Search

To evaluate the safety and efficacy of percutaneous mitral valve repair for the management of functional mitral insufficiency. Severe functional mitral regurgitation (FMR) is present in 25–30% of patients with heart failure and is an independent predictor of mortality and hospitalizations in

Coronary flow response to low-dose (5 and 10 micrograms/kg/min) dobutamine infusion was used to assess myocardial viability at the time of cardiac catheterization in 13 patients (age, 60 +/- 11 years) with recent myocardial infarction. Echocardiographic improvement in regional wall motion performed 4 to 6 weeks after discharge was used as the marker for viability. Viable patients demonstrated a 2-fold increase in flow from baseline (p < 0.001) during intravenous infusion. In contrast, patients without viability demonstrated no increase in flow. The coronary flow response to dobutamine measured at the time of catheterization shows promise in identifying viable myocardium in postinfarction patients.

The ultraviolet pulsed excimer laser (308 nm wavelength) is currently the only laser approved by the FDA for percutaneous intervention in patients with ischemic coronary artery disease. The clinical presentation of the treated patients varies from stable and unstable angina to acute myocardial infarction. Potential advantages of excimer laser revascularisation in acute coronary syndromes and in ischaemic obstructive peripheral vascular disease include concomitant plaque debulking and thrombus removal; absence of systemic lytic state; shortened thrombus clearing time and facilitation of adjunct balloon angioplasty and stenting. Improved understanding of laser-tissue interactions and positive clinical outcomes through the use of safe lasing techniques have led to expansion of indications/applications for laser angioplasty. These include stent restenosis, complex lesions and thrombotic stenoses, bifurcation lesions, balloon failure, total occlusions, focal saphenous vein graft lesions and peripheral arterial obstructions. The excimer laser can be effectively utilised in patients with depressed left ventricular ejection fraction and does not require implantation of a temporary pacemaker as no-reflow phenomenon and severe arrhythmias are rarely encountered. Careful case selection, proper utilisation of equipment and incorporation of efficient lasing techniques play a crucial role in effective and safe cardiovascular laser applications.

Ablation technique and adjunctive strategy may affect restenosis after rotational atherectomy. To minimize trauma to the vascular wall, we changed the technique of rotablation as follows: the RPM range was decreased to 140,000-160,000 RPM, the ablation was performed using a repetitive pecking motion, avoiding a decrease in the rotational speed of the burr greater than 3,000 RPM, long lesions were divided into segments and each segment was separately ablated, and the burr-to-artery ratio was intended to be approximately 0.75. To prevent coronary spasm, before and after each pass, 100-200 microg nitroglycerin and 100-200 microg verapamil i.c. boluses were administered. Adjunctive PTCA was performed using a closely sized 1.1:1 balloon-to-artery ratio with a noncompliant balloon at low pressures for 120 sec. The study incorporated 111 patients with a combined total of 146 calcified lesions. Results. A total of 31.5% of patients underwent a multivessel procedure. No deaths occurred. Q-wave MI and/or creatine kinase elevation greater than three times baseline levels occurred in 4.5% of patients. By quantitative coronary angiography (QCA), the reference vessel diameter was 3.13+/-0.59 mm, mean lesion length was 33.41+/-18.58 mm. Percent stenosis and mean luminal diameter were as follows: at baseline 75.7%+/-10.8%, or 0.76+/-0.41mm, Post-rotational atherectomy 41.5%+/-3.6%, or 1.83+/-0.43 mm, Post-PTCA 18.2%+/-11.9%, or 2.56+/-0.50 mm. Six-month angiographic follow-up was available in 64 (57.7%) pts. Net luminal gain was 1.15+/-0.76 mm, with a late luminal loss of 0.65+/-0.84 mm. The mean diameter stenosis at follow-up was 37.6%+/-28.5%, with MLD 1.91+/-1.21 mm. The binary restenosis rate was 28.1%. Therefore, modification of rotational atherectomy technique with adjunctive PTCA resulted in a favorable restenosis rate in long, calcified lesions. Cathet. Cardiovasc. Intervent. 48:48-53, 1999.

The purpose of this study was to determine the results of directional coronary atherectomy (DCA) combined with stenting in a high-risk patient population. The use of stenting or DCA alone for aorto-ostial lesions, total chronic occlusions, long lesions, and lesions containing thrombus is associated with lowered success and a relatively high restenosis rate. Between July 1993 and October 1996, we treated 89 lesions with the combined approach of DCA and stenting in 60 consecutive patients. Thirty-one (51.7%) patients were treated because of unstable angina, 11 (18.3%) for post-myocardial infarction (MI) angina, 3 (5.0%) for acute MI, and 15 (25.0%) patients for stable angina. A total of 43 (71.7%) patients had multivessel disease, 19 (31.7%) had undergone previous coronary artery bypass graft (CABG), and 17 (28.3%) patients had undergone multivessel revascularization. The procedure was successful in all patients; and no postprocedural deaths or emergent CABG occurred. Two patients (3.3%) had non-Q-wave MI after the procedure and 1 patient (1.7%) experienced Q-wave MI due to subacute stent closure 7 days after the procedure. During follow-up ranging from 6 months to 3 years, 2 (3.3%) patients died, 2 (3.3%) required CABG surgery, 1 (1.7%) patient had an MI, and 6 patients (10.0%) required target vessel revascularization. By the quantitative coronary angiography, the initial minimal luminal diameter (MLD) averaged 0.91 ± 0.45 mm (74.7 ± 11.8% stenosis) increasing to 3.80 ± 0.44 mm (−6.7 ± 12.1%) after the combined approach procedure. Thirty patients (50.0%) met criteria for late (≥6 months) angiographic follow-up. Late MLD loss averaged 1.13 ± 1.07 mm, for a mean net gain of 1.61 ± 1.23 mm. Available angiographic follow-up evaluation showed a restenosis rate of 13.3%. A combined approach, defined as the use of both DCA and stenting, is safe and yields a low restenosis rate in high-risk patients who have lesions known to respond less favorably to stenting or DCA alone. Cathet. Cardiovasc. Diagn. 45:105–112, 1998. © 1998 Wiley-Liss, Inc.

A novel skin dose monitor was used to measure radiation incident on maximal X-ray exposed skin during 135 diagnostic and 65 interventional coronary procedures. For the diagnostic studies (n = 135), mean skin dose was 180 ± 64 mGy; for PTCA (n = 35), it was 1021 ± 674 mGy, single stents (n = 25) 1529 ± 601 mGy, and multiple stents with rotational atherectomy (n = 5) 2496 ± 1028 mGy. The dose independently increased with more cine runs, more fluoroscopy, and greater patient weight. Physicians should consider the potential for adverse radiation exposure when planning coronary interventional cases and deciding on the X-ray mode and angles used. Cathet. Cardiovasc. Diagn. 43:367–370, 1998. © 1998 Wiley-Liss, Inc.

Initial reports of percutaneous transluminal coronary angioplasty (PTCA) in the elderly (≥: 75 years) showed a significantly lower primary success rate, higher in-hospital mortality, and a higher risk of emergency or elective coronary artery bypass graft (CABG) compared to younger patients. There are few data concerning acute outcomes and clinical follow-up after the use of coronary stenting in the elderly compared to < the 75-year-old age group. We evaluated 82 elderly patients and 280 younger patients who received Palmaz-Schatz stents during 1995, at a time when high pressure deployment and antiplatelet therapy was routinely used. The success rate and acute major complications were not significantly different between the elderly and younger patients. Clinical events (death, myocardial infarction [MI], repeat PTCA, or CABG) during 6-month follow-up were also not significantly different. Coronary stenting in the elderly can be carried out with a high success rate and low incidence of acute major complications. Thus, short-term clinical outcomes in elderly patients appear similar to results obtained in younger patients.

Recently, the Palmaz-Schatz coronary stent was approved by the FDA as an alternative to coronary angioplasty in the treatment of de novo native coronary stenosis. Developed by Dr. Julio Palmaz and Dr. Richard Schatz, the Palmaz-Schatz intracoronary stent design was implanted in 1987 at Brooke Army Medical Center. During the past 7 years, The University of Texas Health Science Center-San Antonio (clinical sites include University Hospital, Brooke Army Medical Center, and Audie Murphy Veterans Administration Hospital) has used this intracoronary stent to treat more than 300 patients. Nursing care for this patient population is both distinct and challenging. Successful patient outcomes require a knowledgeable staff and a team approach. This article will emphasize the nursing care and patient education required both before and after the stent procedure, as well as considerations for long-term follow-up.

To examine the results of high balloon dilatation pressures during percutaneous transluminal coronary angioplasty (PTCA), we retrospectively reviewed 482 angioplasty cases from our institution and divided them into three groups by the peak inflation pressure used during the procedure. Group one was defined by inflation pressures of 1–6 atmospheres (atm), group two by 7–12 atm, and group three by 13–20 atm. There were 166 patients in group 1 (34.4%), 235 in group 2 (48.8%), and 81 (16.8%) in group 3. The success rates were not statistically different; 90% in group 1, 96% in group 2, and 95% in group 3. Large dissections occurred in 27 patients in group 1 (16.3%), 19 in group 2 (8.1%), and 4 (4.9%) in group 3 (P > 0.006). There were no differences in the rates of death (1.2% vs. 0.9% vs. 1.2%), myocardial infarction (3.0% vs. 1.3% vs. 3.7%), or in-hospital CABG (3.0% vs. 1.7% vs. 1.2%) in groups 1, 2, and 3, respectively. Six-mo target vessel revascularization rates also were not different: 19% vs. 13% vs. 18%. In summary, selectively using high balloon pressures during PTCA does not result in increased complications. © 1995 Wiley-Liss, Inc.1

To overcome the adverse complications of percutaneous coronary interventions in thrombus laden lesions (i.e., distal embolization, platelet activation, no-reflow phenomenon), mechanical removal of the thrombus or distal embolization protection devices are frequently required. Pulsed-wave ultraviolet excimer laser light at 308 nm can vaporize thrombus, suppress platelet aggregation, and, unlike other thrombectomy devices, ablate the underlying plaque. The following multicenter registry was instituted to evaluate the safety and efficacy of laser ablation in patients presenting with acute myocardial infarction (AMI) complicated by persistent thrombotic occlusions. Patients with AMI and complete thrombotic occlusion of the infarct-related vessel were included in eight participating centers. Patients with further compromising conditions (i.e., cardiogenic shock, thrombolysis failures) were also included. Primary endpoint was procedural respective laser success; secondary combined endpoints were TIMI flow and % stenosis by quantitative coronary analysis and visual assessment at 1-month follow-up. Eighty-four percent of all patients enrolled (n = 56) had a very large thrombus burden (TIMI thrombus scaleor = 3), and 49% were compromised by complex clinical presentation, i.e., cardiogenic shock (21%), degenerated saphenous vein grafts (26%), or thrombolysis failures (5%). Laser success was achieved in 89%, angiographic success in 93%, and the overall procedural success rate was 86%. The angiographic prelaser total occlusion was reduced angiographically to 58% +/- 25% after laser treatment and to 4% +/- 13% final residual stenosis after adjunctive balloon angioplasty and/or stent placement. TIMI flow increased significantly from grade 0 to 2.7 +/- 0.5 following laser ablation (P0.001) and 3.0 +/- 0.2 upon completion of the angioplasty procedure (P0.001 vs. baseline). Distal embolizations occurred in 4%, no-reflow was observed in 2%, and perforations in 0.6% of cases. Laser-associated major dissections occurred in 4% of cases, and total MACE was 13%. The safety and efficacy of excimer laser for thrombus dissolution in a cohort of high-risk patients presenting with AMI and total thrombotic occlusion in the infarct-related vessel are encouraging and should lead to further investigation.