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This is a case report of a patient who developed profound thrombocytopenia during treatment with eptifibatide after PCI of the mid right coronary artery., (Copyright 2003 Wiley-Liss, Inc.)

The purpose of this single-center study was to evaluate the long-term (> or =8 years) outcome of Palmaz-Schatz intracoronary stenting and to identify independent predictors of outcome. Although short-term results of Palmaz-Schatz intracoronary stenting have been promising, with a reduction in both angiographic restenosis and clinical cardiac events up to 3 years, longer-term follow-up has not been established. We analyzed clinical outcome in 426 consecutive patients at least 8 years after coronary stenting. Demographic, clinical, and procedural predictors of restenosis, survival, and event-free survival, defined as freedom from death, myocardial infarction (MI), and coronary revascularization (target stented site, target vessel, and any revascularization) were analyzed. Before discharge, 28 patients (6.6%) sustained at least 1 major cardiovascular event: 3 deaths (0.7%), 18 MIs (4.2%), and 17 repeat revascularizations. Surviving patients were followed for 8.9 years (interquartile range 8.4 to 9.4). After discharge, 59 patients (13.9%) died, 47 (11.1%) sustained an MI, and 188 (44.4%) underwent coronary revascularization. The 8-year event-free survival (freedom from death, freedom from death/MI/target-stented site revascularization, and freedom from death/MI/any coronary revascularization) was (mean +/- SE) 0.86 +/- 0.01, 0.62 +/- 0.03, and 0.47 +/- 0.02, respectively. Unstable angina, lower left ventricular ejection fraction, and saphenous vein graft stenting were found to be independent predictors of death during follow-up. Hypertension, unstable angina, multivessel disease, and multiple stent implantation were found to be independent predictors of the composite of death/MI/any coronary revascularization during follow-up. This study provided a useful assessment of very long-term outcome in survival, event-free survival, and predictors of major cardiac events 8 to 10 years after Palmaz-Schatz stent implantation.

Objectives: This study was designed to evaluate the immediate and long-term clinical results of patients undergoing endoluminal reconstruction in diffusely degenerated saphenous vein grafts (SVGs) with elective implantation of one or more less-shortening Wallstents., Background: The optimal treatment strategy for patients with diffusely degenerated SVGs is controversial. Endoluminal reconstruction by stent implantation is one proposed strategy; however, there are few data regarding long-term clinical outcome., Methods: Between May 1995 and September 1998, 6,534 consecutive patients underwent angioplasty in our institution, including 440 who were treated for SVG lesions. Of these, 126 (115 men, 11 women, median age 69.5 years, range: 33-86 years) with old SVGs (mean age: 13+/-5 years) diffusely degenerated stenosed or occluded (mean lesion length: 27+/-12 mm) were treated electively with implantation of one or multiple (total 197) less-shortening Wallstents., Results: Before discharge, 13 patients (10.3%) sustained at least one major cardiovascular event, including 4 deaths (3.2%), 11 myocardial infarctions (MI) (8.7%), and 3 repeat revascularizations (target vessel = 1, nontarget vessel = 2, 2.4%). Surviving patients were followed for 22+/-11 months: 13 patients (11.1%) died, 11 (9.4%) sustained an MI, 37 underwent angioplasty (31.6%), and 4 (3.4%) underwent bypass surgery. The estimated three-year event-free survival rates (freedom from death, and freedom from death/MI/target vessel revascularization) were (mean +/- SE) 81.1+/-7.8% and 43.2+/-18.5%, respectively., Conclusions: The long-term clinical outcome of patients undergoing endoluminal reconstruction in diffusely degenerated SVG is relatively poor, mainly because of a high incidence of death or MI and the frequent need for repeat angioplasty. It is unlikely that percutaneous intervention alone will provide a satisfactory or definitive solution for these patients.

Objectives: We sought to evaluate the long-term clinical outcome of patients undergoing successful balloon angioplasty for in-stent restenosis, and to determine correlates of the need for subsequent target lesion revascularization (TLR)., Background: In-stent restenosis can be safely treated by repeat percutaneous intervention. Reported subsequent TLR rates have varied from 20% to 80% and seem related to the type of restenotic lesion., Methods: The study population comprised 234 patients with follow-up data who were successfully treated with repeat balloon angioplasty for in-stent restenosis in 257 lesions between May 1995 and January 1998 at our institution., Results: Clinical follow-up was available at 459 (286 to 693) days after the repeat procedure. Event-free survival was 78.5% and 74.6% at 12 and 24 months, respectively. Recurrent events occurred in 58 patients (24.8%), including 6 deaths (2.6%), 4 myocardial infarction (1.7%) and repeat target vessel revascularization in 50 patients (21.4%). Independent predictors of repeat TLR were time to in-stent restenosis <90 days (Hazard ratio 4.67, p < 0.001), minimal luminal diameter after repeat procedure (Hazard ratio 0.38, p = 0.034) and the angiographic pattern of in-stent restenosis (Hazard ratio 1.65, p = 0.036)., Conclusions: Balloon angioplasty is an effective means of treating in-stent restenosis. The long-term results are acceptable particularly for focal restenotic lesions. Further restenosis is more common in patients with early initial recurrence, more proliferative lesions and a poorer angiographic result from repeat angioplasty.

The Cepha3DT software is used to generate a 3D model of the human face.

Aims: Vascular complications associated with femoral artery access for interventional cardiological procedures may increase morbidity especially in patients receiving anticoagulants, aspirin, ticlopidine and platelet glycoprotein IIb/IIIa receptor inhibitors. The use of radial arterial access has the potential to reduce the incidence of access site bleeding complications. The purpose of this study was to compare outcomes after the radial and femoral approaches in patients treated with the platelet IIb/IIIa inhibitor, abciximab., Methods and Results: One hundred and fifty consecutive patients treated by abciximab underwent angioplasty by the radial or femoral approach in 83 and 67 cases, respectively. Outcome variables were major cardiac events and major access site bleeding at 1-month follow-up. Freedom from major cardiac events at 1-month follow-up occurred in 78 (93.9%) and 63 (94.0%) patients in the radial and femoral groups, respectively (P=0.99). There were no major access site bleeding complications in the radial group, as opposed to five (7.4%) in the femoral group, P=0.04. Postprocedure length of stay, days (3.7+/-6.0 radial vs 3.7+/-2.6 femoral, P=0.96) as well as total hospital length of stay (5.0+/-4.3 radial vs 4.9+/-3.0 femoral, P=0.72) were similar in both groups., Conclusion: Coronary angioplasty in patients treated by abciximab using the transradial approach is efficacious with fewer major access site complications than with the transfemoral approach., (Copyright 2000 The European Society of Cardiology.)

The authors report the results of percutaneous coronary angioplasty using the radial approach with respect to feasibility and safety. Between February 1994 and December 1998, out of a total of 9,070 coronary angioplasties performed in our Institute, the radial arterial approach was chosen in 5,354 cases (59%). During this period, the proportion of procedures performed via the radial artery progressively increased to 78% of cases in 1998. Cannulation of the radial artery was successful in 5,244 cases (98%). Rotatory atherectomy was used in 96 cases (2%), the excimer laser in 38 cases (1%) and stenting was performed in 3,350 cases (64%). Angiographic success was obtained in 5,224 patients (99%). Serious cardiac complications occurred in 82 patients (1.5%), including 17 deaths (0.3%), 22 Q wave myocardial infarctions (0.4%), 28 non-Q wave infarcts (0.5%), 5 coronary bypass procedures (0.1%) and 10 sub-acute occlusions (0.2%). The vascular complications included 1 death due to an ischaemic cerebrovascular accident, 25 haematomas at the puncture site (0.5%) and 3 surgical arterial repairs. The radial pulse disappeared after the procedure in 4% of cases, all asymptomatic. Angioplasty by the radial artery in the hands of trained operators is feasible and associated with a relatively low rate of cardiac and vascular complications.

Patients with unstable angina have an increased activation of the coagulation system. Aspirin and ticlopidine given in combination may potentiate each other by the combination of different action mechanisms and may reduce the risk of coronary occlusion and clinical instability. Plasma tissue factor (TF) levels collected into the stenotic coronary artery may be an index of TF expression within the vasculature. In 160 patients undergoing angioplasty for a 81+/-5% coronary lesion, we measured TF in blood samples collected from a vein and from the coronary ostium. Immediately after and 10 minutes after the dilation procedures the samples were withdrawn also beyond the lesion. Heparin 150 U/kg was given as an anticoagulant. All patients were pretreated with 250 mg/day of aspirin. One hundred twenty patients were randomly assigned to receive 24, 48, or 72 hours of ticlopidine treatment (250 mg/twice daily). TF levels did not increase during angioplasty but there was a significantly higher TF expression in unstable than in stable patients, irrespective of the invasiveness of debulking procedures. When ticlopidine was given for 72 hours, TF levels were similar to normal laboratory values both in stable and unstable patients. This combined antiplatelet pretreatment may be of benefit in unstable angina patients, with a favorable cost/benefit ratio.

The authors report the immediate and medium term results of percutaneous angioplasty of unprotected left main coronary disease with systematic stenting. Between March 1994 and December 1998, out of 6,006 patients undergoing coronary angioplasty, 92 had significant unprotected left main stem disease. The majority of patients was male (74 men, 80%) with an average age of 74.3 +/- 8.1 years. Between March 1994 and October 1996, only patients with a surgical contraindication were treated by angioplasty (n = 39). After October 1996, the indications were extended to patients who did not have surgical contraindications (n = 53). During the hospital phase, 4 patients (4%) died (ventricular arrhythmia: 1, cardiogenic shock: 2, gastro-intestinal haemorrhage: 1). No non-fatal infarction with or without Q waves were observed, and no emergency coronary bypass surgical procedures were required. The angiographic success rate was 100%. During follow-up (7.3 +/- 5.8 months), 6 other patients died, 13 required a repeat coronary angioplasty, 4 for restenosis of the left main coronary artery, and 2 underwent coronary bypass surgery. The actuarial survival rate was 89 +/- 5% at 1 year and 85 +/- 17% at 3 years. Percutaneous angioplasty for unprotected left main coronary disease with systematic stenting was performed with acceptable hospital and medium term results.

Degeneration of venous aorto-coronary bypass grafts results in a reduction in their patency: 60% are patent at 10 years and only 50% are disease-free. Balloon angioplasty has been proposed as a therapeutic alternative to surgical reoperation. This delicate technique is associated with immediate, medium and long-term results which are less satisfactory than those obtained on the native coronary vessels. The risk of distal embolisation influences the immediate operative results. Restenosis, more common than after angioplasty of native vessels, and the progression of atherosclerosis, explain the mediocre long-term results. Of all the techniques of interventional cardiology, coronary stenting seems to provide the best results, especially on short, focal lesions. The immediate and long-term results are more disappointing in cases of diffuse degeneration of the graft. The pre-, peri- and postoperative medical environment, especially treatment with platelet inhibitors and statins, seems to play a decisive part in the improvement of long-term clinical results.

The use of the c2000 software led us to develop a new 3D cephalometric construction, based on the selection on the axial CT Scans of 8 anatomical landmarks and of teeth, all of which were situated along the trigeminal neuro matriciel facial growth axes. The analysis of this construction is based on the use of an original mathematical tool in biology: the axes of inertia. Using the selection of both mental foramen, both infra and supra orbital foramen and the head of both malleus, the C 2000 software creates a geometrical construction called: "the maxillo-facial frame", as well as, a 3D cephalometric analysis: angles, distances, areas, volumes center of gravity and axes of inertia. Using the selection of teeth, the C 2000 software calculates the axes of inertia of each tooth or of groups of teeth. The use of the axes of inertia allow us to create of a hierarchy of anatomical levels the teeth, the half arches, the arches, both arches and the maxillo-facial frame. In addition, for each of these anatomical levels, the axes of inertia create a 3D landmark which allows the calculation of the orientation of each of these elements in relation to the others. The study of 28 orthomorphic people using this analysis revealed the existence of a maxillo-facial balance that is unique for each individual.

Balloon angioplasty in diabetics is associated with acceptable immediate results but with high rates of restenosis, target vessel revascularization, and late mortality. The impact of coronary stenting on the outcome of these patients remains controversial. We reported the immediate and mid-term clinical outcome of 272 consecutive diabetic patients, representing 12.5% of the population undergoing coronary stenting between May 1995 and April 1997. Diabetes mellitus was insulin-requiring in 58 patients and non-insulin-requiring in 214. Stenting performed on large vessels (mean diameter >/=3 mm) was successful in 99.2% of nondiabetic patients and in all cases in diabetics. During in-hospital stay, the complications rate, including mortality, nonfatal myocardial infarction, emergency coronary bypass surgery, and stent subacute thrombosis, was similar in nondiabetic patients, insulin-requiring, and non-insulin-requiring diabetics (2.55%, 0%, and 2.0%, respectively). No complication occurred in the insulin-requiring group. One patient (0.5%) died from myocardial infarction and another (0.5%) presented a nonfatal myocardial infarction (subacute stent thrombosis) in the non-insulin-requiring group. The clinical follow-up (mean length 13 +/- 8 months) was obtained in 93% and 97% of the insulin-requiring and non-insulin-requiring diabetics, respectively. Overall mortality was significantly higher in insulin-requiring patients (9.3% vs. 2.4%). Nonfatal myocardial infarction and target lesion revascularization rates were similar in the two groups (0% vs. 0.5% and 8.2% vs. 10.5%). These results suggest that coronary stenting in diabetics could be performed with acceptable immediate and mid-term results. Cathet. Cardiovasc. Intervent. 47:279-284, 1999., (Copyright 1999 Wiley-Liss, Inc.)

The object of this study was to assess the feasibility, efficacy and risks of ablation of common atrial flutter using a single catheter electrode. Recent studies have shown that radiofrequency ablation is effective for interrupting atrial flutter but with a variable rate of recurrence. Therefore, the search for a conduction block in the isthmic region has become the reference method for reducing the incidence of recurrence but this requires the use of costly material. The necessity of single usage has incited research to find a less costly method without compromising efficacy. The authors reviewed the results in 70 consecutive patients with common atrial flutter resistant to anti-arrhythmic medication. The site of ablation was located using anatomical landmarks and electrophysiological criteria. The anatomic site was situated either on a lateral isthmus or, to a variable degree, a septal isthmus; the electrophysiological criterion was an endocavitary auriculogramme, the amplitude of which had to decrease by more than 2/3 after application of the radiofrequency. The technique was interrupted not after the interruption of the flutter but after obtaining a microvoltage atrial activity along the isthmus. Radiofrequency energy of 10 to 50 W was delivered at each site for 90 seconds. Atrial flutter was interrupted in all 70 patients (100%). The average number of applications to interrupt the flutter was 12.67 and to create a microvoltage barrier 14.58. The average duration of the radiofrequency procedure was 50.43 minutes. After an average of six months' follow-up, the recurrence rate was 13%: 9 patients, 5 of whom underwent a second session of radiofrequency ablation. There were no immediate complications after this method of ablation.

Since the extensive use of abciximab, a potent antiplatelet agent directed against GP IIb/IIIa platelet receptors, to prevent ischemic complications of percutaneous transluminal coronary angioplasty, few cases of thrombocytopenia have been observed. This paper reports a case of acute profound thrombocytopenia (platelet count: 800/mm3) occurring 16 h after abciximab therapy during coronary angioplasty. As thrombocytopenia occurrence is not predictable, platelet count should be evaluated periodically after drug administration. Mechanisms of this adverse effect remain unknown. Platelet transfusion results in a rapid and sustained improvement of platelet count, avoiding the occurrence of major hemorrhagic complications.

From March 1994 to September 1996, 39 patients underwent stenting of the unprotected left main coronary artery because of high surgical risk. Stenting appeared to improve clinical outcome, but there was a significant mortality rate at long-term follow-up.

The authors report the case of a 70 year old woman with frequent attacks of supraventricular tachycardia resistant to antiarrhythmic therapy. The tachycardia was irregular with predominantly normal QRS complexes. Electrophysiological investigation showed dual conduction in the atrioventricular node and tachycardia was induced by atrial extrastimulus. However, reentrant tachycardia could not be induced, the refractory period of the slow pathway being much longer than that of the rapid pathway. The mechanism of the tachycardia was simultaneous conduction of the sinus rhythm through the two nodal conduction pathways. This was successfully treated by radiofrequency ablation of the slow pathway.

Introduction and Objectives: Intracoronary stenting has been proposed as an adjunct to balloon angioplasty in order to improve the immediate and long-term results. The purpose of this study was evaluate the short-term results, subacute closure rate and to try to identify angiographic predictors of subacute thrombotic after Palmaz-Schatz stent implantation., Methods: Through a prospective registry, we have evaluated in 500 patients the safety and efficacy of Palmaz-Schatz stent implantation (580 in total) in coronary arteries and saphenous vein grafts. The identification of clinic and angiographic predictors of subacute closure have been evaluated with the assistance of a BMDP statistical software using an univariate and multivariate statistical analysis (logistic regression). The determination of diameter and stenosis has been achieved by electronic caliper., Results: The stent was implanted successfully in 98.6% of the patients. There was no abrupt closure (< or = 1 day), however 36 patients (7.2%) developed subacute thrombotic closure (among 2nd-21st day after stenting). The major complications were: death 9 patients (1.8%), bypass surgery 7 patients (1.4%) and myocardial infarction 21 patients (4.2%). The predictors of subacute thrombotic closure through univariate statistical were: stenting for bail-out (S.T.: 27%; p < or = 0.0001), multiple stenting (S.T.: 24.1%; p < or = 0.0001), final diameter stent < or = 3.25 mm (S.T.: 12.6%; p < or = 0.013), and left ventricular ejection fraction < or = 45% (S.T.: 15.7%; p < or = 0.022). We showed with logistic regression that final diameter stent < or = 3.25 mm; p < or = 0.0030, left ventricular ejection fraction < or = 45%; p < or = 0.0012, stenting for bail-out; p < or = 0.0195 and multiple stenting; p < or = 0.0252, were predictors of subacute thrombotic closure., Conclusions: The Palmaz-Schatz coronary stenting will preferably realize in those arteries bigger than 3.25 mm and left ventricular ejection fraction > 45%, showing multiple stenting and stenting for bail-out greater subacute thrombotic closure rate.

The authors report four observations: three are essentially clinical cases where sustained rate dependent left bundle branch block can induce syncope, where as there is no syncope when the same supraventricular tachycardia at the same frequency has narrow QRS complexes. The fourth case demonstrates the dramatic decrease of arterial electrophysiological slowly accelerated atrial pacing in a patient investigated for a loss of consciousness of unknown origin. The hemodynamic impairment due to intermittent left bundle branch block has been demonstrated even in patients with normal ventricular function. If there are critical hemodynamic events such as during fast supraventricular rhythms occurrence of a left bundle branch block may determinate a dramatic decrease of arterial pressure with syncope. Syncope of supraventricular tachycardias might be induced not only by very fast rate but also by functional left bundle branch block. It might have some interesting applications in the diagnosis of syncope when coexist electrophysiological data of supraventricular arrhythmia substrate and frequency dependent left bundle branch block.

The aim of this study was to compare the electrophysiologic properties of asymptomatic Wolff-Parkinson-White (WPW) syndromes with those of symptomatic WPW, and in particular the anterograde refractory period of the accessory tract and atrial vulnerability. This retrospective study involved 171 patients with WPW seen in their surface electrocardiogram, untreated, having undergone standard invasive electrophysiologic investigation. These patients were divided into two groups: group I consisting of 42 asymptomatic patients and group II consisting of 129 asymptomatic patients. 1) The mean anterograde refractory period (mean ARP) did not differ statistically between group I (330 +/- 97 msec) and group II (311 +/- 110 msec). The mean minimum interval between two preexcited complexes during atrial fibrillation (mean RR min) did not differ statistically between group I (313 +/- 80 msec) and II (300 +/- 105 msec). The mean retrograde refractory period (mean RRP) was significantly (p < 0.001) longer in group I (416 +/- 126 msec) than in group II (307 +/- 75 msec). 2) A reciprocal tachycardia was induced in 95% of cases in group II (122 patients) as compared with 9.5% of cases in group I (4 patients), with a very significant (p < 0.001) difference. Atrial fibrillation was induced in 24% of cases in group I (10 patients) and 34% of cases in group II (44 patients), the difference not being significant. 3) The incidence of potentially serious forms did not differ statistically between groups I and II. Nine patients in group I (21.4%) and 49 patients in group II (38%) had rapid anterograde conduction in the accessory tract (ARP or RR < or = 250 msec).(ABSTRACT TRUNCATED AT 250 WORDS)

Direct coronary angioplasty as an emergency procedure in the first hours of myocardial infarction without prior thrombolytic therapy requires a heavy infrastructure. The different results reported in the literature show a recanalisation rate of 90% with an average hospital mortality of 7%, an acceptable risk given the inclusion of patients of over 75 years of age in these series and cases of cardiogenic shock. The reocclusion rate in the hospital phase is between 10 and 15%. At medium term, the survival rates of single vessel disease are excellent but the mortality is higher in multivessel disease (78% survival at 2 years). Angioplasty performed in the first three hours after the onset of symptoms is associated with an improvement in global an regional left ventricular function in patients with anterior infarction and altered initial left ventricular function. The preliminary results of a randomised multicenter trial comparing direct angioplasty with intravenous thrombolytic therapy with rt-PA (PAMI) seem to show in favour of angioplasty with a lower rate of complications in the hospital phase. The results of this multicenter trial should provide information as to the exact role of direct angioplasty in the initial phase of infarction, a procedure reserved for well-equipped cardiological centres with highly trained invasive cardiologists.