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OBJECTIVE: To study clinical outcomes in patients given glycoprotein (GP) IIb/IIIa inhibitors with concomitant clopidogrel at the time of ad hoc percutaneous coronary interventions (PCI). PATIENTS AND METHODS: We studied 30-day and long-term outcomes of patients undergoing elective or urgent PCI from March 1, 1998, to December 31, 2006, stratified by administration of GP IIb/IIIa inhibitors with concomitant clopidogrel treatment at the time of ad hoc PCI. RESULTS: The mean+/-SD age was 66.3+/-11.9 years in 5196 patients receiving compared with 67.8+/-11.8 years in 4681 patients not receiving a GP IIb/IIIa inhibitor (P<.001). Overall, 30-day unadjusted mortality was lower in patients who received a GP IIb/IIIa inhibitor (1.0% vs 1.2%; P=.22). Long-term mortality was significantly lower (P<.001) in patients receiving GP IIb/IIIa inhibitors at the time of PCI. After propensity analysis to adjust for the likelihood of receiving GP IIb/IIIa inhibitors on the basis of clinical, angiographic, and procedural characteristics, a significant reduction in 30-day mortality with GP IIb/IIIa inhibitor use was identified (hazard ratio, 0.56; 95% confidence interval, 0.36-0.87; P=.01). Kaplan-Meier analysis (median follow-up, 48 months) revealed a significant improvement in long-term survival in patients receiving a GP IIb/IIIa inhibitor at the time of ad hoc PCI that persisted after propensity adjustments (hazard ratio, 0.88; 95% confidence interval, 0.79-0.98; P=.021). Patients treated with drug-eluting stents showed a significant improvement in adjusted long-term mortality. CONCLUSION: In patients undergoing elective or urgent ad hoc PCI, coadministration of a GP IIb/IIIa inhibitor and dual antiplatelet therapy is associated with reduced risk-adjusted 30-day and long-term mortality. [ABSTRACT FROM AUTHOR]

We describe a 61-year-old woman with 'broken heart syndrome' (Takotsubo-like cardiomyopathy) after abrupt postsurgical withdrawal of OxyContin. Her medical history was remarkable for long-term opiold dependence associated with the treatment of multi-Joint degenerative osteoarthritis. The patient presented to the emergency department 1 day after discharge from the hospital following total knee arthroplasty revision with acute-onset dyspnea and mild chest pain. She had precordial ST-segment elevation characteristic of acute myocardial infarction and elevated cardiac biomarkers. Emergency coronary angiography revealed no major coronary atherosclerosis. However, the left ventricular ejection fraction was severely decreased (26%), and new regional wall motion abnormalities typical of broken heart syndrome were noted. In addition to resuming her opioid therapy, she was treated supportively with bilevel positive airway pressure, diuretic therapy, morphine, aspirin, metoprolol, enalaprilat, intravenous heparin, nitroglycerin infusion, and dopamine infusion. Ventricular systolic function recovered completely by the fourth hospital day. To our knowledge, broken heart syndrome after opioid withdrawal has not been reported previously in an adult. Our case illustrates the importance of continuing adequate opiate therapy perioperatively in the increasing number of opioid-dependent patients to prevent potentially life-threatening complications such as broken heart syndrome. [ABSTRACT FROM AUTHOR]

Objective: To explore the safety and efficacy of FFR-guided percutaneous coronary intervention (PCI) in vessels with severe diameter stenosis., Methods & Results: Of 1090 patients undergoing fractional flow reserve (FFR) assessment from 2002 to 2009, we identified 167 patients in whom FFR was measured in at least one 70%-89% stenotic lesion. These patients were subdivided into an FFR-defer group ( n = 49) if PCI was deferred (FFR > 0.80), and an FFR-perform group ( n = 118) if PCI was performed (FFR ≤ 0.80). Comparatively, an additional 1176 patients undergoing PCI in at least one lesion with 70%-89% stenosis but without measurement of FFR served as a control (angiography-guided) group. Clinical outcomes were compared during a median follow-up of 49.0 months. The 5-year Kaplan-Meier estimated revascularization rates were 16% in the FFR-defer group and 33% in the FFR-perform group ( P = 0.046). The incidence of major adverse cardiac events were comparable in these two groups (HR = 0.82, 95% CI: 0.37-1.82, P = 0.63). The number of stents placed was significantly lower in the FFR-guided group (0.9 ± 0.8 vs. 1.4 ± 0.8, P < 0.001)., Conclusions: Functional revascularization for lesions with visually severe stenosis is clinically safe and associated with fewer stents use. This study suggests that extending the use of FFR to more severe coronary lesions may be reasonable.

Background: Objective measures of frailty have not been well defined as risk factors for a poor outcome after transcatheter aortic valve insertion. We hypothesized that assisted care as a baseline patient characteristic was a simple objective measure of frailty. We reviewed our experience to assess for an association between assisted care and outcome of operation., Methods: We retrospectively reviewed the records of 597 patients operated with transcatheter aortic valve insertion from November 2008 through July 2015. The study cohort included patients with a dichotomous baseline characteristic of receiving assisted care (AC group, n = 60, 10.1%) or not receiving assisted care (NC group, n = 537, 89.9%). The endpoints of the study were operative stroke/death and 1-year survival., Results: The age of the patients was 80.6 ± 9.0 years, male sex was present in 349 (58.5%), and STS predicted risk of mortality was 9.2 ± 6.2%. Alternate access was used in 26 (43.3%) patients in the AC care group and in 220 (41.0%) in the NC group (P = 0.724). Operative stroke/death occurred in 4 (6.7%) patients in the AC group and in 25 (4.7%) in the NC group (P = 0.492). Mortality at 1 year in the AC group was 14.8 ± 5.2% and in the NC group was 12.9 ± 1.7%; (P = 0. 250)., Conclusions: Assisted care as a baseline patient characteristic does not result in increased operative stroke/death or 1-year mortality in patients following transcatheter aortic valve insertion. Assisted care should not by itself preclude operation. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Objectives: To determine the feasibility of automated co-registration of angiography and intravascular ultrasound (IVUS) to facilitate integration of these two imaging modalities in a synchronous manner., Background: IVUS provides cross-sectional imaging of coronary arteries but lacks overview of the vascular territory provided by angiography. Co-registration of angiography and IVUS would increase utility of IVUS in the clinical setting., Methods: Forty-nine consecutive patients undergoing surveillance for cardiac allograft vasculopathy with angiography and IVUS of the left anterior descending artery (LAD) were enrolled. A pre-IVUS angiogram of the LAD was performed followed by an ECG-triggered fluoroscopy (ECGTF) during IVUS pullback at 0.5 mm/s using an automatic pullback device. ECGTF was used to track the IVUS catheter during pullback and establish a spatial relationship to the pre-IVUS angiogram. Angio-IVUS co-registration was performed with a research prototype (Siemens Healthcare, Germany) and accuracy was evaluated by distance mismatch between angiography and IVUS images at vessel bifurcations., Results: Median age was 54 (44.5, 67) years. The population was 82.6% male with minimal risk factors. The median (IQR) co-registration distance mismatch measured at 108 bifurcations in 42 (85%) patients was 0.35 (0.00-1.16) mm. Seven patients were excluded due to inappropriate data acquisition (n = 3) and failure of tracking (n = 4), e.g., due to overlapping sternal wires. Estimated effective radiation dose for ECGTF was 0.09 mSv., Conclusion: This study demonstrates the feasibility of angio-IVUS co-registration which may be used as a clinical tool for localizing IVUS cross-sections along an angiographic roadmap. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Background: Prior publications note increased adverse events after transapical compared with transfemoral access transcatheter aortic valve insertion (TAVI). We reviewed our TAVI experience to understand the differences in baseline patient characteristics and outcomes associated with the two access methods., Methods: The records were reviewed of 567 patients who underwent transfemoral (n = 351, 61.9%) and transapical (n = 216, 38.1%) TAVI from November 2008 through July 2015., Results: Compared with patients who underwent transfemoral access, the patients who underwent transapical access were older (82.0 ± 7.5 versus 79.6 ± 9.7 years; p = 0.006), had more peripheral vascular disease (78.2% versus 54.7%; p < 0.001), more previous coronary artery bypass graft operations (50.9% versus 32.5%; p < 0.001), and higher Society of Thoracic Surgeons predicted risk of mortality (9.4% ± 5.4% versus 8.8% ± 6.5%; p = 0.032). In-hospital and 30-day mortality rates, however, were similar between the two groups (transapical, n = 7, 3.2%; transfemoral, n = 13, 3.7%; p = 0.772). Follow-up echocardiography in 547 (100.0%) surviving patients at a median of 182 days (interquartile range, 35 to 420) demonstrated less paravalvular regurgitation grade of moderate or greater in patients who underwent transapical access (transapical, n = 6, 2.9%; transfemoral, n = 35, 10.4%; p = 0.001) but similar ejection fraction in the two groups (transapical, 55.4% ± 12.2%; transfemoral, 55.9% ± 13.0%; p = 0.419). Mortality rates at 1 year (transapical, 19.2% ± 3.0%; transfemoral,14.7% ± 3.2%) and 4 years (transapical, 47.4% ± 6.4%; transfemoral, 42.7% ± 4.9%) were also similar between the two groups (p = 0.342)., Conclusions: Transapical and transfemoral transcatheter aortic valve insertions result in similar operative and longer term mortality rates, despite differences in baseline patient risk. The findings support the concept that access does not influence treatment-related mortality rates., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Extreme-risk patients (ie, Society of Thoracic Surgeons [STS] risk 15% or higher) with severe aortic valve stenosis may not obtain mortality benefit from aortic valve replacement (AVR). We reviewed our experience with this group of patients to better understand our triage process and outcomes., Methods: We performed a retrospective review of 97 patients with severe aortic valve stenosis and STS risk of 15% or higher treated from 2008 through 2013. The median patient age was 85 years (minimum, 44; maximum, 97 years), and 47 patients (48.5%) were male. The STS risk of mortality was 19.8% (minimum, 15.1%; maximum, 60.9%). Patients were assigned to treatment groups based on the first aortic valve intervention of balloon aortic valvuloplasty (BAV group, 66 [68%]) or de novo AVR (d-AVR group, 31 [32%])., Results: Patients in the BAV group were sicker, with a reduced ejection fraction (0.35 vs 0.57; p = 0.002) and greater prevalence of urgent/emergency operative status (32% vs 10%; p = 0.004) compared with those in the d-AVR group. After BAV, 33 patients (50%) demonstrated clinical improvement and went on to receive subsequent staged AVR after a median of 64 days (minimum, 3; maximum, 390 days). The mortality rate at 2 years was worse in the BAV group (57.3% ± 6.3%) than in the d-AVR group (29.5% ± 8.3%; p = 0.015), but was similar in patients who received BAV followed by staged AVR and de novo AVR (p = 0.426)., Conclusions: BAV may triage select patients with STS risk 15% or higher who are questionable candidates for AVR. Patients with clinical improvement after BAV experience benefit from staged AVR., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The finding of a mobile calcific plaque attached to the aortic valve cusp during transcatheter aortic valve implantation (TAVI/TAVR) necessitated utilization of an embolic protection device, for cerebral protection. We report the urgent but successful deployment of such a filter in a patient with a single patent internal carotid artery. Although stroke rates observed in first-generation TAVI trials were higher than those reported following conventional open aortic valve replacement, adjunctive neuroprotective measures, particularly in patients with a large amount of threatened cerebral territory, may minimize potential neurologic injury., (© 2014 Wiley Periodicals, Inc.)

Smoke-free ordinance implementation and advances in smoking cessation (SC) treatment have occurred in the past decade; however, little is known about their impact on SC in patients with coronary artery disease. We conducted a retrospective cohort study of 2,306 consecutive patients from Olmsted County, Minnesota, who underwent their first percutaneous coronary intervention (PCI) from 1999 to 2009, and assessed the trends and predictors of SC after PCI. Smoking status was ascertained by structured telephone survey 6 and 12 months after PCI (ending in 2010). The prevalence of smoking in patients who underwent PCI increased nonsignificantly from 20% in 1999 to 2001 to 24% in 2007 to 2009 (p = 0.14), whereas SC at 6 months after PCI decreased nonsignificantly from 50% (1999 to 2001) to 49% (2007 to 2009), p = 0.82. The 12-month quit rate did not change significantly (48% in 1999 to 2001 vs 56% in 2007 to 2009, p = 0.38), even during the time periods after the enactment of smoke-free policies. The strongest predictor of SC at 6 months after PCI was participation in cardiac rehabilitation (odds ratio [OR] 3.17, 95% confidence interval [CI] 2.05 to 4.91, p <0.001), older age (OR 1.42 per decade, 95% CI 1.16 to 1.73, p <0.001), and concurrent myocardial infarction at the time of PCI (OR 1.77, 95% CI 1.18 to 2.65, p = 0.006). One-year mortality was lower in the group of smokers compared with never smokers (3% vs 7%, p <0.001). In conclusion, SC rates have not improved after PCI over the past decade in our cohort, despite the presence of smoke-free ordinances and improved treatment strategies. Improvements in delivery of systematic services aimed at promoting SC (such as cardiac rehabilitation) should be part of future efforts to improve SC rates after PCI., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Sex-specific differences affect the evaluation, treatment, and prognosis of coronary artery disease. We tested the hypothesis that long-term outcomes of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) are different between women and men., Methods and Results: Consecutive 1090 patients, referred for PCI and undergoing FFR measurements at the Mayo Clinic between October 2002 and December 2009, were included in this registry study. Clinical events were compared between the sexes during a median follow-up of 50.9 months. Of all patients, women had higher FFR adjusted by visual coronary stenosis than men (P=0.03). The Kaplan-Meier percent of major adverse cardiac events at 5 years was 35% in women and 38% in men (P=0.54). Interestingly, in patients undergoing PCI with an FFR <0.75, the incidence of death or myocardial infarction was significantly higher in women than in men (hazard ratio, 2.16; 95% confidence interval, 1.04-4.51; P=0.04). Moreover, compared with patients with FFR >0.80, deferral of PCI for those with FFR between 0.75 and 0.80 was associated with an increased rate of major adverse cardiac events, particularly death or myocardial infarction in women (hazard ratio, 3.25; 95% confidence interval, 1.56-6.74; P=0.002) and revascularization in men (hazard ratio, 2.66; 95% confidence interval, 1.66-4.54; P<0.001)., Conclusions: Long-term outcome differs between women and men undergoing FFR-guided PCI. Our data suggest that the sex-based treatment strategy is necessary to further optimize prognosis of patients with coronary artery disease.

This paper reports the outcomes of patients initially deemed inoperable for standard aortic valve replacement who received transcatheter aortic valve insertion. Each patient experienced a transcatheter valve insertion complication and was then subsequently reconsidered for urgent standard valve replacement. We review the outcomes of these inoperable patients and discuss recommendations for managing this complication., (© 2013 Wiley Periodicals, Inc.)

Aims: Fractional flow reserve (FFR) is the reference standard for the assessment of the functional significance of coronary artery stenoses, but is underutilized in daily clinical practice. We aimed to study long-term outcomes of FFR-guided percutaneous coronary intervention (PCI) in the general clinical practice., Methods and Results: In this retrospective study, consecutive patients (n = 7358), referred for PCI at the Mayo Clinic between October 2002 and December 2009, were divided in two groups: those undergoing PCI without (PCI-only, n = 6268) or with FFR measurements (FFR-guided, n = 1090). The latter group was further classified as the FFR-Perform group (n = 369) if followed by PCI, and the FFR-Defer group (n = 721) if PCI was deferred. Clinical events were compared during a median follow-up of 50.9 months. The Kaplan-Meier fraction of major adverse cardiac events at 7 years was 57.0% in the PCI-only vs. 50.0% in the FFR-guided group (P = 0.016). Patients with FFR-guided interventions had a non-significantly lower rate of death or myocardial infarction compared with those with angiography-guided interventions [hazard ratio (HR): 0.85, 95% CI: 0.71-1.01, P = 0.06]; the FFR-guided deferred-PCI strategy was independently associated with reduced rate of myocardial infarction (HR: 0.46, 95% CI: 0.26-0.82, P = 0.008). After excluding patients with FFR of 0.75-0.80 and deferring PCI, the use of FFR was significantly associated with reduced rate of death or myocardial infarction (HR: 0.80, 95% CI: 0.66-0.96, P = 0.02)., Conclusion: In the contemporary practice, an FFR-guided treatment strategy is associated with a favourable long-term outcome. The current study supports the use of the FFR for decision-making in patients undergoing cardiac catheterization.

Transcatheter aortic valve insertion is an accepted treatment for select patients at high-risk for standard aortic valve insertion. Constraints imposed by the Food and Drug Administration, Centers for Medicare and Medicaid Services, and the PARTNER Trial Executive Committee require a transfemoral approach in certain patients. The presence of aortoiliac aneurysms, occlusive disease, and excessive vessel tortuosity may create difficulties for safe transfemoral access. We report a case in which the limitation of severe iliac artery occlusive disease was overcome by placement of an abdominal aortic endovascular graft that subsequently allowed successful transfemoral access and transcatheter aortic valve implantation., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Alcohol septal ablation has emerged as a therapy for patients with obstructive hypertrophic cardiomyopathy (HCM). However, there are limited data on the predictors of success with the procedure., Methods: We examined patient characteristics and cardiac morphology as well as procedural data on 166 HCM patients (mean age, 63 years; 43% men), who underwent ablation at Mayo Clinic. Patients were contacted to determine vital status and symptoms to assess the primary endpoint of survival free of death and severe symptoms (New York Heart Association, class III or IV dyspnea)., Results: The strongest patient characteristics that predicted clinical success were older age, less severe left ventricular outflow tract gradient, lesser ventricular septal hypertrophy, and a smaller left anterior descending (LAD) diameter. Mitral valve geometry or ventricular septal morphology did not predict outcome. Patients with ≥3 characteristics (age ≥65 years, gradient <100 mmHg, septal hypertrophy ≤18 mm, LAD diameter <4.0 mm) had superior 4-year survival free of death and severe symptoms (90.4%) in comparison to those with two characteristics (81.6%) and ≤1 characteristic (57.5%). Case volume with >50 patients was an independent predictor of survival free of severe symptoms. The volume of alcohol injected, number of arteries injected, or size of septal perforator artery were not predictive of clinical success., Conclusions: Greater case volume and selection for key patient and anatomic characteristics are associated with superior outcomes with alcohol septal ablation., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: High sensitivity C-reactive protein (hsCRP) has been identified as a predictor of adverse cardiovascular outcomes. Whether hsCRP is a useful biomarker for risk stratification in contemporary percutaneous coronary intervention remains unknown., Methods and Results: We conducted a prospective study among 513 patients undergoing non-emergency percutaneous coronary intervention and examined the relationship between pre- and postprocedural hsCRP levels and outcomes. The patients were divided according to the median preprocedural hsCRP level (0.3 mg/dL). Patients with high hsCRP had significantly more adverse clinical characteristics. Preprocedural hsCRP level was an independent predictor of periprocedural myocardial infarction (odds ratio per doubling of hsCRP 1.15 [95% confidence interval, 1.01-1.31]; P=0.038). Unadjusted mortality (29.7% versus 9.9%; P<0.001) and the combined end point of death or myocardial infarction (36.5% versus 16.0%, P<0.001) during a follow-up of 5 years were markedly greater in patients with high preprocedural hsCRP. Similar relationships existed for postprocedural hsCRP. However, after multivariable adjustment, neither preprocedural hsCRP levels (hazard ratio per doubling 0.96 [0.92, 1.00]; P=0.066) nor postprocedural hsCRP levels (hazard ratio 0.98 [0.94, 1.02]; P=0.27) were significantly associated with mortality., Conclusions: High hsCRP is associated with a greater independent risk of periprocedural myocardial infarction, as defined by the universal definition, but is not an independent determinant of mortality after percutaneous coronary intervention. Our findings suggest that routine measurement of hsCRP in patients undergoing percutaneous coronary intervention in contemporary practice is unlikely to be beneficial.

Purpose: A prospective nonrandomized multicenter registry of 160 patients with severe carotid stenosis and high-risk features for carotid endarterectomy was conducted during the 3-month period from March to May 2005., Methods: Carotid artery stenting (CAS) was performed with the SpideRX™ Embolic Protection System (ev3, Inc., Plymouth, MN, USA) as part of an investigational device exemption from the Food and Drug Administration., Results: The primary end-point of major adverse cardiac and cerebrovascular events at 30 days after CAS was observed in nine patients (5.6%), including death in four patients (2.5%), nonfatal stroke in five patients (3.1%), and nonfatal myocardial infarction in one patient (0.6%). A secondary end-point of technical success (defined as successful deployment of all devices, filter retrieval, and final diameter stenosis <50%) was achieved in 156 of 160 patients (97.5%). The only independent predictor of death or stroke at 30 days was baseline stenosis severity (P < 0.05)., Conclusion: CAS with distal embolic protection using the SpideRX™ Embolic Protection System is a reasonable alternative for revascularization of some high-risk patients with severe carotid stenosis., (©2010, Wiley Periodicals, Inc.)

Background: In clinical trials, drug-eluting stents (DES) improve clinical outcomes but are more expensive than bare-metal stents (BMS)., Objective: To assess clinical and economic outcomes of all percutaneous coronary intervention (PCI) procedures in a general interventional cardiology practice before and after DES introduction in 2003., Methods: We identified all patients undergoing PCI in 2000-2002 (early cohort, pre-DES era) and from 2004 through April 31, 2006 (late cohort, DES era) in a large PCI registry. Logistic and Cox proportional hazard models estimated the risk of adverse events; generalized linear modeling predicted economic outcomes., Results: We compared 4303 early-cohort patients with 3422 late-cohort patients. Most early-cohort patients (90%) had BMS implanted; the rest had atherectomy or balloon angioplasty only. Among late-cohort patients, 83% had DES, 14% BMS, and 6% balloon angioplasty or atherectomy only. In-hospital adverse-event rates and incidence of death or myocardial infarction (during a median follow-up of 22 months) were similar. Follow-up procedures were significantly fewer in the later era (hazard ratio for target lesion revascularization: 0.58; 95% confidence interval [CI], 0.50-0.68). Although catheterization lab supply costs were higher in the DES era, length of stay following index PCI and overall practice costs were reduced, on average, 0.40 days and $2053 in the late cohort (95% bootstrapped CI of adjusted mean difference, -$2937 to -$1197). Follow-up cardiac hospitalization costs were similar at 1 year., Conclusions: Patients undergoing PCI following DES introduction experienced improved clinical outcomes during follow-up and reduced overall procedural costs, despite higher stent acquisition costs.

Objectives: The current study was designed to determine whether drug-eluting stents (DES) are superior to bare-metal stents (BMS) in patients with stable angina., Background: Percutaneous coronary intervention has been shown to decrease symptoms of angina; its use for stable angina has not been shown to reduce myocardial infarction or mortality., Methods: We conducted a retrospective, cross-sectional analysis of prospective data comparing the use of BMS versus DES in patients who met criteria used by the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) study investigators. The primary outcome was a composite of death, myocardial infarction, stroke, and revascularization on follow-up., Results: The 1-year primary event rate was 15% in the DES group (95% confidence interval [CI]: 11% to 18%), compared with 27% in the BMS group (95% CI: 23% to 31%, p < 0.001). A Cox proportional hazard regression model was used to adjust for differences in patient characteristics and showed a 1-year DES hazard ratio of 0.51 (95% CI: 0.36 to 0.71, p < 0.001). After 1 year, event rates for the primary outcome increased in DES subjects relative to BMS patients, such that longer follow-up analyses resulted in nonsignificant comparisons., Conclusions: These results suggest that the use of DES for patients with stable coronary disease is superior to BMS for 1 year, but that the increment in benefit decreased over continued follow-up. Further research is necessary to identify additional factors to promote longer-term efficacy and safety of DES.

Objective: The objective of this study is to investigate the clinical outcome of a large cohort of patients with ST-segment elevation myocardial infarction (STEMI) treated with drug-eluting stents (DES) compared to bare metal stents (BMS)., Background: Several randomized controlled trials have demonstrated that PCI with the routine use of DES is safe and effective in patients with STEMI. However as randomized trials have strict inclusion criteria, further studies in unselected patient populations are needed., Methods: We performed a retrospective cohort analysis of the Mayo Clinic PCI database. A total of 552 consecutive STEMI patients who underwent a DES implantation between May 2003 and April 2006 were included in the study and compared to 557 who had BMS for STEMI earlier. No specific patient subsets were excluded., Results: Procedural success was achieved in 532 patients (96%). During initial hospitalization, 16 patients (2.9%) died and 8 (1.5%) suffered from a recurrent myocardial infarction. The median follow-up was 23 months (IQR: 13-27 months). At 12 months post discharge, the rate of target lesion revascularization and death were 2.9% and 3.7%, respectively, and survival free of major adverse cardiac events (MACE) was 90.9%. These rates were similar to or lower than those of patients treated for STEMI with BMS prior to the availability of DES., Conclusion: DES are safe and effective in the treatment of STEMI in an unselected cohort; 90.9% of patients are free of MACE at 12 months post discharge., (2008 Wiley-Liss, Inc.)

Background: Large randomized controlled trials have demonstrated that percutaneous coronary intervention with the routine use of drug-eluting stents is safe and effective. However, octogenarians are usually excluded from these trials., Methods: We analyzed 2453 consecutive patients who underwent DES implantation at the Mayo Clinic (Rochester, MN). The patients were classified in 2 age groups: patients > or = 80 years of age < or = 79 years of age., Results: Patients > or = 80 years old had significantly more adverse baseline characteristics including more comorbid conditions and more severe extensive coronary artery disease. Procedural success was high irrespective of the age group--97% in patients > or = 80 years of age versus 98% in the younger patients. Multivariate analysis demonstrated that age of > or = 80 years was significantly associated with inhospital major adverse cardiac events (MACEs) (P = .004). In addition, among inhospital survivors, octogenarians also had higher follow-up MACE rates (P < .001). At 12 months of follow-up, patients > or = 80 years of age had a mortality of 8.9% versus 3.0% for the younger patients (P < .001). The older patients also had more recurrent myocardial infarction (5.2% vs 2.6%, P = .019). However, there was no significant difference in 12-month target lesion revascularization (4.5% vs 4.9% [> or = 80 years of age vs < or = 79 years of age]) or coronary artery bypass grafting (1.8% vs 1.3% [> or = 80 years of age vs < or = 79 years of age]). After age-sex adjustment, life expectancy of octogenarians was similar to that of the general population (P = .78)., Conclusion: This study showed that drug-eluting stent implantation in octogenarians has high initial procedural success rates compared with the younger patients despite having more severe baseline risk characteristics. During follow-up, death and overall MACE rates remain higher in octogenarians but target lesion revascularization rates are similar.

Objectives: The authors studied the safety and efficacy of the Cardiva Boomerang vascular closure device in patients undergoing diagnostic cardiac catheterization., Background: Conventional vascular closure devices (sutures, collagen plugs, or metal clips) have been associated with catastrophic complications including arterial occlusion and foreign body infections; furthermore, they cannot be utilized in patients with peripheral vascular disease or vascular access site in a vessel other than the common femoral artery. The Cardiva Boomerang device facilitates vascular hemostasis without leaving any foreign body behind at the access site, can be used in peripheral vascular disease, and can be used in vessels other than the common femoral artery, Methods: A total of 96 patients undergoing transfemoral diagnostic cardiac catheterization were included in this study, including 25 (26%) patients with contraindications to conventional closure devices. Femoral angiography was performed prior to deployment of the Cardiva Boomerang closure device. Patients were ambulated at 1 hr after hemostasis was achieved., Results: The device was successfully deployed and hemostasis achieved with the device alone in 95 (99%) patients. The device failed to deploy in 1 (1%) patient and required conversion to standard manual compression. Minor complications were observed in 5 (5%) patients. No patients experienced major complications including femoral hematoma > 4 cm, red blood cell transfusion, retroperitoneal bleed, arteriovenous fistula, pseudoaneurysm, infection, arterial occlusion, or vascular surgery., Conclusions: The Cardiva Boomerang device is safe and effective in patients undergoing diagnostic cardiac catheterization using the transfemoral approach, facilitating early ambulation with low rates of vascular complications., ((c) 2006 Wiley-Liss, Inc.)

Objective: To study the safety of a protocol that allows ambulation 1 hour after diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system., Patients and Methods: A total of 1005 consecutive patients (1009 procedures) undergoing outpatient diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system at the Mayo Clinic in Rochester, Minn, were included in this study from January 1, 2004, to August 31, 2005. All patients underwent standard manual compression to achieve hemostasis and were ambulated after 1 hour of bed rest., Results: The mean age of the patients was 64.5 years, and 62% were male. Minor vascular complications occurred in 33 procedures (3.3%), Including 14 hematomas (1.4%) less than 4 cm and 19 cases of rebleeding (1.9%) that required repeated manual compression. Only 1 patient (0.1%) had a hematoma greater than 4 cm. No patient had a major complication, such as surgical repair, red blood cell transfusion, retroperitoneal bleeding, formation of an arteriovenous fistula or pseudoaneurysm, arterial occlusion, or an infection., Conclusions: Ambulation 1 hour after diagnostic cardiac catheterization with a transfemoral approach using a 5F catheter system is safe and associated with low rates of vascular complications. This strategy may improve patient comfort, reduce resource utilization, and be preferable to use of vascular closure devices.

Objectives: The purpose of this study was to determine the safety of carotid artery stenting with a unique distal embolic protection system in high-risk patients with severe carotid stenosis., Background: Previous studies suggest that some patients with carotid stenosis and serious comorbid conditions are at high risk for carotid endarterectomy, and may be safely treated by carotid artery stenting., Methods: A prospective non-randomized multicenter registry of 419 patients with severe carotid stenosis and high-risk features for carotid endarterectomy was conducted between April 2004 and October 2004. Carotid artery stenting was performed with the Protégé Self-Expanding Nitinol Stent and the SPIDER Embolic Protection System (ev3 Inc., Plymouth, Minnesota). Aspirin and clopidogrel were prescribed at least 24 h before and three months after revascularization. The primary outcome was the combined incidence of major adverse cardiac and cerebrovascular events at 30 days after intervention, including death, stroke, and myocardial infarction. A secondary outcome was the technical success, defined as successful deployment of all devices, filter retrieval, and final diameter stenosis <50%., Results: Technical success was achieved in 408 of 419 patients (97.4%). The primary end point was observed in 26 patients (6.2%), including death in 8 (1.9%), nonfatal stroke in 14 (3.3%), and nonfatal myocardial infarction in 4 (1%). Independent predictors of death or stroke at 30 days included duration of filter deployment, symptomatic carotid stenosis, and baseline renal insufficiency., Conclusions: For some patients with severe carotid stenosis and high-risk features for carotid endarterectomy, carotid artery stenting with distal embolic protection is a reasonable alternative for revascularization.

Percutaneous revascularization of diseased saphenous vein grafts is associated with increased risk of adverse events, although the use of distal protection mitigates this to a significant extent. However, anatomic characteristics may preclude the use of such devices in a proportion of vein grafts intended for percutaneous treatment. We reviewed our consecutive experience of saphenous vein graft interventions from 1 May 2001 through 30 April 2002 to determine suitability for distal protection. Relevant angiographic characteristics included lesion within 5 mm of the ostium; lesion < 20 mm from the distal anastomosis; planned distal landing site of the occlusion balloon < 3 mm or > 6 mm in diameter; total occlusion of the vein graft; or lesion in a sequential vein graft distal to the first anastomosis. One hundred twenty-seven patients (140 procedures, 147 vein grafts) were treated. One or more of the angiographic exclusion criteria for a balloon occlusion protection system existed in 57% of grafts, while 42% had exclusions for a filter device. A large number of patients with vein graft disease intended for percutaneous treatment have anatomic exclusions to available distal protection technology., ((c) 2004 Wiley-Liss, Inc.)

This study evaluated the suitability of some disinfection and sterilization methods for use with microdialysis probes. Disinfection or sterilization should minimize the tissue inflammatory reaction and improve the long-term health of rats on study and ensure the quality of data obtained by microdialysis sampling. Furthermore, the treatment should not negatively impact probe integrity or sampling performance. The techniques chosen for evaluation included two disinfection methods (70% ethanol and a commercial contact lens solution) and two sterilization methods (hydrogen peroxide plasma, and e-beam radiation). Linear microdialysis probes treated by these processes were compared to untreated probes removed from the manufacturer's packaging as if sterile (the control group). The probes were aseptically implanted in the livers of rats and monitored for 72 hours. The parameters chosen to evaluate probe performance were relative sample mass recovery and the relative in vivo extraction efficiency of the probe for caffeine. Post mortem bacterial counts and histopathology examination of liver tissue were also conducted. The probes remained intact and functional for the entire study period. The methods tested did not acutely alter the probes although hydrogen peroxide plasma and contact lens solution groups showed reduced extraction efficiencies. Minimal tissue damage was observed surrounding the probes and acute inflammatory reaction was mild to moderate. Low numbers of bacterial colonies from the implantation sites indicates that the health of animals in this study was not impaired. This was also true for the control group (untreated probe).

Earlier studies documented an increased risk of percutaneous coronary intervention (PCI) in patients with angiographic evidence of thrombus. With newer antiplatelet agents and stents, it is not known whether thrombus is a risk factor after PCI. This study examines whether outcome of PCI in patients with thrombus has improved, and whether thrombus is associated with adverse outcome after PCI in the current era. This single-institution retrospective analysis of PCI in 7,184 patients was divided into 2 periods: group I, 1990 to 1995 (n = 3,640), and group II, 1996 to 1999 (n = 3,544). The groups were subdivided according to the presence or absence of angiographic thrombus before PCI. We compared the outcome of PCI for patients with and without thrombus in group II. A comparison was made in the 2 groups in patients with angiographic thrombus. Procedural success improved in group II compared with group I patients with thrombus (93% vs 88%, p <0.001). There was significant reduction in abrupt closure in the recent era in patients with thrombus (4% vs 7%, p = 0.01). In group II, procedural success remained lower in patients with (93% vs 96%) than without thrombus (p <0.001). After adjusting for the significant univariate characteristics of group II patients, thrombus remained an independent predictor of Q-wave infarction (odds ratio 3.78; 95% confidence interval [CI], 1.8 to 8.0; p <0.0013) and the composite end point of death, Q-wave infarction, and emergency bypass surgery (odds ratio 2.37; 95% CI 1.4 to 4.1; p = 0.002). There was a trend toward increased in-hospital death among patients with thrombus (odds ratio 2.06; 95% CI 0.9 to 4.8; p = 0.09). The 1-year outcome after successful PCI was similar for those with and without thrombus. Despite improvement in the outcome of patients with thrombus undergoing PCI in recent years, thrombus is still an independent predictor of adverse in-hospital outcomes after PCI.

Objective: Violence is a global problem that poses a major challenge to individuals and society. This document is a consensus statement on neurobehavioral aspects of violence as one approach to its understanding and control., Background: This consensus group was convened under the auspices of the Aspen Neurobehavioral Conference, an annual consensus conference devoted to the understanding of issues related to mind and brain. The conference is supported by the Brain Injury Association and by individual philanthropic contributions. Participants were selected by conference organizers to represent leading opinion in neurology, neuropsychology, psychiatry, trauma surgery, nursing, evolutionary psychology, medical ethics, and law., Methods: A literature review of the role of the brain in violent behavior was conducted and combined with expert opinion from the group. The major goal was to survey this field so as to identify major areas of interest that could be targeted for further research. Additional review was secured from the other attendees at the Aspen Neurobehavioral Conference., Results: The group met in the spring of 1998 and 1999 for two 5-day sessions, between which individual assignments were carried out. The consensus statement was prepared after the second meeting, and agreement on the statement was reached by participants after final review of the document., Conclusions: Violence can result from brain dysfunction, although social and evolutionary factors also contribute. Study of the neurobehavioral aspects of violence, particularly frontal lobe dysfunction, altered serotonin metabolism, and the influence of heredity, promises to lead to a deeper understanding of the causes and solution of this urgent problem.

Objectives: The aim of this study was to evaluate the immediate and long-term outcome of intracoronary stent implantation for the treatment of coronary artery bifurcation lesions., Background: Balloon angioplasty of true coronary bifurcation lesions is associated with a lower success and higher complication rate than most other lesion types., Methods: We treated 131 patients with bifurcation lesions with > or =1 stent. Patients were divided into two groups; Group (Gp) 1 included 77 patients treated with a stent in one branch and percutaneous transluminal coronary angioplasty (PTCA) (with or without atherectomy) in the side branch, and Gp 2 included 54 patients who underwent stent deployment in both branches. The Gp 2 patients were subsequently divided into two subgroups depending on the technique of stent deployment. The Gp 2a included 19 patients who underwent Y-stenting, and Gp 2b included 33 patients who underwent T-stenting., Results: There were no significant differences between the groups in terms of age, gender, frequency of prior myocardial infarction (MI) or coronary artery bypass grafting (CABG), or vessels treated. Procedural success rates were excellent (89.5 to 97.4%). After one-year follow-up, no significant differences were seen in the frequency of major adverse events (death, MI, or repeat revascularization) between Gp 1 and Gp 2. Adverse cardiac events were higher with Y-stenting compared with T-stenting (86.3% vs. 30.4%, p = 0.004)., Conclusions: Stenting of bifurcation lesions can be achieved with a high success rate. However, stenting of both branches offers no advantage over stenting one branch and performing balloon angioplasty of the other branch.

Objectives: The aim of our study was to compare the in-hospital and long-term clinical outcomes of direct coronary stenting with balloon predilation followed by stent placement., Background: With improvement in stent designs, the practice of direct stenting without balloon predilation has become more widespread., Methods: We analyzed the Mayo Clinic Coronary Intervention data base between January 1, 1995 and March 5, 1999 and identified 777 patients who were treated with direct stenting (DS) and 3,176 patients treated with balloon angioplasty plus stenting (BA+S)., Results: The procedural success rates between the DS and BA+S groups were not significantly different (96.3% vs. 96.4%). The ability to deliver the stent in a subgroup of patients who had DS was 95%, with 5% requiring crossover to predilation. Multivariate analysis showed no significant differences with respect to in-hospital death (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.5 to 1.8), in-hospital myocardial infarction (OR 0.9, 95% CI 0.6 to 1.2) or revascularization (OR 0.7, 95% CI 0.4 to 1.5) in the DS compared with the BA+S group. Long-term outcomes were not significantly different between the DS and BA+S groups. The procedural duration was significantly shorter in the DS group, and there was a decreased utilization of contrast agent, balloons and wires., Conclusions: The in-hospital and long-term clinical outcomes in patients undergoing a coronary intervention are equivalent when comparing stenting without balloon predilation with balloon angioplasty followed by stenting. Direct stenting is associated with decreased utilization of contrast agent and equipment and shorter procedure times. A randomized study should be performed to better determine the impact of this technique on short- and long-term procedural outcomes.

Our objective was to document change in stent usage in a single practice over time and to study "off-label" compared to Food and Drug Administration (FDA)-approved indications. Although only two intracoronary stents have been approved by the FDA, the relatively limited approved indications do not account for the dramatic increase in stent implantation. This increase has important implications for patient health care delivery. This study of stent usage in a single center over a 36-mo period included all patients treated with coronary stents at the Mayo Clinic from January 1993-December 1995, and evaluated the relative difference in frequency between "off-label" and FDA-approved indications for implantation. During the 36-mo period of study, 3,614 interventional procedures were done and one or more stents were placed in 25.4% of patients. The proportion of patients receiving stents increased throughout this time: during the first 6-mo period, stents were placed in 6.2% of procedures; during the last 6-mo period, stents were placed in 46.3% of procedures, an eightfold increase. During the final 6 mo, an unapproved device or an unapproved indication for an approved device constituted 59.4% of all stent procedures. In addition, use of the non-FDA-approved adjunctive treatment regimen without warfarin increased from 2.9% in the first 6-mo period of observation to 82.7% in the last 6 mo. The use of stents increased strikingly over a 36-mo period, from 6% to 46% of all procedures. The majority of implantations were performed either for an "off-label" unapproved indication or with an unapproved device.

We describe a method of validation of computerized quantitative coronary arteriography and report the results of a new UNIX-based quantitative coronary arteriography software program developed for rapid on-line (digital) and off-line (digital or cinefilm) analysis. The UNIX operating system is widely available in computer systems using very fast processors and has excellent graphics capabilities. The system is potentially compatible with any cardiac digital x-ray system for on-line analysis and has been designed to incorporate an integrated database, have on-line and immediate recall capabilities, and provide digital access to all data. The accuracy (mean signed differences of the observed minus the true dimensions) and precision (pooled standard deviations of the measurements) of the program were determined x-ray vessel phantoms. Intra- and interobserver variabilities were assessed from in vivo studies during routine clinical coronary arteriography. Precision from the x-ray phantom studies (6-In. field of view) for digital images was 0.066 mm and for digitized cine images was 0.060 mm. Accuracy was 0.076 mm (overestimation) for digital images compared to 0.008 mm for digitized cine images. Diagnostic coronary catheters were also used for calibration; accuracy.varied according to size of catheter and whether or not they were filled with iodinated contrast. Intra- and interobserver variabilities were excellent and indicated that coronary lesion measurements were relatively user-independent. Thus, this easy to use and very fast UNIX based program appears to be robust with optimal accuracy and precision for clinical and research applications.

Roman Catholic moral theology follows a centuries-old tradition of moral reflection. Contemporary Roman Catholic moral theory applies these traditional arguments to the realm of medical ethics, including the issues of active euthanasia and physician-assisted suicide. Unavoidable moral limits on licit medical intervention sometimes require that the moral duty to treat cede to the duty to cease treatment when measures become more harmful than beneficial to the patient. This does not reduce the need for the compassionate use of palliative care in response to suffering. However, it does mean that rather than being excessively committed to maintaining mere biological human life, or actively seeking death, that we learn a sober realism about the limits of human life. Catholic moral analysis examines an act objectively, both in its relation to the agent and as a material event in the world. This allows both the virtuous or vicious intentions of the agent and the effects of the action to be included in its moral evaluation. Thus, Catholic moral analysis is both quasi-deontological and quasi-consequentialist. Objectively, active euthanasia and physician-assisted suicide, as acts of deliberate killing, are seen as repugnant, in that they fail to incarnate a benign inner intention or to form an agent in virtue. Catholic moral theology is extremely skeptical that an act of intending death directly can be consonant with a sincere compassion for the dying, suffering person and views it as a direct negation of the precious gift of human life.

Objective: To evaluate the outcome in patients who underwent directional coronary atherectomy after unsuccessful balloon angioplasty., Design: We conducted a retrospective computerized data bank search of patients in whom unsuccessful balloon angioplasty and subsequent "rescue" coronary atherectomy had been performed at the Mayo Clinic between Nov. 1, 1988, and May 1, 1993., Material and Methods: Among the 336 patients who underwent directional coronary atherectomy during the study period, in 16 the procedure was a rescue attempt. The mean age of these 16 study patients was 67 years. The following vessels were treated: left anterior descending coronary artery, six patients; right coronary artery, six; circumflex artery, two; and saphenous vein graft, two. Coronary angioplasty had failed because of dissection in eight patients, elastic recoil without evident dissection in seven, and recurrent thrombus without evident dissection in one., Results: After coronary atherectomy, the mean stenosis was 41% (in comparison with 90% before coronary angioplasty and 71% after coronary angioplasty). Both angiographic success (20% or more decrease in stenosis after tissue removal and a final stenosis of less than 50%) and clinical success (angiographic success without in-hospital Q-wave myocardial infarction, bypass operation, or death) were achieved in 10 patients. Adventitia was obtained in two patients, both of whom underwent atherectomy for elastic recoil. In six patients, a stenosis of more than 50% remained after atherectomy; one patient suffered a Q-wave myocardial infarction, and one underwent emergent coronary artery bypass grafting. No deaths occurred in the study group. During follow-up (mean, 22 +/- 19 months), one patient suffered a non-Q-wave myocardial infarction, and two others underwent elective coronary artery bypass grafting. Eleven patients were asymptomatic at last contact. Repeated angiography, done in five patients a mean of 3.4 +/- 3.1 months after the procedure, showed restenosis in three., Conclusion: Rescue directional coronary atherectomy seems to be safe and effective in achieving angiographic and clinical successes in carefully selected patients after unsuccessful coronary angioplasty.

Objective: To compare the short-term and long-term outcomes of directional coronary atherectomy in women and men., Design: We retrospectively analyzed 291 consecutive directional atherectomy procedures performed in 61 women and 230 men at the Mayo Clinic between October 1988 and November 1992., Material and Methods: The baseline clinical and angiographic characteristics, including extent of coronary artery disease and left ventricular ejection fraction, were compared for the male and female patients, and the short-term and long-term complications associated with atherectomy were summarized on the basis of gender., Results: At baseline, women were older than men (67 +/- 12 versus 61 +/- 11 years; P = 0.001), and more women than men had class III or IV angina (90% versus 64%; P < 0.001); slightly more women than men had rest pain (64% versus 52%). Overall clinical success (improvement in luminal diameter of 40% or more and no death, Q-wave myocardial infarction, or emergency coronary bypass operation) was achieved in 89% of women and 95% of men (P = 0.054). In-hospital mortality was similar in women and men (1.6% and 1.7%, respectively), but acute myocardial infarction occurred more frequently in women than in men (4.9% versus 0.4%; P = 0.03). Significant peripheral vascular complications occurred in 6.6% of women versus 0.9% of men (P = 0.02). During long-term follow-up (mean, 2.9 years), survival and freedom from recurrent angina were similar among women and men., Conclusion: Directional coronary atherectomy is associated with slightly lower success and a higher frequency of myocardial infarction among women than among men. The higher postprocedural rate of myocardial infarction among women may reflect their worse clinical status at time of initial assessment. Despite these observations, women and men seem to have comparable survival and freedom from recurrence of angina during extended follow-up.

Objectives: This study assessed the frequency of perforation with excimer coronary angioplasty., Background: Coronary artery perforation after conventional percutaneous transluminal coronary angioplasty is extremely rare. Because laser coronary angioplasty involves actual tissue ablation, it has an increased potential for perforation., Methods: All patients in the Excimer Laser Coronary Angioplasty Registry were included in this prospective study. Those who had a perforation related to the procedure were compared with those who did not have this complication., Results: Of 2,759 consecutive patients in the Excimer Laser Coronary Angioplasty Registry, 36 (1.3%) had perforation. In these patients, the left anterior descending coronary artery was the most frequently treated vessel (53%). There were no differences in fiber sizes between patients with and those without perforation. Among the patients with perforation, 36.1% required coronary artery bypass surgery, 16.7% experienced an infarction and 5.6% had a fatal outcome. Among the patients without perforation, the rates were 3.1%, 3.8% and 0.6%, respectively. However, 41.7% of the patients with documented coronary artery perforation did not need coronary artery bypass surgery or experience myocardial infarction or death. No angiographic characteristics distinguished lesions with from those without perforation. The frequency of coronary artery perforation declined over time with increasing operator experience, from 1.6% in the first 1,888 patients to only 0.4% in the last 1,000 patients (p = 0.002)., Conclusions: With increasing operator experience, the rate of perforation with excimer laser coronary angioplasty has decreased. When perforation occurs, subsequent event rates increase.

Objectives: We report the comprehensive results of the first consecutive 3,000 patients treated in an excimer laser coronary angioplasty registry., Background: Excimer laser coronary angioplasty involves the use of a pulsed, 308-nm ultraviolet laser transmitted by optical fibers to reduce coronary stenoses. Preliminary reports have described safety and efficacy profiles in small numbers of patients., Methods: Patients were enrolled in a prospective, nonrandomized manner. The catheters used were 1.3, 1.6, 2.0, 2.2 and 2.4 mm in diameter, at energy densities up to 70 mJ/mm2. Procedures were performed by standard angioplasty technique with conventional guide catheters., Results: Seventy-five percent of patients were male, 68% were in Canadian Cardiovascular Society functional class III or IV and the cohort included 3,592 lesions. Procedural success (final stenosis < or = 50% without in-hospital Q wave myocardial infarction, coronary artery bypass surgery or death) was 90% and did not differ between the first 2,000 and the last 1,000 patients treated. There was no significant difference in success or complication rates with respect to lesion length, nor were there differences between selected complex and simple lesions. Complications included in-hospital bypass surgery (3.8%), Q wave myocardial infarction (2.1%) and death (0.5%). Coronary artery perforation occurred in 1.2% of patients (1% of lesions) but significantly decreased to 0.4% in the last 1,000 patients (0.3% of lesions). Angiographic dissection occurred in 13% of lesions, transient occlusion in 3.4% and sustained occlusion in 3.1%. Comprehensive lesion morphologic data collected in the latter portion of the study showed the procedure predominantly limited to American College of Cardiology-American Heart Association type B2 and C lesions, with no significant difference in short-term outcome between groups., Conclusions: Excimer laser angioplasty can be safely and effectively applied, even in a variety of complex lesions not well suited for percutaneous transluminal coronary angioplasty. These types may include aorto-ostial, long lesions, total occlusions crossable with a wire, diffuse disease and vein grafts. Most recent data show a trend for the selection of predominantly complex lesions and a reduction in the incidence of perforation. This procedure may broaden the therapeutic window for the interventional treatment of selected complex coronary artery disease.

Early tomographic myocardial perfusion imaging with technetium-99m sestamibi was performed during inferior wall acute myocardial infarction to determine the relation between the amount and location of myocardium at risk and the presence or absence or anterior ST depression. The total size of the acute perfusion defect and its lateral and septal borders were measured in 29 consecutive patients who were admitted with > 30 minutes of chest pain and acute inferior ST elevation on their initial electrocardiogram. The 22 patients with anterior ST depression had significantly more left ventricular myocardium at risk than the 19 patients who did not have anterior ST depression (23 +/- 2% of the left ventricle vs 15 +/- 1%, p = 0.008). All 8 patients with > 25% of the left ventricle at risk had anterior ST depression. Patients with anterior ST depression had a significantly greater lateral extent of the acute perfusion defect (49 degrees +/- 8 degrees from the midinferior wall vs 23 degrees +/- 7 degrees, p = 0.002). There was no difference in the septal border of the perfusion defect between patients with and without anterior ST depression (-44 degrees +/- 4 degrees vs -46 degrees +/- 7 degrees, p = NS). No patient had a measurable anterior perfusion defect. Although there is considerable overlap between groups with and without anterior ST depression, anterior ST depression is a simple and readily available indicator of myocardium at risk in inferior wall acute myocardial infarction.