits further investigation., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

A wild fungal strain of Aspergillus terreus, labeled as PM3, was isolated by using the Candida albicans bioassay and confirmed by 18S r DNA analyses. Lovastatin was produced by submerged and solid state fermentations. Of the 30 isolated fungal strains, 11 showed lovastatin production with Aspergillus terreus PM3 being the best with a yield of 240 mg/L at the 10th day of submerged fermentation. Carboxymethylcellulose had a stimulatory effect on lovastatin production. It restricted uncontrolled filamentous growth, induced pellet formation and, thereby, improved lovastatin yield. In solid state fermentation (SSF), of the agro wastes from five crops (bran of wheat and rice, husks of red gram and soybean, and green gram straw), wheat bran showed maximum lovastatin production (12.5 mg/g of dry substrate) at pH 7.1 and a temperature of 30 +/- 2 degrees C. Development of a lovastatin production process based on wheat bran as a substrate in SSF is economically attractive as it is a cheap and readily available raw material in agriculture-based countries.

Objectives: This study evaluated the outcomes of patients discharged the day of percutaneous coronary intervention (PCI) by analyzing the data from a single-center, large, multioperator registry of interventions., Background: Although same-day discharge is likely safe after interventions on low-risk stable patients, there is limited data to guide selection of a broader population of patients. Due to numerous patient variables and physician preferences, standardization of the length of stay after PCI has been a challenge. Most of the reported studies on same-day discharge have strict inclusion criteria and hence do not truly reflect a real-world population., Methods: We analyzed the outcomes of consecutive same-day discharge in 2,400 of 16,585 patients who underwent elective PCI without any procedural or hospital complication. Composite end point included 30-day major adverse cardiac cerebral events and bleeding/vascular complications., Results: The mean age of the study population was 57.0 +/- 23.7 years with 12% aged over 65 years. Twenty-eight percent received glycoprotein IIb/IIIa inhibitor with closure devices in 90.5%. Clinical and angiographic success was noted in 97% of all PCIs. The average length-of-stay following PCI was 8.2 +/- 2.5 h. The composite end point was reached in 23 patients (0.96%). Major adverse cardiac cerebral events occurred in 8 patients (0.33%) and vascular/bleeding complications in the form of Thrombolysis In Myocardial Infarction minor bleeding in 14 patients (0.58%) and pseudoaneurysm in 1 patient (0.04%)., Conclusions: When appropriately selected, with strict adherence to the set protocol, same-day discharge after uncomplicated elective PCI is safe despite using femoral access in a wide spectrum of patients., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective of this study is to analyze the clinical outcomes and treatment strategies of coronary wire perforations (WPs) in the era of heparin use compared to the era of bivalirudin use., Background: Percutaneous coronary intervention (PCI) advances have led to progressive decrease in complications. Therefore, complex coronary lesions such as chronic total occlusions and calcified lesions are being attempted with stiff/hydrophilic wires with resultant higher incidence of coronary WP., Methods: A single-center retrospective data analysis of coronary perforation (CP) for the last 4 years with review of coronary angiograms was done and WPs were identified. A simple classification scheme based on angiographic appearance of CP was made: Type I ("myocardial stain," with no frank dye extravasation) and type II ("myocardial fan," with dye extravasation to pericardial cavity or cardiac chambers)., Results: Overall incidence of CP was 0.49% (82/16,859). Of these 50 (61%) were caused by WP; 30 occurred with heparin use (Group A) and 20 with bivalirudin use (Group B). WPs always occurred in type B2/C lesions (100%) and commonly with use of hydrophilic guidewires (70%). Major adverse cardiac events and cardiac tamponade were frequent in group A (50%) and none in group B (0%); P < 0.01. All WP in group B responded to stopping anticoagulation and prolonged balloon inflation, while group A type II perforations frequently required additional interventions (pericardiocentesis, coil embolization)., Conclusions: Cardiac tamponade and major adverse cardiac events from WPs were less frequent with bivalirudin use compared to heparin use. This beneficial effect of bivalirudin may be explained on the basis of its short half-life and reversible thrombin inhibition property. Therefore, bivalirudin may offer a safer alternative for anticoagulation in complex PCI., (Copyright 2009 Wiley-Liss, Inc.)

Unlabelled: The occurrence of contrast induced nephropathy (CIN) is associated with increased mortality after percutaneous revascularization procedures. However, the exact correlation between various levels of creatinine elevation relative to the baseline and subsequent mortality in patients with chronic renal insufficiency (CRI) is not well established. In addition, the relationship between elevated postprocedural creatinine and ensuing mortality in patients with normal baseline renal function needs to be investigated., Methods: All percutaneous coronary intervention (PCI) patients (n = 12,997) were analyzed for any rise in serum creatinine (SCr): CRI group (BSC > or = 1.5 mg/dl) (n = 1,853) and normal baseline renal function (NBR BSC < 1.5 mg/dl) group (n = 11,144). Patients in each group were analyzed for any elevation in SCr postprocedure and subdivided based on the SCr ratio [peak SCr/Baseline creatinine (BSC)] of <1.25, 1.25-1.5, and >1.5. The overall incidence of CIN (defined as an increment of 25% over baseline creatinine) was 5.9%: 11.3% in the CRI group versus 5.1% in normal BSC group (P < 0.01). Recursive partitioning and Cox hazard modeling were used to assess significant variables associated with mortality within 1 year. Only serum creatinine ratio (SCrR) > 1.5 correlated with increased mortality in both CRI group as well as normal BSC group., Conclusions: SCrR > 1.5 predicts mortality at 1 year after PCI. The association between SCrR > 1.5 and increased mortality at follow-up is observed in patients with CRI as well as normal baseline renal function. SCrR may thus serve as a useful clinical tool for risk stratification and prognostication of patients after PCI., (Copyright 2009 Wiley-Liss, Inc.)

High-density lipoprotein (HDL) cholesterol level is a strong predictor of morbidity and mortality in the general population. Conflicting data exist on the protective effects of high HDL cholesterol in patients with optimal low-density lipoprotein (LDL) cholesterol levels. To determine the association of high HDL cholesterol with mortality in patients with LDL cholesterol levels <70 mg/dl who undergo percutaneous coronary intervention, 3,616 consecutive patients with LDL cholesterol levels <70 mg/dl who underwent percutaneous coronary intervention from July 1, 1999, to June 1, 2007, were retrospectively analyzed and followed through July 1, 2007. All-cause mortality was identified using the National Death Index. The mortality rates was 34.7, 25.2, 23.7, and 18.8 per 1,000 person-years in patients with HDL cholesterol levels of <40, 40 to 49, 50 to 59, and > or =60 mg/dl, respectively (p for trend <0.001). After multivariate adjustment for demographic characteristics, cigarette smoking, biochemical variables, and co-morbid conditions, the hazard ratios for mortality in patients with HDL cholesterol levels of 40 to 49, 50 to 59, and > or =60 mg/dl, compared with their counterparts with HDL cholesterol levels <40 mg/dl, were 0.68 (95% confidence interval [CI] 0.50 to 0.93), 0.55 (95% CI 0.35 to 0.85), and 0.45 (95% CI 0.27 to 0.74), respectively. For each 1-SD increase in HDL cholesterol level (14 mg/dl), the multivariate-adjusted hazard ratio for all-cause mortality was 0.68 (95% CI 0.58 to 0.79). In conclusion, in patients with LDL cholesterol levels <70 mg/dl who underwent percutaneous coronary intervention, a strong inverse association was present between HDL cholesterol level and all-cause mortality.

Background: The present study was done to analyze if glycoprotein IIb/IIIa inhibitors (GPI) bolus-only will reduce vascular/bleeding complications and cost with similar major adverse cardiac events (MACE) when compared with GPI bolus + infusion. Evidence-based therapy of GPI inhibitors during percutaneous coronary intervention (PCI) incorporates intravenous bolus followed by 12 to 18 hours of infusion. However, GPI bolus + infusion may increase vascular/bleeding complications and may not reduce MACE when compared with GPI bolus-only., Methods: From January 1, 2003, to December 31, 2004, 2,629 consecutive patients received GPI during PCI at a single center. Of these, 1,064 patients received GPI bolus + infusion in 2003 and were compared with 1,565 patients that received GPI bolus-only in 2004. Baseline characteristics were similar in both groups., Results: Patients receiving GPI bolus-only had reduced vascular/bleeding complications when compared with bolus + infusion (4.9% vs 7%, P < .05, odds ratio 0.62, 95% confidence interval 0.45-0.89). Furthermore, ischemic complications were similar in both groups, including periprocedural creatine kinase-MB enzyme release (12.8% vs 15.3%, P = NS), MACE at 30 days (3.2% vs 3%, P = NS), and death and myocardial infarction at 1 year (7.1% vs 7.8%, P = NS). In addition, GPI bolus-only reduced cost in US dollars ($323 vs $706, P < .001) and increased ambulatory PCI (13.1% vs 3.2%, P < .01), with reduced length of stay (1.1 vs 1.6 days, P < .01), when compared with GPI bolus + infusion., Conclusions: Glycoprotein inhibitor bolus-only reduces vascular/bleeding complications with similar MACE and reduced cost when compared with GPI bolus + infusion. In addition, GPI bolus-only improved ambulatory PCI and reduced length of stay. These results are consistent with a safer and cost-effective strategy for bolus-only when GPI therapy is considered during PCI.

Patients with diabetes mellitus (DM) have poor long-term outcome after percutaneous coronary intervention (PCI) partly because of microvascular disease and distal embolization. Microvascular obstruction can be assessed by measuring coronary flow reserve (CFR). The Prediction of CK-MB RElease During Successful Stenting Correlating with Indicators of Microvascular ObstruCTion (PREDICT) trial compared the CFR in patients with versus without DM during PCI. Patients undergoing elective PCI were prospectively enrolled according to diabetic (n = 36) and nondiabetic (n = 36) status. All patients received drug-eluting stent with abciximab and were followed for 30-day major adverse cardiac events. CFR and FFR (fractional flow reserve) before and after stenting were measured before and after intracoronary adenosine bolus. Procedural success, MB enzyme of creatine-kinase (CK-MB), troponin I, and high-sensitive C-reactive protein elevation, vascular complications, and major adverse cardiac events were not different. FFR before stenting was 0.77 +/- 0.03 in patients with DM versus 0.76 +/- 0.02 in patients without DM (p = 0.69). FFR after stenting was 0.97 +/- 0.03 and 0.99 +/- 0.01 (p = 0.26), respectively. CFR before stenting was 1.36 +/- 0.31 in patients with DM versus 1.49 +/- 0.25 in patients without DM (p = 0.064). However, CFR after stenting was significantly lower in patients with versus without DM (1.89 +/- 0.30 versus 2.44 +/- 0.67, p <0.001, respectively). CFR after stenting only moderately correlated with CK-MB and high-sensitive C-reactive protein after PCI but did not correlate with 30-day major adverse cardiac events. In conclusion, patients with DM have significantly lower CFR after stenting despite equivalent FFR and myonecrosis compared with patients without DM, indicating greater microvascular obstruction after PCI despite abciximab.

Objectives: The objectives of the present study were to evaluate the feasibility and safety of implanting a prophylactic left ventricular (LV) assist device prior to high-risk percutaneous coronary intervention (PCI) and to assess the impact of suturemediated preclosure of the arteriotomy site on minimizing vascular complications., Background: Patients with multivessel disease, left main coronary artery disease (LMCA) or left main equivalent and/or moderate-to-severe LV dysfunction with elevated LV end-diastolic pressure are at increased risk of complications during PCI. The TandemHeart (TH) is a nonpulsatile percutaneous transseptal ventricular assist device (PTVA) that offers vital temporary hemodynamic support during high-risk PCI., Methods: Between April 2004 and November 2005, the TH was implanted in 20 patients undergoing high-risk PCI. Eight patients underwent unprotected LMCA stenting, and rotational atherectomy was used in 17 patients. Suture-mediated femoral artery preclosure was performed prior to inserting a large-bore arterial cannula., Results: The TH was successfully implanted in all 20 patients. Mean LV ejection fraction of the study patients was 38 +/- 18%. Time-to-implantation of the TH, duration of hemodynamic support and mean flow of the TH device were 31 +/- 9 minutes, 74 +/- 40 minutes and 2.5 +/- 1.3 L/minute, respectively. At the end of PCI, the TH was removed in all cases and Perclose sutures were deployed in 18/20 (90%) patients. There was only 1 minor vascular complication, and the average length of stay was 2 +/- 1 days. Periprocedural and inhospital mortality was 0%., Conclusions: Implantation of the TH PTVA is safe and feasible in patients undergoing high-risk PCI with excellent hemodynamic support. Application of suture-mediated devices prior to large arteriotomies can significantly reduce the incidence of vascular complications.

Objectives: The aim of the present study was to study the outcome of coronary stenting in patients with symptomatic myocardial bridging refractory to standard medical therapy., Background: Medical therapy constitutes the first line treatment for patients with symptomatic myocardial bridge, surgical correction may be offered to select patients with refractory symptoms. Limited data exists on the outcome of coronary stenting in this patient cohort., Methods: Twenty-nine patients with symptoms of angina, documented myocardial ischemia and angiographically documented myocardial bridge of the left anterior descending artery (defined as [mt]50% systolic compression) were identified retrospectively. Seventeen (59%) patients responded to maximized medical therapy (mean age 51 +/- 16 years, range 29-80, 7 female) and 12 (41%) patients received coronary stents following a failed attempt of minimum 3 months of maximal medical therapy (mean age 49 +/- 15 years, range 32-76 years, 5 females). Medical therapy responders were compared with intracoronary stent group for recurrent severe angina, target vessel revascularization (TVR), myocardial infarction (MI), and death at follow-up., Results: Intracoronary stents were placed in all patients successfully. The incidence of recurrent severe angina and TVR were significantly greater in the stent group (P = 0.04) while MI and death in two groups were similar at mean follow-up of 15 +/- 3 months., Conclusions: Coronary stent placement for medically refractory symptomatic myocardial bridge failed to relieve severe angina and is associated with high clinical restenosis and hence should be avoided., (Copyright 2008 Wiley-Liss, Inc.)

Diastolic dysfunction is a poorly understood pathophysiological entity; its importance is magnified by the increasing prevalence of diastolic heart failure. Forty-six million people in the US are experiencing heart failure and 550000 new cases are diagnosed annually. A large percentage of these patients with heart failure have a normal or nearly normal left-ventricular ejection fraction. Isolated diastolic dysfunction may be associated with an increased mortality. One of the major causes of diastolic dysfunction is hypertension. Advances in diagnosis and treatment strategies may improve the clinical outcome for patients with diastolic dysfunction.